DEFINITION: Mania: An abnormally elevated mood state characterized by such symptoms as inappropriate elation, increased

irritability, severe insomnia, grandiose notions, increased speed and/or volume of speech, disconnected and racing thoughts,
increased sexual desire, markedly increased energy and activity level, poor judgment, and inappropriate social behavior. A mild
form in mania that does not require hospitalization is termed hypomania. Mania that also features symptoms of depression
("agitated depression") is called mixed mania.

Mania is the Greek word for madness. It is derived from mainmai, to rave in anger. The Maniai in Greek mythology were the Furies
who pursued those who had done unavenged crimes and drove them to madness.

See also: Bipolar disorder, Hypomania, Mixed mania.

Sometimes, when I look over what I've created in the Phrontistery, I start to think
I'm more than a bit crazy, and must be suffering from verbomania. Still, I probably
don't officially have any of the 142 manias or obsessions listed below. Some of
these mania words represent clinical illnesses, while others are merely facetious.
They show the range of unusual and weird things with which one can become
obsessed. These words are the ones found in major dictionaries; no doubt there
are many others, given that, like phobias, manias are easy to form by taking a root
word from Latin or Greek and affixing the suffix 'mania'. Also my word list of types
of love and attraction or 'philias', some of which indicate pathological attractions.

Word Definition

ablutomania mania for washing oneself

aboulomania pathological indecisiveness

agromania intense desire to be in open spaces

andromania nymphomania

anglomania craze or obsession with England and the English

anthomania obsession with flowers

aphrodisiomania abnormal sexual interest

arithmomania obsessive preoccupation with numbers

balletomania abnormal fondness for ballet

bibliomania craze for books or reading

bruxomania compulsion for grinding teeth

cacodemomania pathological belief that one is inhabited by an evil spirit

catapedamania obsession with jumping from high places

chinamania obsession with collecting china

choreomania dancing mania or frenzy

clinomania excessive desire to stay in bed

copromania obsession with feces

cytheromania nymphomania

dacnomania obsession with killing

demonomania pathological belief that one is possessed by demons

dinomania mania for dancing

dipsomania abnormal craving for alcohol

discomania obsession for disco music

doramania obsession with owning furs

doromania obsession with giving gifts

drapetomania intense desire to run away from home

dromomania compulsive longing for travel

ecdemomania abnormal compulsion for wandering

egomania irrational self-centered attitude or self-worship

eleutheromania manic desire for freedom

empleomania mania for holding public office

enosimania pathological belief that one has sinned

entheomania abnormal belief that one is divinely inspired

epomania craze for writing epics

ergasiomania excessive desire to work; ergomania

ergomania excessive desire to work; workaholism

erotomania abnormally powerful sex drive

etheromania craving for ether

ethnomania obsessive devotion to one's own people

eulogomania obsessive craze for eulogies

flagellomania abnormal enthusiasm for flogging

florimania craze for flowers

francomania craze or obsession with France and the French

gallomania craze or obsession with France and the French

gamomania obsession with issuing odd marriage proposals

Graecomania obsession with Greece and the Greeks

graphomania obsession with writing

gynaecomania abnormal sexual obsession with women

habromania insanity featuring cheerful delusions

hagiomania mania for sainthood

Hellenomania obsession with Greece and the Greeks; Graecomania

hexametromania mania for writing in hexameter

hieromania pathological religious visions or delusions

hippomania obsession with horses

hydromania irrational craving for water

hylomania excessive tendency towards materialism

hypermania severe mania

hypomania minor mania

hysteromania nymphomania

iconomania obsession with icons or portraits

idolomania obsession or devotion to idols

infomania excessive devotion to accumulating facts

islomania craze or obsession for islands

Italomania obsession with Italy or Italians

kleptomania irrational predilection for stealing

klopemania kleptomania

logomania pathological loquacity

lypemania extreme pathological mournfulness

macromania delusion that objects are larger than natural size

megalomania abnormal tendency towards grand or grandiose behaviour

melomania craze for music

methomania morbid craving for alcohol

metromania insatiable desire for writing verse

micromania pathological self-deprecation or belief that one is very small

monomania abnormal obsession with a single thought or idea

morphinomania habitual craving or desire for morphine

musomania obsession with music

mythomania lying or exaggerating to an abnormal extent

narcomania uncontrollable craving for narcotics

necromania sexual obsession with dead bodies; necrophilia

nosomania delusion of suffering from a disease

nostomania abnormal desire to go back to familiar places

nymphomania excessive or crazed sexual desire

oenomania obsession or craze for wine

oligomania obsession with a few thoughts or ideas

oniomania mania for making purchases

onomamania mania for names

onomatomania irresistible desire to repeat certain words

onychotillomania compulsive picking at the fingernails

opiomania craving for opium

opsomania abnormal love for one kind of food

orchidomania abnormal obsession with orchids

parousiamania obsession with the second coming of Christ

pathomania moral insanity

peotillomania abnormal compulsion for pulling on the penis

phagomania excessive desire for food or eating

phaneromania habit of biting one’s nails

pharmacomania abnormal obsession with trying drugs

phonomania pathological tendency to murder

photomania pathological desire for light

phyllomania excessive or abnormal production of leaves

phytomania obsession with collecting plants

planomania abnormal desire to wander and disobey social norms

plutomania mania for money

polemomania mania for war

politicomania mania for politics

polkamania craze for polka dancing

polymania mania affecting several different mental faculties

poriomania abnormal compulsion to wander

pornomania obsession with pornography

potichomania craze for imitating Oriental porcelain

potomania abnormal desire to drink alcohol

pseudomania irrational predilection for lying

pteridomania passion for ferns

pyromania craze for starting fires

rhinotillexomania compulsive nose picking

rinkomania obsession with skating

satyromania abnormally great male sexual desire; satyriasis

scribbleomania obsession with scribbling

sebastomania religious insanity

sitiomania morbid aversion to food

sophomania delusion that one is incredibly intelligent

squandermania irrational propensity for spending money wastefully

stampomania obsession with stamp-collecting

syphilomania pathological belief that one is afflicted with syphilis

technomania craze for technology

Teutomania obsession with Teutonic or German things

thanatomania belief that one has been affected by death magic, and resulting illness

theatromania craze for going to plays

theomania belief that one is a god

timbromania craze for stamp collecting

tomomania irrational predilection for performing surgery

toxicomania morbid craving for poisons

trichotillomania neurosis where patient pulls out own hair

tulipomania obsession with tulips

typhomania delirious state resulting from typhus fever

typomania craze for printing one’s lucubrations

uranomania obsession with the idea of divinity

verbomania craze for words

xenomania inordinate attachment to foreign things

zoomania insane fondness for animals

Mania, Hypomania, Mixed State And Bipolar Disorder

Mania is a mood disturbance, which causes the person to have a severely elevated or irritable mood. Episodes of mania are
generally associated with bipolar disorder.

To be diagnosed with Bipolar I Disorder, the person must have had at least one manic or mixed episode. For people who have
bipolar disorder, their moods may fluctuate between episodes of mania and episodes of depression.

Besides the stereotypical euphoria of a manic episode, other symptoms of mania include extreme optimism, talkativeness and rapid
speech, racing thoughts, agitation, poor judgment, recklessness, difficulty sleeping or decreased need for sleep, distractibility, and
difficulty concentrating.

Some researchers and psychiatric professionals would like to have more classifications of manic episodes. The personal experience
of manic episodes varies greatly from person to person. Currently, the Diagnostic and Statistical Manual (DSM IV) of the
American Psychiatric Association only recognizes mania, hypomania, and mixed episodes as variations of mania. Emil Kraepelin,
the pioneering German psychiatrist, described an additional classification of mania to refer to those who experience psychotic
symptoms during manic episodes.

Researchers at Duke University have expanded upon Kraepelin's four classes of mania. They have described the variations of
mania to include hypomania, severe mania, extreme mania, and two forms of mixed mania. Hypomania is a milder form of mania
featuring mainly euphoria. Severe mania includes euphoria, grandiosity, high levels of sexual drive, irritability, volatility, psychosis,
paranoia, hostility and aggression. Extreme mania, or dysphoric, is characterized by most of the displeasures, hardly any of the
possible pleasures of mania. Mixed mania is episodes of both manic and depressive symptoms.

Hypomania is a less severe form of mania. Hypomania may not cause impairment in functioning like mania can. People
experiencing a hypomanic episode may actually have increased productivity and goal-directed behavior. Hypomania does not lead
to psychotic episodes. Many of the symptoms of mania are present, but to a lesser degree than during a true manic episode.

People with hypomania are generally perceived as being energetic, euphoric, overflowing with new ideas, and sometimes highly
confident and charismatic, and unlike full-blown mania, they are sufficiently capable of coherent thought and action to participate in
everyday activities. People with frequent episodes of hypomania may dress colorfully and boldly. They are often very social.

In the context of bipolar disorder, a mixed states is a condition during which symptoms of mania or hypomania and symptoms of
depression occur simultaneously. During a mixed episode, the person may experience the impulsiveness, insomnia, irritability, and
flight of ideas that can be present in a manic episode as well as suicidal thoughts, guilt, feelings of hopelessness, and changes in
appetite that are common during depressive episodes. Mixed episodes can be incredibly distressing to the individual. It can lead to
panic attacks, substance abuse, and suicide.

Manic episodes in bipolar disorder are typically treated with mood stabilizing medications, therapy, and antipsychotic medication if
necessary. It is sometimes necessary to hospitalization until the patient is stabilized on their medication. The mood stabilizing
medications can take weeks to effectively control the symptoms. Some people neglect treatment because they like the euphoria that
is present during manic episodes. Treatment for manic episodes is important, because bipolar disorder tends to get worse if left
untreated.

Next article: Living In Mania

Etiology
The genetic predisposition to bipolar disorder suggests a biological etiology. Researchers seeking to confirm a
biochemical basis have focused on diverse neurotransmitter systems and their interactions, neuroendocrine
abnormalities,[30] neuropeptides, electrolytes, and, most recently, membrane transport systems. Small samples
and the difficulty of clinical implementation have limited the utility of these findings. Several studies do indicate
greater noradrenergic activity during manic than depressive illness episodes, and a specific link of
noradrenergic dysfunction to bipolar disorder, [31] not major depressive disorder has been identified. [21,32] Recent
reports of reduced levels of key substances involved in intraneuronal signal transduction (protein kinase C,
marcks protein) have the potential to link biochemistry to improved pharmacotherapy for bipolar disorder.
Recently published structural neuroimaging studies in mood disorders suggest that a smaller frontal lobe,
cerebellum, caudate, and putamen appear present in unipolar depression, whereas a larger third ventricle but
smaller cerebellum and temporal lobe appear present in bipolar disorder. The most recent studies of
intracellular signaling systems and brain structure and function continue to have the serious limitation of small
samples that may be atypical.[33
Other Medical Causes
Manic and hypomanic symptoms can reflect neuropathologies, infections, metabolic disturbances, and other
conditions, including drug effects.[34,35] Reversible causes of bipolar disorder should always be considered when
evaluating symptomatic patients. The term secondary mania is applied to bipolar conditions resulting as
sequelae to other medical disorders, such as stroke, brain trauma, infections, substance abuse, and metabolic
and endocrine disorders.[36] Secondary mania is frequently precipitated by sleep disruption and is not typically
associated with family history of mood disturbances. [37] Manic symptoms tend to predominate, and irritability is
more common than euphoria. Li is not so effective with secondary mania. [28,38] Recognition of secondary mania
is therefore important for planning treatment--an added reason for establishing the presence of comorbidity.
Medical problems and drug effects also can underlie depression. It is therefore imperative that a
comprehensive assessment consider underlying diseases or drugs that can precipitate manic depression.

Comorbid Conditions
If a patient has no family history of affective illness or responds poorly to treatments for bipolar disorder, other
medical conditions (such as renal or hepatic dysfunction, thyroid disease, or other metabolic illness, infections,
tumors, or seizures) should be considered. The association with hypothyroidism is seen particularly in women
with rapid-cycling bipolar illness.[39]

Psychotic symptoms occur with more severe mania but can also occur in conjunction with depression.

Eating disorders, panic attacks, borderline personality disorder, ADHD, and compulsive behavior all may be
evidence of bipolar disorder or other psychologic syndromes. [40,41]

Dual diagnosis with substance abuse, especially cocaine and alcohol abuse/dependence, is common. In fact,
dependence on these chemicals is more prevalent among people with affective disorder than it is in the general
population, although the sequence of their respective occurrences is debated. The ECA study found that 41%
of people with bipolar I disorder have abused or were dependent on 1 or more of the following: marijuana,
cocaine, opiates, barbiturates, LSD, and PCP; 46% abused or were dependent on alcohol. It is estimated that
about 35% (range, 3% to 75%) of people with bipolar disorder also have been diagnosed as being alcoholics,
compared with about 8% of the general population. [42] Conversely, the incidence of bipolar disorder in people
who abuse alcohol is several times greater than its occurrence in the general population (about 6% to 9%). [43]
Alcohol abuse is most likely to occur during manic or mixed phases.

Recent research has found that bipolar patients who abuse drugs or alcohol have an earlier onset and worse
course of illness compared with those who do not. These individuals are more likely to experience irritable and
dysphoric mood states and increased treatment resistance, and to require hospitalization. [44

DIAGNOSIS

1. Bipolar Disorder
2. Major Criteria (all must be present)
1. Persistent abnormally elevated or expansive mood
1. May present as irritability in some cases
2. Distinct period lasts at least one week
3. Does not meet criteria for mixed disorder
4. Not due to Mania Secondary Causes
5. Sufficient severity
1. Impaired work or social functioning or
2. Hospitalization required or
3. Psychosis
 3. Minor Criteria (3 or more present)
1. Inflated self esteem or grandiosity
2. Decreased need for sleep
3. Pressured speech or more talkative than usual
4. Flight of ideas or racing thoughts
5. Distractibility (derailed on irrelevant topics)
6. Increased goal directed activity
7. Excessive involvement in risky pleasurable activities
1. Unrestrained shopping sprees
2. Sexual indiscretions
3. Foolish business investments

Bipolar Disorder: Diagnostic confusion and concerning findings in youth

by Leslie E. Packer, PhD

Last Updated July 2010

PREFACE: DIAGNOSTIC DILEMMA

Bipolar Disorder is a condition in which the individual “swings” or cycles between different types of mood episodes. Bipolar Disorder
used to be called “Manic-Depression.”

For some individuals with Bipolar Disorder, there may be relatively long periods of wellness between the different mood cycles.
Adults usually do not cycle as frequently as children and adolescents.

At the present time, the diagnosis of Bipolar Disorder in children and teens continues to be somewhat controversial due to how the
diagnostic criteria are being applied (or not applied, in some cases) and due to the difficulty in distinguishing between ADHD with
severe irritability and Bipolar Disorder. If a child or teen has clear cycles of mood episodes, it is easier to make a diagnosis, but if
there are no clear cycles, then it is more difficult.

Galanter and Leibenluft (2008) have an excellent article on the diagnostic dilemma (abstract). Carlson also has an excellent editorial
(pdf) pointing out that “rages” are too often being confused with mania resulting in (inappropriate) diagnosis of Bipolar Disorder in
some cases. Children and teens with “rages” or “severe mood dysregulation” do not necessarily have Bipolar Disorder. As Carlson
points out, the diagnostic dilemma is not really between ADHD and Bipolar Disorder, but between ADHD+Oppositional Defiant
Disorder and Bipolar Disorder.

The controversy over the diagnosis of Bipolar Disorder in youth and the justification for a proposal for a new diagnosis, Temper
Dysregulation Disorder with Dysphoria, can be found on the DSM-5 web site.

In order to understand the subtypes of Bipolar Disorder, it’s necessary to understand what the different type of mood episodes are.
Major Depression (or more simply, “depression”) is covered in its own files on this site. The remaining types of mood episodes are
described below.
WHAT ARE MANIA AND HYPOMANIA?

The prefix “hypo” means “under,” so “hypomania” actually translates into “under mania,” or just below the level of (full) mania. An
individual who is hypomanic will be sleeping less (or may not sleep at all), will have a burst of energy, feel heightened focus or
creativity, a sense of increased confidence, and may be able to accomplish a lot and tackle a number of meaningful and organized
projects.

If the individual is able to control the hypomania, it is a state that may actually be very positive and pleasurable. Some of the
impulsivity and increased energy may result in spending sprees or other activities that, while not bizarre, are not what the individual
would normally do. While some aspects of hypomania are experienced as positive, the individual’s impulsivity can pose genuine
problems. Distractibility is often present, and as in mania, speech may be very rapid as the person responds to everything going on
around them.  About half of the time,  hypomania progresses into full-blown mania.

While some people think of mania as the opposite of depression, i.e., as a “high,” it is necessarily that way, although hypomania
(and early stages of mania) are associated with feelings of euphoria or exuberance.  A person who is in a manic episode may look
“mean as a snake” and not euphoric at all. The evolution of a hypomanic episode into mania might look like this:

 Manic episodes generally begin with what is experienced as an improvement or upward shift in
mood. This initially euphoric or elated mood, accompanied by decreased need for sleep is
usually experienced as an initially increased sense of energy and confidence. This is the
hypomanic state.
 As the hypomania progresses into mania, thoughts begin to race and speech becomes rapid
(pressured).  The individual may laugh often and giggle inappropriately.
 The euphoria is replaced by irritability, and in some cases, assaultiveness.
 The individual becomes more impulsive, disinhibited, and takes more risks.
 Thoughts become more disorganized, and in severe cases, delusional or psychotic.

An individual in a severely manic state is in as much danger as an individual in a major depression. Overly confident (and having
grandiose thoughts), there is an excess of what are usually thought of as “approach behaviors.” Anything the individual might seek
out while in normal mood (such as sex, alcohol or drugs, or excitement) becomes magnified. Wild spending sprees or impulsive
purchases are not uncommon, nor are impulsive marriages or major commitments. Patty Duke, the actress, in describing her manic
episodes in her autobiography, “A Brilliant Madness“, gives readers a clear picture of how devastating mania can be. During some
of her manic episodes, Ms. Duke invited a stranger and her daughter to come live with her upon hearing that the young woman had
no place to live (the woman later stole all her belongings), married a man she had met only four hours earlier, threw tantrums on the
set while working on her show, abused drugs, and would impulsively decide to move and buy a different home.

As with depression, in severe mania, the individual may experience hallucinations. With or without hallucinations, however,
individuals in severely manic states had a significant mortality rate until lithium started being prescribed. In some cases, death was
accidental, but related to the risk-taking or impulsive behaviors. In other cases, patients died of dehydration (they might neglect to
eat and drink in their manic state) or cardiovascular collapse as the body couldn’t keep up with increased psychomotor agitation and
‘racing.’

MIXED EPISODE

Some individuals may experience both depression and mania at the same time, giving rise to the notion of a “mixed episode.”
Indeed, if the predominant symptom is irritability, it may be difficult to know whether it is from depression or mania. An individual in a
mixed episode may exhibit signs of agitation, suffer from insomnia, experience changes in appetite, have some psychotic features,
and experience suicidal thinking.  Janice Papalos, co-author of The Bipolar Child, believes that mixed episodes are actually the
most dangerous type of mood episode because the individual may have the suicidal thoughts of depression combined with the
increased impulsivity and energy of mania that enables them to act on the suicidal thoughts.

SUBTYPES OF MANIA

When Kraepelin first described mania, several subtypes were described, including hypomania, acute mania, delusional mania, and
depressive or anxious mania. Cassidy et al. (2001) attempted to validate the different subtypes using a multivariate structural
analysis. They found five subtypes with good validity, and validated the major Kraepelinian subtypes noted above, but they also
identified two other subtypes involving mixed mania presentations characterized by significant mood variability. The first of these
subtypes is quite different than what we normally think of as mania, as the dominant mood was severely depressive with labile
periods of pressured, irritable hostility and paranoia and the complete absence of any euphoria or humor. The second new mixed
mania subtype they identified involved a mixture of affects: periods of classical manic symptoms (euphoria, elevated mood, humor,
grandiosity, psychosis, and psychomotor activation), switching frequently to depressed mood accompanied by anxiety and irritability.

SUBTYPES OF BIPOLAR DISORDER

Now that we’ve defined the different types of mood episodes, we can talk about the different subtypes of Bipolar Disorder (BPD).
BPD is generally classified according to the type of mood episodes the individual swings between. Simply put, the designations
simply tell us how high are the highs and how low are the lows.

 Bipolar I Disorder is characterized by at least one manic episode or mixed episode, with or
without major depression or hypomania. Most people who are hospitalized for the first time for
Bipolar Disorder are hospitalized because of mania.
 Bipolar Disorder type II is characterized by at least one episode of hypomania and at least one
episode of major depression. Some children or teens who are initially diagnosed as Bipolar I
seem to resolve into Bipolar II. Bipolar II is the most common subtype of Bipolar Disorder in
teens.
 Cyclothymic Disorder is not as severe as either Bipolar Disorder II or I, but the condition is more
chronic. The disorder lasts at least two years, with single episodes persisting for more than two
months (in adults; the criterion is 1 year for youth). Cyclothymic disorder may be a precursor to
full-blown bipolar disorder in some people or it may continue as a low-grade chronic condition.
 Bipolar – NOS is a diagnosis that is reserved for when the individual has a cycling mood disorder
that does not meet the other subtypes’ criteria.

To Bipolar Disorder subtypes and criteria may be changing when the DSM-5 comes out in a few years. To see all the proposed
changes, follow the links from the Mood Disorders page on the DSM-5 site.

SOME FINDINGS OF CONCERN IN BIPOLAR YOUTH

In a study of 300 children and adolescents, Dr. Boris Birmhauer and his colleagues found that 2.5 years after diagnosis of Bipolar
Disorder:

 Nearly 1/3 had recovered

 The remaining 2/3 took about 17 months to recover
 About 80% had at least one recurrence
 Children experienced serious symptoms about 2/3 of the time
 Children averaged 16 cycles of mood changes a year (compared to 3.5 cycles per year for adults)

Other studies have also reported data that suggest the enormous challenges that parents, their parents and educators face:

 In a longer-term study of 25 children and adolescents who had presented with mania, Jairam et
al. (2004) found that although all of the children recovered from the episode, 16 of them (64%)
relapsed after a mean period of 18 +/- 16.4 months. A majority of the relapses (72.4%) occurred
while they were adhering to their treatment.
 Geller et al. (2004) followed 86 children over a 4-year period. They found that manic episodes
persisted for 79.2 +/- 66.7 consecutive weeks, and that children were symptomatic (met criteria
for any mood episode such as depression, mixed, hypomania, or mania) 1/3 – 2/3 of time during
the 4-year period.

-###-
Diagnostic Findings in Endoscopic Screening of
Superficial Colorectal Neoplasia: Results from a
Prospective Study
1. Ikuro Koba1,
2. Shigeaki Yoshida1,
3. Takahiro Fujii1,
4. Koichi Hosokawa1,
5. Sun Hwa Park1,
6. Atsushi Ohtsu1,
7. Yasushi Oda1,
8. Kei Muro1,
9. Hisao Tajiri1 and
10. Takahiro Hasebe2
+ Author Affiliations

1. 1
Endoscopy Division, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
2. 2
Pathological Division, National Cancer Center Research Institute East, Kashiwa, Chiba,
Japan

1. For reprints and all correspondence: Takahiro Fujii, Endoscopy Division, National Cancer
Center Hospital East, 5-1, Kashiwanoha 6-chome, Kashiwa, Chiba 277, Japan

 Received March 9, 1998.

 Accepted June 17, 1998.

 
Next Section

Abstract
Background: A prospective study was carried out to clarify the efficacy of an endoscopic screening
program for detecting superficial colorectal neoplasias by color changes such as faint redness or
discoloration, which have been described as a key finding of these lesions in the literature.

Methods: We enrolled 716 consecutive cases in this study, but more than half of them did not reveal
any abnormalities colonoscopically.

Results: Of the 716 cases, 48 (7%) were examined by magnifying colonoscopy with a dye spraying
technique, following the detection of superficial color changes. Sixteen neoplastic lesions (in 16
cases) were detected among the 48 cases and the detection rate was calculated as 2.2% (16/716) in
the total number of cases and 33% (16/48) in those showing color abnormalities. Histologically, all
of the 16 were adenomas. These neoplastic lesions were most frequent (52%; 11/21) in those
showing faint redness in an oval shape, whereas 14 (94%) of the 15 lesions were non-specific in
those showing faint redness with unclear margin.

Conclusions: These results may confirm the diagnostic utility of color abnormality, particularly faint
redness in an oval shape, for endoscopic screening of superficial colorectal neoplasias.

Key words

Key words

 endoscopic screening

 superficial colorectal neoplasia

 faint redness

Previous SectionNext Section

Introduction
With the substantial progress in colonoscopy recently, a number of cases with non-polypoid
superficial or depressed colorectal neoplasias have been reported. Also, the previous literature has
described the diagnostic utility of color changes such as faint redness or discoloration in these
lesions. Nevertheless, the above consideration was based on retrospective observations and the
actual utility has not yet been confirmed. In other words, colonoscopic abnormalities of such lesions
are usually so faint that in practice most of them are detected by subjective, empirical or incidental
diagnosis.

This paper attempts to clarify the diagnostic utility of color patterns for endoscopic screening of
superficial colorectal neoplasias, employing a prospective study.

Previous SectionNext Section

Subjects and Method

During the period between April and August 1994, 716 consecutive cases of total colonoscopy, the
subjects of this study, had been examined at the National Cancer Center Hospital East (NCCHE). All
of the cases were entered into a prospective study consisting of the following steps: (i) colonoscopic
screening for color abnormalities; (ii) description in detail of color change, if assessed as diagnostic;
(iii) magnifying colonoscopy using a CF-2002 (Olympus); (iv) dye spraying observation with
indigocarmine with both conventional and high-power magnification; and (v) endoscopic mucosal
resection (EMR), if a neoplastic crypt pattern is suggested (1,2). Endoscopic pictures were taken in
every step of observation and the hard copies were put on the report form for each case. Resected
specimens were examined under stereomicroscopy with Karachi-hematoxylin staining for
determining their crypt patterns and the final diagnosis was made histopathologically.

For the clinicopathological classification of colorectal neoplasias in this study, we adopted The
General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus defined
by the Japanese Research Society for Cancer of the Colon and Rectum (3).

Table 1

Number of lesions examined in each step of the screening in the prospective study

Table 2

Endoscopic findings and histological diagnosis of lesions in the prospective study

Table 3
Macroscopic type and LC sign of 16 neoplastic lesions in the prospective study

Previous SectionNext Section

Results
Table 1 shows the number of lesions examined in each step of the screening. Of the 716 cases
enrolled, more than half did not reveal any abnormalities, 48 (7%) were examined by magnifying
colonoscopy with the dye spraying technique following the detection of a color change and finally 18
(2.5%) were operated on with EMR, because a neoplastic crypt pattern was suspected in magnifying
colonoscopy. The resected 18 lesions in 18 cases consisted of 16 adenomas and 2 hyperplasias
histologically.

Table 2 shows the endoscopic findings of the color patterns and the final histological diagnosis of
the above 48 lesions in 48 cases. The color patterns were classified into four categories: (i) faint
redness in an oval shape, (ii) faint redness with unclear margin, (iii) discoloration and (iv) normal
colored with loss of original capillary pattern (LC sign). Neoplastic lesions were most frequent (52%;
11/21 ) in the lesions showing faint redness in an oval shape, whereas 14 (94%) of the 15 lesions
were non-specific in those showing faint redness with an unclear margin. Concerning the site
distribution of these cases, lesions of oval shape with faint redness were frequently seen in the
sigmoid colon, whereas those with an unclear margin of faint redness occurred in the transverse
colon.

Figure 1

Conventional colonoscopy of case 1. Faint redness in an oval shape was noted.

Figure 2

Dye spraying endoscopy of case 1. The lesion showed a depressed component surrounded by gently
sloped elevation (type IIc + IIa).

Table 3 shows the macroscopic types and the presence or absence of LC sign for the 16 neoplasias.
In the lesions of type IIc, although a small number of cases, LC sign was more frequently seen than
in the other types.

Previous SectionNext Section

Case Presentation
Case 1: 45-year-old Female
The diagnostic finding with conventional colonoscopy was faint redness in an oval shape (Fig. 1). Dye
spraying endoscopy revealed a depressed component surrounded by a gently sloped elevation (type
IIc + IIa; Fig. 2). EMR was carried out and the histological examination of the resected specimen
revealed that it was a colonic adenoma with moderate atypia (Fig. 3).
Figure 3

Histological finding of case 1 (H&E stain, original magnification ×40). The resected specimen was
diagnosed as colonic adenoma with moderate atypia.

Figure 4

Conventional colonoscopy of case 2. Faint redness was noted and the margin of redness was
unclear.

Case 2: 56-year-old Female

Faint redness was noted in the sigmoid colon during the screening colonoscopy (Fig. 4). Although it
is suggestive of a neoplastic lesion, the margin of redness was unclear and dye spraying endoscopy
revealed an intact capillary network and innominate grooves (Fig. 5). Because the crypt patterns by
magnifying colonoscopy were non-neoplastic, this lesion was not resected by EMR in this
prospective study. Biopsy was carried out and revealed normal mucosa.

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Discussion
Since Yoshida et al. (4) stressed the importance of detecting early gastric cancer showing faint
mucosal irregularity (gastritis-like type), which is easily overlooked and mostly found in advanced
stages, greater attention has been paid to the faint color and structural abnormalities of
gastrointestinal mucosa. As a result, there has been a general acceptance in Japan that early
gastrointestinal malignancies may not appear polypoid or ulcerative. In the field of colorectal cancer,
Kudo et al. (1), pioneers of the diagnosis of type IIc (superficial depressed) early colorectal cancer,
reported the importance of detecting color changes, particularly faint redness or discoloration, as a
diagnostic finding of this type, which includes high malignant potential (high incidence of deeper
invasion even when the lesion is small). The diagnostic findings as mentioned above, however, were
based on the results of retrospective observation and their efficacy in endoscopic screening has not
yet been confirmed.

Figure 5

Dye spraying endoscopy of case 2. Capillary network and innominate grooves were seen and the
crypt patterns by magnifying colonoscopy were non-neoplastic.
We therefore employed a prospective stud y and it demonstrated that colonoscopic screening based
on color abnormality gave a considerable detection rate of superficial neoplastic lesions. In addition,
color abnormality, particularly faint redness in an oval shape, was very frequent in neoplastic lesion s
whereas that with an unclear margin was mostly non-specific. In addition, although there was a
smaller number of cases, LC sign was more frequently seen in type IIc than in the other types. These
results may indicate that it is valid to perform colonoscopic screening of superficial neoplasias based
on color patterns of faint redness in an oval shape and that LC sign will be helpful for detecting type
IIc.

In the latter days of detailed colonoscopy, when Kudo et aI. (1) initially reported a considerable
number of type IIc early cancers, most Japanese colonoscopists regarded this type as a kind of
endemic disease in Akita prefecture where Kudo's group was located. In spite of this, early diagnosis
of type IIc is now widespread in Japan, following great educational efforts by Kudo and his group.
Very recently (after this study), type IIc colonic cancer was also detected in the UK by Rembacken (5),
who had been trained in our hospital, indicating that the diagnostic findings which we have
presented here can be useful for screening superficial colorectal neoplasia, regardless of
geographical considerations, although diagnosing faint mucosal abnormalities still tends to be
subjective or empirical.

After the detection of the mucosal abnormality, the dye spraying technique is indispensable to
confirm the findings in detail. As shown in the case presentation, the presence or absence of a
depressed component cannot be assessed without this technique, particularly in a small lesion. Good
colorectal preparation and colonoscopic skills are also obviously indispensable for detecting and
treating (EMR) superficial neoplasia.

The detection rate of superficial neoplasia in our prospective study was 2.2% (0.6% in type IIc). It may
be debatable whether this incidence is meaningful or not, but no other papers have reported the
detection rate of superficial colonic neoplasia. The detection rate of type IIc early invasive cancer is
reported to be approximately 0.1% in colonoscopic examinations. Considering this, our result of
0.6% in type IIc seems to be satisfactory.

 © 1998 Foundation for Promotion of Cancer Research