What is the most appropriate time interval for surveillance in IBD patients?

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What is the most appropriate time interval for surveillance in IBD patients?

The ideal surveillance interval has not been tested, nor has the impact of co-existing risk factors ever been assessed. Early surveillance programmes included patients with extensive UC who were subjected to biennial colonoscopy. In the St Mark’s series involving 600 patients with extensive UC who underwent 2627 colonoscopies at one to two yearly intervals during 5932 patient years of follow-up, 30 cancers developed of which 16 were “interval” cases.[1] Itzkowitz and Harpaz[2]suggested that surveillance should be conducted annually or biennially provided no dysplasia is found or suspected.[2] Recommendations by the Crohn’s and Colitis Foundation of America (CCFA) state that surveillance intervals depend on initial biopsy findings. If the initial colonoscopy is negative for dysplasia, repeat colonoscopy should be performed every one to two years. After two negative colonoscopies further colonoscopies may be performed every one to three years until IBD has been present for 20 years, at which point surveillance colonoscopies should be repeated every one to two years. In contrast, patients found to have dysplasia on screening or surveillance colonoscopy require colectomy or more aggressive surveillance. Patients with co-existing PSC and IBD require annual surveillance colonoscopies.[3] Although the impact of a family history of CRC on surveillance intervals in IBD has not been evaluated, both American and British guidelines recommend more frequent surveillance when this risk factor is present.[4][5] The need to intensify surveillance after 20 years has been disputed by the results of the St Mark’s series, which showed a constant cancer incidence for up to 40 years of colitis duration and included a relatively large number of patients.[1]

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Evidence summary and recommendations

Practice point(s)

Annual colonoscopic surveillance is recommended for patients with ulcerative colitis extending proximal to the sigmoid colon or patients with Crohn’s colitis affecting more than one third of the colon and with one or more of the following risk factors:

  • Active disease
  • Primary sclerosing cholangitiis
  • Family history of colorectal cancer in first degree relative < 50 years old
  • Colonic stricture, patients with multiple inflammatory polyps or shortened colon
  • Previous dysplasia

Three yearly colonoscopy is recommended for patients with:

  • Inactive ulcerative colitis extending proximal to the sigmoid colon without any of the above risk factors
  • Patients with Crohn’s colitis affecting more than one third of the colon without any of the above risk factors
  • IBD patients with a family history of colorectal cancer in a first degree relative > 50 years old

Five yearly colonoscopy recommended for patients in whom two previous colonoscopies that were macroscopically and histologically normal.

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References

  1. 1.0 1.1 Rutter MD, Saunders BP, Wilkinson KH, Rumbles S, Schofield G, Kamm MA, et al. Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis Gastroenterology 2006 Apr;130(4):1030-8 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16618396].
  2. 2.0 2.1 Itzkowitz SH, Harpaz N. Diagnosis and management of dysplasia in patients with inflammatory bowel diseases Gastroenterology 2004 May;126(6):1634-48 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15168373].
  3. Ahmadi AA, Polyak S. Endoscopy/surveillance in inflammatory bowel disease Surg Clin North Am 2007 Jun;87(3):743-62 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17560423].
  4. Farraye FA, Odze RD, Eaden J, Itzkowitz SH. AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease Gastroenterology 2010 Feb;138(2):746-74, 774.e1-4; quiz e12-3 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20141809].
  5. Cairns SR, Scholefield JH, Steele RJ, Dunlop MG, Thomas HJW, Evans D, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups. The British Society of Gastroenterology and Association of Colopractology for Great Britain and Ireland 2010.

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