13 New Recommendations for Surveilling and Managing Colorectal Dysplasia in Patients With IBD

David A. Johnson, MD


October 20, 2021

Inflammatory bowel disease (IBD) has a well-established association with the development of colorectal cancer, with both ulcerative colitis and Crohn's disease known to increase the risk for this malignancy.

Guidelines have consistently recommended colonoscopic surveillance beginning at 8 years after the onset of IBD symptoms in order to determine the extent of disease and to establish surveillance intervals. Historically, it has been the standard recommendation while the patient has quiescent disease for four-quadrant biopsies to be performed, randomly taken every 10 cm, with additional targeted biopsies of focal mucosal lesions suspect for dysplasia.

Until recently, the identification of dysplasia in the colon was a general indication for total colectomy. However, contemporary advances in detection and endoscopic resection of focal lesions have established a new standard for best practice management, in most cases sparing patients from the morbidity of surgical colectomy.

With such recent changes in mind, the American Gastroenterological Association convened an expert panel to provide new recommendations on the endoscopic surveillance and management of colorectal dysplasia in IBD. This viewpoint highlights the top 13 "best practice" recommendations from that review.

Recommendation #1

Suspect dysplastic lesions should be characterized as polypoid (elevation of ≥ 2.5 mm), nonpolypoid, or invisible (detected on random biopsy). In turn, experts recommend abandoning older terms such as "dysplasia-associated mass or lesion."

Recommendation #2

In patients with primary sclerosing cholangitis (PSC), colon surveillance should begin immediately upon diagnosis and not wait for the standard 8-year interval following symptom onset that was previously recommended.

Recommendation #3

A careful inspection of all mucosal areas to identify any suspicious abnormalities is best achieved by the use of high-definition scopes and meticulous washing practices.

Recommendation #4

Endoscopic resection is safe and preferred to biopsies of focal lesions when they are well demarcated and not suspected for invasive cancer or submucosal fibrosis. If the lesion is not suspected of having more advanced neoplasia, resection should be performed by an expert in this technique or referred to a specialized center of excellence.

Recommendation #5

Adjunctive measures to enhance detection of dysplasia should be used by appropriately trained endoscopists in all patients, particularly in those with PSC, a history of dysplasia, or when a high-definition scope is not used.

Recommendation #6

Chromoendoscopy via dye spray can be done using indigo carmine (0.03%-0.1%) or methylene blue (0.04%-0.1%) for general exam. The use of more concentrated dye (0.13% or 0.2%, respectively) is sometimes recommended if a suspicious area is identified, as this helps better define the lesion pit patterns and borders.

In my institution's lab, the 0.03% concentration of indigo carmine is achieved by mixing 10 mL of indigo carmine 0.8% with 250 mL of water, whereas the more concentrated solution of 0.13% is achieved by mixing 5 mL of indigo carmine with 25 mL of water. This dye coats the mucosal surface immediately.

The 0.04% concentration solution of methylene blue is achieved by mixing 10 mL of methylene blue 1% with 240 mL of water, whereas the 0.2% concentration is achieved by mixing 10 mL of methylene blue with 40 mL of water. Unlike indigo carmine, methylene blue takes approximately 1 minute before full effect to visualize dysplastic and inflamed tissues, which absorb less dye.

Recommendation #7

Virtual chromoendoscopy (VCE) is a suitable alterative to the dye spray option. This can include narrow-band imaging, i-scan, or color enhancement. Notably, data comparing VCE and dye spray have reported that these methods are similar in their ability to detect dysplasia.

Recommendation #8

Nontargeted biopsies are not needed routinely if dye spray or VCE is performed, unless there is a history of PSC or prior dysplasia.

Recommendation #9

Detection of "invisible dysplasia" (ie, not by directed biopsies) should prompt repeat colonoscopy by an expert endoscopist who uses high-definition scopes and advanced imaging techniques. Detection of multifocal dysplasia or high-grade dysplasia following that examination should prompt surgical referral for colectomy.

Recommendation #10

Following the index colonoscopy screening, repeat recommendations should be based on the associated relative risks. For PSC or prior dysplasia, the recommendation remains to conduct annual exams. Previously, the traditional intervals have been every 2 years, decreasing to yearly after age 50 years. With the improvements in imaging and endoscopic management, however, there is increasing evidence that these intervals can be moved to every 5 years in low-risk individuals with well-controlled disease. Intervals should be 2-3 years if there is any question regarding adequacy of treatment or dysplasia risks.

Recommendation #11

Patients with isolated small bowel Crohn's disease do not have an incremental risk for colorectal cancer and can be followed according to the surveillance recommendations for those at average risk.

Recommendation #12

Surveillance of a J-pouch should be done annually if a patient has a history of prior dysplasia or colon cancer, PSC, or persistent moderate to severe pouchitis. Patients without these risk factors have a lower colorectal cancer incidence than the general non-IBD population. The British Society of Gastroenterology recommends that such patients undergo surveillance in 5-year intervals.

Recommendation #13

For pseudopolyps, targeted biopsy/removal is recommended only if dysplasia is suspected.

A Shift in Management Strategies

There has been an evidence-based paradigm shift in the management strategies for dysplasia screening and management in IBD. New approaches call for inspection and targeted sampling performed by an expert, particularly one who is using a high-definition scope and advanced imaging techniques. Referral for surgical colon resection of lesions should only occur when — after examination by an expert — they are deemed not amenable to endoscopic resection, the same approach that we should employ for non-IBD patients with large polyps.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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