Colorectal carcinoma surveillance

Perform a screening colonoscopy 6-8 years after symptom onset in those with Crohn’s disease. Thereafter, some national organizations recommend interval surveillance based on the most recent colonoscopy and risk stratification as follows:

Future surveillance not indicated:

  • Absence of colonic inflammation

5-yearly colonoscopy:

  • Colitis affecting less than 50% of the colon surface area
  • Extensive colitis with mild endoscopic or histological active inflammation

3-yearly colonoscopy:

  • Post-inflammatory polyps
  • Colorectal cancer in a first-degree relative older than 50 years
  • Extensive colitis with moderate or severe endoscopic or histological inflammation

Annual colonoscopy:

  • Stricture within the past 5 years
  • Dysplasia within the past 5 years in a patient who declines surgery
  • PSC (including post-orthotopic liver transplant) from time of diagnosis of PSC
  • Colorectal cancer in a first-degree relative younger than 50 years

Pan-colonic dye spray (e.g. 0.1% indigo-carmine solution) should be used, with targeted biopsy of abnormal areas. If dye is not used, take 2-4 random biopsies from every 10 cm of the colon.

  • Colectomy is not necessary if a dysplastic polyp can be entirely removed endoscopically, in the absence of dysplasia in the surrounding tissues.
  • There is little evidence for pouch surveillance. Perform surveillance every 5 years. Consider annual surveillance in those with:
    • previous dysplasia or colorectal cancer
    • PSC
    • Type C pouch mucosa (permanent, persistent atrophy and severe inflammation)
  • Longstanding colitis increases the risk of developing colon cancer.
  • Population based studies have shown that this is less than previously thought, and mainly limited to sub-groups (e.g. onset before adulthood; duration> 10y; concomitant PSC).
  • Histologic or macroscopic pancolitis carries the highest risk, with no increased risk for patients with proctitis.
  • Disease activity, post-inflammatory polyps and possibly a family history of CRC are additional risk factors.
  • Surveillance colonoscopies may detect CRC earlier, and although this may improve prognosis it has not been definitely proven to do so.
  • Colonoscopy can be considered in all patients with at least distal colitis 8 years following symptom onset, but annually at any time point following diagnosis of PSC.

5-yearly colonoscopy:

  • Colitis affecting less than 50% of the colon surface area
  • Extensive colitis with mild endoscopic or histological active inflammation

3-yearly colonoscopy:

  • Post-inflammatory polyps
  • Colorectal cancer in a first-degree relative older than 50 years
  • Extensive colitis with moderate or severe endoscopic or histological inflammation

Annual colonoscopy:

  • Stricture within the past 5 years
  • Dysplasia within the past 5 years in a patient who declines surgery
  • PSC (including post-orthotopic liver transplant) from time of diagnosis of PSC
  • Colorectal cancer in a first-degree relative younger than 50 years

A rectal remnant still requires standard-interval surveillance. The procedure should be performed when the disease is in remission. Procedures need repeating with poor bowel preparation.

Pan-colonic chromoendoscopy (e.g. 0.1% indigo-carmine solution) should be undertaken, with targeted biopsies of any lesion and 2 biopsies taken each 10 cm to assess disease activity and extent. If only white light colonoscopy is performed, 4 biopsies should be taken every 10 cm although this is clearly an inferior surveillance strategy. Polypectomy depends on type of lesion.

Relevant ECCO Statements

ECCO statement 8A (UC 2017)

The risk of colorectal cancer in ulcerative colitis is increased compared with the general population. Risk is associated with disease duration [EL 2], extent [EL 2], and more severe or persistent inflammatory activity [EL 2]

ECCO statement 8B (UC 2017)

Concomitant primary sclerosing cholangitis [EL 2] and a family history of colorectal cancer [EL 3] confer an additional risk for colorectal cancer

ECCO statement 8C (UC 2017)

Surveillance colonoscopy may permit earlier detection of colorectal cancer with a corresponding improved prognosis [EL 3]

ECCO Statement 9E (UC 2012)

In all patients with UC irrespective of the disease activity, a screening colonoscopy could be carried out 6–8 years after the beginning of symptoms in order to assess the patient's individual risk profile [EL 5, RG D].

ECCO statement 8E (UC 2017)

When disease activity is limited to the rectum without evidence of previous or current endoscopic and/or microscopic inflammation proximal to the rectum, inclusion in a regular surveillance colonoscopy programme is not necessary [EL2]

ECCO statement 8F (UC 2017)

In patients with concurrent primary sclerosing cholangitis, annual surveillance colonoscopy should be performed following the diagnosis of primary sclerosing cholangitis, irrespective of disease activity, extent, and duration [EL3]

ECCO statement 8G (UC 2017)

Ongoing surveillance should be performed in all patients apart from those with proctitis [EL3]. Patients with high-risk features [e.g. stricture or dysplasia detected within the past 5 years, primary sclerosing cholangitis, extensive colitis with severe active inflammation] should have their next surveillance colonoscopy scheduled for 1 year [EL4]. Patients with intermediate risk factors should have their next surveillance scheduled for 2 to 3 years. Intermediate risk factors include extensive colitis with mild or moderate active inflammation, post-inflammatory polyps, or a family history of colorectal cancer in a first-degree relative diagnosed at age 50 years and above [EL5]. Patients with neither intermediate nor high-risk features should have their next surveillance colonoscopy scheduled for 5 years [EL5]

ECCO statement 8H (UC 2017)

Colonoscopic surveillance is best performed when ulcerative colitis is in remission, because it is otherwise difficult to discriminate between dysplasia and inflammation on mucosal biopsies [EL5]

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