Question provided by:
Dr. Adolfo Parra Blanco (who was consulted about this case by a colleague)
Hospital Universitario Central de Asturias, Oviedo, Spain

Sometimes we have used lugol to rule out remaining Barrett´s islands after apparently having completed the ablation of the BE.. The reason to use this method instead of NBI for instance, is that lugol chromoendoscopy probably provides much clearer  images so that remnant BE tissue can be more precisely traced.  However, when we have found  BE islands which we have then treated with Halo 90, it is our impression that the mucosa becomes somewhat swollen, and the oesophagus collapsed, and therefore the maneuverability of the endoscope –and therefore probably the safety and efficacy of the ablation could be compromised. Could you give any hints or suggestions about the use of lugol in patients undergoing RFA?

Suggestion provided on behalf of the RFA Academia training committee by:
Dr. Jacques Bergman
Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands

In early esophageal squamous cell neoplasia, Lugol’s chromoendoscopy is used to detect unstained lesions, as these are predictive for the presence of neoplasia. However, given the caustic effect of this solution, RFA should be performed within the same endoscopic session. Lugol’s staining makes the epithelium vulnerable to superficial bleeding, and RFA (or any other therapeutic intervention) should not be performed within the first 3-4 weeks after Lugol’s staining [Zhang, Endoscopy, 2010]

When applied in Barrett’s esophagus, another downside of Lugol’s staining is the difficulty in distinguishing residual Barrett islands from reflux-related islands. Narrow-band imaging (NBI) is a good alternative for Lugol’s staining especially in Barrett’s esophagus. Optical filters are used for imaging of the mucosa, and by utilizing short wavelength light the mucosal surface pattern and microvascular details are higlighted, without the need for dye staining. It is therefore user-friendly and allows for inspection of the whole endoscopic field, whereas with chromoendoscopy the dye does not always distribute equally over the mucosa. Furthermore, Barrett islands and reflux changes are well distinguishable with NBI and RFA treatment can be performed upon identification of islands without the drawbacks of dye staining like Lugol’s. [Curvers, Gastrointestinal Endoscopy 2009; Kara, Endoscopy, 2005].