EDITORIAL
Artificial intelligence for the detection of gastric
precancerous conditions using image-enhanced endoscopy:
What kind of abilities are required for application in
real-world clinical practice?
The term “artificial intelligence” (AI) is used to describe
machines that think like humans. It was coined by the
computer scientist John McCarthy at the 1956 Dartmouth
workshop in the United States. Although there is no fixed
definition, AI is the simulation of human intelligence pro-
cesses by machines, especially computer systems. Image
recognition, a type of pattern recognition technology that
uses the features of images and videos to identify objects,
is one field of AI research. AI image recognition has
advanced significantly since the development of convolu-
tional neural networks (CNN), a typical method of deep
learning (a type of machine learning). Deep learning ex-
hibited dramatic progress over conventional methods
such as Bag-of-Visual Words at the 2012 ImageNet Large
Scale Visual Recognition Challenge (ILSVRC), a major AI
image recognition contest. In 2015, AI achieved a lower er-
ror rate than did humans, demonstrating its greater image
recognition capacity. After improvements in computer per-
formance, many reports mentioned the use of AI to sup-
port software for diagnostic imaging, particularly in the
fields of radiology,1 dermatology,2 and pathology.3
Endoscopic diagnosis of GI tract lesions uses pattern
recognition to identify lesions from images. Hence, it is
very compatible with AI and is currently being devel-
oped.4,5 With medical devices such as CT and MRI
scanners, the diagnosis is usually made from saved
images after the imaging examination. However, in GI
endoscopy, the endoscopist performs operations and
simultaneously makes the diagnosis while viewing the
images displayed on a monitor. Thus, high-level observa-
tional and imaging skills are required even from nonexpert
endoscopistsda situation different from the use of AI to
support modalities such as CT and MRI.
AI endoscopies can be broadly divided into lesion detec-
tion and differential diagnosis. Lesion detection is currently
the subject of much research4 and has been the most
useful and common application of AI in the field of GI
endoscopy to date. Observation of the digestive tract
makes it possible to detect obscure lesions, thereby
Copyright ª 2021 by the American Society for Gastrointestinal Endoscopy
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improving the discovery rate of lesions that might have
been otherwise overlooked. In contrast, differential
diagnosis of a lesion’s stage or classification goes a step
further than the use of automatic software to detect
abnormalities, which required precise endoscopic
manipulations. Further, for an endoscopic diagnosis,
multiple findings must be assessed in an integrated manner,
resulting in a complicated diagnostic process that must also
be addressed. A problem faced by endoscopists is the
If the goal is to make diagnoses by nonexperts
more uniform, it is important for AI to be
capable of providing auxiliary diagnoses from
lower-quality images acquired through endos-
copies performed by nonexperts. Learning
how to use low-quality images may help create
more robust AI diagnostic systems.
attainment of the advanced manipulation skills required to
identify sites for diagnosis by performing magnifying
endoscopic observations. Thus, nonexperts, who are most
in need of diagnostic support, find it difficult to obtain high-
quality images for diagnosis. To date, research has indicated
that a differential diagnosis comparable with that made by a
GI endoscopist may be possible with the use of AI with
CNN and high-quality images.6 From this perspective, it is of
great interest to read the article by Xu et al,7 which
describes the development of a deep CNN system to
evaluate endoscopic images of gastric precancerous
conditions by image-enhanced endoscopy, through video
clips, to perform computer-aided detection (CADe) in real
time in clinical practice.
Regarding diagnostic abilities, CADe has achieved diag-
nostic sensitivity and specificity similar to those of experts
and superior to those of nonexperts for detecting gastric
atrophy (CADe, experts, and nonexperts, sensitivity
0.873, 0.912, and 0.828, respectively; and specificity,
0.861, 0.715, and 0.594, respectively) and intestinal meta-
plasia (CADe, experts, and nonexperts, sensitivity 0.901,
0.828, and 0.738, respectively; and specificity, 0.861,
Volume 94, No. 3 : 2021 GASTROINTESTINAL ENDOSCOPY 549
Editorial
0.806, and 0.733, respectively). These results of CADe were
similar to those of another systematic review for the diag-
nosis of intestinal metaplasia with narrow-band imaging
(NBI) (pooled sensitivity 0.86 and specificity 0.77).8
However, in actual clinical practice, differentiating images
that are easily understandable is not as important as the
ability to correctly differentiate images that are difficult to
understand. In other words, low-confidence images are
the ones that need AI-assisted diagnosis when the diag-
nosis is made by expert endoscopists. Even if the correct
diagnosis rate for high-confidence images does not surpass
that of experts, a comparable rate is acceptable for practical
use. However, if AI is unable to establish the correct diag-
nosis in instances where physicians can, the reliability of
the AI diagnosis becomes questionable.9 If the correct
diagnosis rate is higher with AI than with expert
endoscopists for the diagnosis of low-confidence images,
AI may provide useful assistance. We understand that the
present study used an experimental design; however, we
expect further development of AI systems from the
perspective mentioned above.
Considering robustness, poor-quality images showing
halation, blurs, defocus, and mucus taken by 2 doctoral
students were excluded from the study. Therefore, a total
of 106 poor-quality images taken by magnifying endoscopy
with narrow-band imaging/blue-laser imaging (ME-NBI/BLI)
from 1180 patients were retrospectively excluded from 2
internal sets, and 159 poor-quality ME-NBI/BLI images
from 616 patients were retrospectively excluded from 3
external sets. After quality control evaluation, 90% of the
5198 ME-NBI/BLI images were selected from 547 patients
and were used as training images. However, it is important
for nonexperts lacking established endoscopic skills to be
able to make diagnoses not only from good-quality images
but also from lower-quality images. This study did not
describe the degree of blurring and defocus in the images
that were excluded. If the goal is to make diagnoses by
nonexperts more uniform, it is important for AI to be
capable of providing auxiliary diagnoses from lower-
quality images acquired through endoscopies performed
by nonexperts. Learning how to use low-quality images
may help create more robust AI diagnostic systems.10
Considering the configuration of other practical systems,
we suspect that the current model may require much
more real-world training data.5
Further advances in image sensors will provide ultra-
high resolution and sensitivity and will also enable the
simultaneous acquisition of white-light and NBI images;
we expect that this will lead to the development of special-
ized AI endoscopes that can perform markings and issue
warnings through AI image processing of magnifying NBI
images in the background of white-light observation.
With these endoscopes, even nonexperts without estab-
lished endoscopic skills may be capable of performing
550 GASTROINTESTINAL ENDOSCOPY Volume 94, No. 3 : 2021
Yoshida & Tanaka
endoscopic diagnosis at a level similar to that of an expert.
However, despite the lack of development for such an im-
age sensor, AI endoscopy is a rapidly growing area of
research. Therefore, AI may provide auxiliary diagnoses
that are clinically useful even at present, and progress
may be possible in terms of supplementing the weaker
points in diagnoses made by endoscopists.
DISCLOSURE
Both authors disclosed no financial relationships.
Shigeto Yoshida, MD, PhD
Department of Gastroenterology
J R Hiroshima Hospital
Shinji Tanaka, MD, PhD
Department of Endoscopy
Hiroshima University Hospital
Hiroshima, Japan
Abbreviations: AI, artificial intelligence; CADe, computer-aided
detection; CNN, convolutional neural networks; ME-NBI/BLI,
magnifying endoscopy with narrow-band imaging/blue laser imaging;
NBI, narrow-band imaging.
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