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 oneƞs 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 oneƞs 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 ³swings´ or cycles between different types of mood episodes. Bipolar Disorder
used to be called ³Manic-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 ³rages´ are too often being confused with mania resulting in (inappropriate) diagnosis of Bipolar Disorder in
some cases. Children and teens with ³rages´ or ³severe 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, ³depression´) 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 ³hypo´ means ³under,´ so ³hypomania´ actually translates into ³under 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 ³high,´ 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
³mean as a snake´ and not euphoric at all. The evolution of a hypomanic episode into mania might look like this:
y 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.
y As the hypomania progresses into mania, thoughts begin to race and speech becomes rapid
(pressured). The individual may laugh often and giggle inappropriately.
y The euphoria is replaced by irritability, and in some cases, assaultiveness.
y The individual becomes more impulsive, disinhibited, and takes more risks.
y 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 ³approach 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, ³A Brilliant Madness³, 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
µracing.¶
MIXED EPISODE
Some individuals may experience both depression and mania at the same time, giving rise to the notion of a ³mixed 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.
y 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.
y 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.
y 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.
y Bipolar ʹ NOS is a diagnosis that is reserved for when the individual has a cycling mood disorder
that does not meet the other subtypes͛ 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:
y Nearly 1/3 had recovered
y The remaining 2/3 took about 17 months to recover
y About 80% had at least one recurrence
y Children experienced serious symptoms about 2/3 of the time
y 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:
y 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.
y 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 ʹ 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 Kobu
1
,
2. Shlgeukl Yoshldu
1
,
3. Tukuhlro Fu|ll
1
,
4. Kolchl Hosokuwu
1
,
5. Sun Hwu Purk
1
,
6. Atsushl Ohtsu
1
,
7. Yusushl Odu
1
,
8. Kel Muro
1
,
9. Hlsuo Tu|lrl
1
und
10. Tukuhlro Husebe
2

Author Afflllutlons
1.
1
Endoscopy Dl+lslon, Nutlonul Cuncer Center Hospltul Eust, Kushlwu, Chlbu, Jupun
2.
2
Futhologlcul Dl+lslon, Nutlonul Cuncer Center Peseurch Instltute Eust, Kushlwu, Chlbu, Jupun
1. For reprlnts und ull correspondence: Tukuhlro Fu|ll, Endoscopy Dl+lslon, Nutlonul Cuncer Center Hospltul
Eust, 5-1, Kushlwunohu 6-chome, Kushlwu, Chlbu 277, Jupun
y 5ecel+ed Murch 9, 1998.
y Accepted June 17, 1998.

Next Sectlon
Abstract
%uckground: A prospectl+e study wus currled out to clurlfy the efflcucy of un endoscoplc screenlng progrum for
detectlng superflclul colorectul neopluslus by color chunges such us fulnt redness or dlscolorutlon, whlch huve been
descrlbed us u key flndlng of these leslons ln the llteruture.
Methods: We enrolled 716 consecutlve cuses ln thls study, but more thun hulf of them dld not reveul uny
ubnormulltles colonoscoplcully.
5esults: Of the 716 cuses, 48 (7%) were exumlned by mugnlfylng colonoscopy wlth u dye spruylng technlque,
followlng the detectlon of superflclul color chunges. Slxteen neoplustlc leslons (ln 16 cuses) were detected umong
the 48 cuses und the detectlon rute wus culculuted us 2.2% (16/716) ln the totul number of cuses und 33% (16/48) ln
those showlng color ubnormulltles. Hlstologlcully, ull of the 16 were udenomus. These neoplustlc leslons were most
frequent (52%; 11/21) ln those showlng fulnt redness ln un ovul shupe, whereus 14 (94%) of the 15 leslons were
non-speclflc ln those showlng fulnt redness wlth uncleur murgln.
Concluslons: These results muy conflrm the dlugnostlc utlllty of color ubnormullty, purtlculurly fulnt redness ln un
ovul shupe, for endoscoplc screenlng of superflclul colorectul neopluslus.

Key words
y endoscoplc screenlng
y superflclul colorectul neopluslu
y fulnt redness
Prevlous SectlonNext Sectlon
Introduction
Wlth the substuntlul progress ln colonoscopy recently, u number of cuses wlth non-polypold superflclul or depressed
colorectul neopluslus huve been reported. Also, the prevlous llteruture hus descrlbed the dlugnostlc utlllty of color
chunges such us fulnt redness or dlscolorutlon ln these leslons. Nevertheless, the ubove conslderutlon wus bused on
retrospectlve observutlons und the uctuul utlllty hus not yet been conflrmed. In other words, colonoscoplc
ubnormulltles of such leslons ure usuully so fulnt thut ln pructlce most of them ure detected by sub|ectlve, emplrlcul
or lncldentul dlugnosls.
Thls puper uttempts to clurlfy the dlugnostlc utlllty of color putterns for endoscoplc screenlng of superflclul colorectul
neopluslus, employlng u prospectlve study.
Prevlous SectlonNext Sectlon
Subjects and Method
Durlng the perlod between Aprll und August 1994, 716 consecutlve cuses of totul colonoscopy, the sub|ects of thls
study, hud been exumlned ut the Nutlonul Cuncer Center Hospltul Eust (NCCHE). All of the cuses were entered lnto
u prospectlve study conslstlng of the followlng steps: (l) colonoscoplc screenlng for color ubnormulltles; (ll)
descrlptlon ln detull of color chunge, lf ussessed us dlugnostlc; (lll) mugnlfylng colonoscopy uslng u CF-2002
(Olympus); (lv) dye spruylng observutlon wlth lndlgocurmlne wlth both conventlonul und hlgh-power mugnlflcutlon;
und (v) endoscoplc mucosul resectlon (EM5), lf u neoplustlc crypt puttern ls suggested (1,2). Endoscoplc plctures
were tuken ln every step of observutlon und the hurd coples were put on the report form for euch cuse. 5esected
speclmens were exumlned under stereomlcroscopy wlth Kuruchl-hemutoxylln stulnlng for determlnlng thelr crypt
putterns und the flnul dlugnosls wus mude hlstoputhologlcully.
For the cllnlcoputhologlcul clusslflcutlon of colorectul neopluslus ln thls study, we udopted The Generul 5ules for
Cllnlcul und Puthologlcul Studles on Cuncer of the Colon, 5ectum und Anus deflned by the Jupunese 5eseurch
Soclety for Cuncer of the Colon und 5ectum (3).

Tuble 1
Number of leslons exumlned ln euch step of the screenlng ln the prospectlve study

Tuble 2
Endoscoplc flndlngs und hlstologlcul dlugnosls of leslons ln the prospectlve study

Tuble 3
Mucroscoplc type und LC slgn of 16 neoplustlc leslons ln the prospectlve study
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Results
Tuble 1 shows the number of leslons exumlned ln euch step of the screenlng. Of the 716 cuses enrolled, more thun
hulf dld not reveul uny ubnormulltles, 48 (7%) were exumlned by mugnlfylng colonoscopy wlth the dye spruylng
technlque followlng the detectlon of u color chunge und flnully 18 (2.5%) were operuted on wlth EM5, becuuse u
neoplustlc crypt puttern wus suspected ln mugnlfylng colonoscopy. The resected 18 leslons ln 18 cuses conslsted of
16 udenomus und 2 hyperpluslus hlstologlcully.
Tuble 2 shows the endoscoplc flndlngs of the color putterns und the flnul hlstologlcul dlugnosls of the ubove 48
leslons ln 48 cuses. The color putterns were clusslfled lnto four cutegorles: (l) fulnt redness ln un ovul shupe, (ll) fulnt
redness wlth uncleur murgln, (lll) dlscolorutlon und (lv) normul colored wlth loss of orlglnul cuplllury puttern (LC
slgn). Neoplustlc leslons were most frequent (52%; 11/21 ) ln the leslons showlng fulnt redness ln un ovul shupe,
whereus 14 (94%) of the 15 leslons were non-speclflc ln those showlng fulnt redness wlth un uncleur murgln.
Concernlng the slte dlstrlbutlon of these cuses, leslons of ovul shupe wlth fulnt redness were frequently seen ln the
slgmold colon, whereus those wlth un uncleur murgln of fulnt redness occurred ln the trunsverse colon.

Flgure 1
Conventlonul colonoscopy of cuse 1. Fulnt redness ln un ovul shupe wus noted.

Flgure 2
Dye spruylng endoscopy of cuse 1. The leslon showed u depressed component surrounded by gently sloped
elevutlon (type IIc IIu).
Tuble 3 shows the mucroscoplc types und the presence or ubsence of LC slgn for the 16 neopluslus. In the leslons of
type IIc, ulthough u smull number of cuses, LC slgn wus more frequently seen thun ln the other types.
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Case Presentation
Case 1: 45-year-old Female
The dlugnostlc flndlng wlth conventlonul colonoscopy wus fulnt redness ln un ovul shupe (Flg. 1). Dye spruylng
endoscopy reveuled u depressed component surrounded by u gently sloped elevutlon (type IIc IIu; Flg. 2). EM5
wus currled out und the hlstologlcul exumlnutlon of the resected speclmen reveuled thut lt wus u colonlc udenomu
wlth moderute utyplu (Flg. 3).

Flgure 3
Hlstologlcul flndlng of cuse 1 (H&E stuln, orlglnul mugnlflcutlon ×40). The resected speclmen wus dlugnosed us
colonlc udenomu wlth moderute utyplu.

Flgure 4
Conventlonul colonoscopy of cuse 2. Fulnt redness wus noted und the murgln of redness wus uncleur.
Case 2: 56-year-old Female
Fulnt redness wus noted ln the slgmold colon durlng the screenlng colonoscopy (Flg. 4). Although lt ls suggestlve of
u neoplustlc leslon, the murgln of redness wus uncleur und dye spruylng endoscopy reveuled un lntuct cuplllury
network und lnnomlnute grooves (Flg. 5). %ecuuse the crypt putterns by mugnlfylng colonoscopy were non-
neoplustlc, thls leslon wus not resected by EM5 ln thls prospectlve study. %lopsy wus currled out und reveuled
normul mucosu.
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Discussion
Slnce Yoshldu et ul. (4) stressed the lmportunce of detectlng eurly gustrlc cuncer showlng fulnt mucosul lrregulurlty
(gustrltls-llke type), whlch ls euslly overlooked und mostly found ln udvunced stuges, greuter uttentlon hus been puld
to the fulnt color und structurul ubnormulltles of gustrolntestlnul mucosu. As u result, there hus been u generul
ucceptunce ln Jupun thut eurly gustrolntestlnul mullgnuncles muy not uppeur polypold or ulcerutlve. In the fleld of
colorectul cuncer, Kudo et ul. (1), ploneers of the dlugnosls of type IIc (superflclul depressed) eurly colorectul cuncer,
reported the lmportunce of detectlng color chunges, purtlculurly fulnt redness or dlscolorutlon, us u dlugnostlc flndlng
of thls type, whlch lncludes hlgh mullgnunt potentlul (hlgh lncldence of deeper lnvuslon even when the leslon ls
smull). The dlugnostlc flndlngs us mentloned ubove, however, were bused on the results of retrospectlve observutlon
und thelr efflcucy ln endoscoplc screenlng hus not yet been conflrmed.

Flgure 5
Dye spruylng endoscopy of cuse 2. Cuplllury network und lnnomlnute grooves were seen und the crypt putterns by
mugnlfylng colonoscopy were non-neoplustlc.
We therefore employed u prospectlve stud y und lt demonstruted thut colonoscoplc screenlng bused on color
ubnormullty guve u conslderuble detectlon rute of superflclul neoplustlc leslons. In uddltlon, color ubnormullty,
purtlculurly fulnt redness ln un ovul shupe, wus very frequent ln neoplustlc leslon s whereus thut wlth un uncleur
murgln wus mostly non-speclflc. In uddltlon, ulthough there wus u smuller number of cuses, LC slgn wus more
frequently seen ln type IIc thun ln the other types. These results muy lndlcute thut lt ls vulld to perform colonoscoplc
screenlng of superflclul neopluslus bused on color putterns of fulnt redness ln un ovul shupe und thut LC slgn wlll be
helpful for detectlng type IIc.
In the lutter duys of detulled colonoscopy, when Kudo et uI. (1) lnltlully reported u conslderuble number of type IIc
eurly cuncers, most Jupunese colonoscoplsts regurded thls type us u klnd of endemlc dlseuse ln Akltu prefecture
where Kudo's group wus locuted. In splte of thls, eurly dlugnosls of type IIc ls now wldespreud ln Jupun, followlng
greut educutlonul efforts by Kudo und hls group. Very recently (ufter thls study), type IIc colonlc cuncer wus ulso
detected ln the UK by 5embucken (5), who hud been trulned ln our hospltul, lndlcutlng thut the dlugnostlc flndlngs
whlch we huve presented here cun be useful for screenlng superflclul colorectul neopluslu, regurdless of
geogruphlcul conslderutlons, ulthough dlugnoslng fulnt mucosul ubnormulltles stlll tends to be sub|ectlve or
emplrlcul.
After the detectlon of the mucosul ubnormullty, the dye spruylng technlque ls lndlspensuble to conflrm the flndlngs ln
detull. As shown ln the cuse presentutlon, the presence or ubsence of u depressed component cunnot be ussessed
wlthout thls technlque, purtlculurly ln u smull leslon. Good colorectul prepurutlon und colonoscoplc skllls ure ulso
obvlously lndlspensuble for detectlng und treutlng (EM5) superflclul neopluslu.
The detectlon rute of superflclul neopluslu ln our prospectlve study wus 2.2% (0.6% ln type IIc). It muy be debutuble
whether thls lncldence ls meunlngful or not, but no other pupers huve reported the detectlon rute of superflclul
colonlc neopluslu. The detectlon rute of type IIc eurly lnvuslve cuncer ls reported to be upproxlmutely 0.1% ln
colonoscoplc exumlnutlons. Conslderlng thls, our result of 0.6% ln type IIc seems to be sutlsfuctory.

y k 1998 Foundutlon for Promotlon of Cuncer 5eseurch