Conventional white light colonoscopy is widely accepted as a primary method of screening and the standard method of surveillance for premalignant colorectal lesions and cancer. However, conventional colonoscopy has a substantial miss rate and is operator dependent with regard to detection of premalignant lesions and even cancer. Conventional colonoscopy also results in resection of lesions that are not premalignant, thereby, producing unnecessary costs and risks to patients. Recent developments in endoscopic imaging have focused on these two issues of improving lesion detection and characterizing histology of detected lesions in real time. Attempts to improve detection have generally been unsuccessful, though high-definition optics appears promising in this regard. On the other hand, diagnosis of the histology of detected lesions has proven feasible using a variety of methods. This chapter will review the new developments in endoscopic imaging of colorectal polyps and cancer.