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“Red” is indistinguishable from “red.” Pooling of blood in the colon is often encountered during urgent colonoscopy and is reportedly useful for detecting the lesion responsible for acute lower gastrointestinal bleeding [1]. However, discerning active or recent bleeding is cumbersome in an environment containing blood that has accumulated over various time points. The novel image-enhanced endoscopic technique, red dichromatic imaging (RDI), may overcome this problem. It clearly demarcates active bleeding from the surrounding residual blood based on the color-contrast principle (i. e. the difference in the target’s hemoglobin concentration and thickness) [2]. A 66-year-old man was admitted to our hospital with hematochezia. Contrastenhanced computed tomography revealed extravasation in the ascending colon (▶Fig. 1). Urgent colonoscopy was performed using the CF-HQ290I enteroscope (equipped with a waterjet) and EVIS X1 device (Olympus Co., Tokyo, Japan) after bowel preparation with polyethylene glycol (PEG). Massive blood pooling was observed in the ascending colon (▶Fig. 2 a), which hindered endoscopic vision and obscured the bleeding points. Upon switching from white-light endoscopy (WLE) to the RDI mode, an amber stream, clearly demarcated from the translucent surroundings, was identified at the medial aspect of the ascending colon (▶Fig. 2b). The amber stream was found to be fresh blood or active bleeding, while the surrounding environment contained blood diluted with PEG. The causative diverticulum with active bleeding from the dome was successfully identified on RDI, having been obscured by residual blood on WLE (▶Fig. 3,▶Video 1). Hemostasis was successfully achieved using endoscopic band ligation. The patient was discharged 5 days after treatment without any rebleeding or adverse events. This case demonstrated the clinical utility of the RDI mode, which enhances only fresh blood that is otherwise missed on WLE and may help to identify the lesion responsible for bleeding, especially in the presence of residual blood in the colon.

Tracking the target in colonic diverticular bleeding using red dichromatic imaging