Surveillance interval for IBD patients

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Background

Routine yearly to 2-yearly surveillance colonoscopy is no longer required for most patients with inflammatory bowel disease (IBD), due to improvements in colonoscopic technology and procedure quality. Current guidelines recommend that surveillance colonoscopy intervals be based on risk stratification and the findings of prior surveillance colonoscopies.[1] Stratification according to risk of IBD can be seen in Table 19.

High-risk patients are those with factors associated with greater risk for the development of colorectal dysplasia, and require more frequent surveillance procedures.

The recommended surveillance intervals are based on the assumption that the examinations are successful, conducted on well-prepared uninflamed colons, carried out by physicians trained in the detection of dysplasia, and performed using contemporary techniques for visualisation of dysplasia and mucosal sampling.

Table 19. Risk stratification in inflammatory bowel disease

Risk category Criteria Recommended surveillance colonoscopy interval
High Any of:
  • primary sclerosing cholangitis
  • ongoing chronic active inflammation
  • prior colorectal dysplasia
  • evidence of intestinal damage with colonic stricture
  • pseudopolyps or foreshortened tubular colon
  • family history of CRC at age ≤50 years.
Yearly
Intermediate All of:
  • quiescent disease
  • no high-risk features
  • no history of CRC in a first-degree relative
Every 3 years
Low All of:
  • quiescent disease
  • no other risk factors
  • inactive disease on consecutive surveillance colonoscopies
Every 5 years

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Evidence

What is the most appropriate time interval for surveillance in IBD patients (SUR2)?

Systematic review evidence

No prospective controlled studies matching the (PICO question) criteria have been published since 2010 to directly answer this clinical question (see Technical report).

Nine observational studies were identified that reported long term (>10 years following IBD diagnosis) outcomes indirectly relevant to the issue of risk stratification of IBD patients and surveillance colonoscopy intervals.[2][3][4][5][6][7][8][9][10] A single study was level III-2 evidence[5] and the remaining studies were level III-3 evidence. Most studies were at high risk of bias, with one study at moderate risk of bias,[5] and another at low risk of bias.[2]

Reported outcomes included colorectal cancer (CRC) prevalence in those with UC, Crohn’s disease or both IBD and primary sclerosing cholangitis (PSC), and CRC rates according to duration of IBD or extent of Crohn’s disease. Studies also reported the prevalence of dysplasia among those with UC, and risk factors for CRC in those with IBD (PSC, duration of IBD).

Colorectal cancer rates were relatively low for the first decade after UC diagnosis, after which some studies reported significantly higher CRC rates in UC patients compared with the general population. The risk of CRC was still significant 20–30 years after UC diagnosis.[4][7][8][10] Increasing duration of IBD was associated with an increasing risk of CRC, the magnitude of which was higher among Crohn’s disease patients, compared with patients with UC, after IBD diagnosis. The increase in CRC risk in these patients was substantial after 10 years post-diagnosis.[2][6] In those with Crohn’s disease, CRC prevalence reached 7% 30-years after the diagnosis of Crohn’s disease.[7]

One study reported that those with both IBD and PSC are at risk of CRC from 10–20 years post PSC diagnosis.[5] Another study reported that individuals with left-sided colitis, or pancolitis had a higher risk of CRC, and this risk was still presence more than 10 years after IBD diagnosis.[2][6] Both PSC and IBD duration are major risk factors for CRC, both being substantial after 5–10 years.[3]

Two studies reported that increasing duration of UC positively correlated with a greater risk of either any dysplasia or high-grade dysplasia.[6][9]

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Evidence summary and recommendations

Evidence summary Level References
The cumulative risk of colorectal cancer (CRC) increases with duration of IBD due to cumulative damage of the mucosa resulting from chronic inflammation. The median time to the development of CRC was 16–23 years. Accordingly, the need to perform surveillance increases over time. The risk in the first decade of symptoms is typically <0.5%, rising to 1% at 10 years after diagnosis of ulcerative colitis. III-3 [2], [6], [4], [8], [10], [7]
Primary sclerosing cholangitis (PSC) is an additional risk factor for CRC, beyond IBD. The duration of PSC was a risk factor for CRC after 5 years. However, PSC and the colitis associated with PSC are often subclinical, meaning that they are diagnosed many years after disease onset. III-2, III-3 [5], [3]
The risk of CRC arising in patients with proctitis or ileitis alone is low. III-3 [6]


Consensus-based recommendationQuestion mark transparent.png

Patients with IBD at high risk of CRC (those with PSC, ongoing chronic active inflammation, prior colorectal dysplasia, evidence of intestinal damage with colonic stricture, pseudopolyps or foreshortened tubular colon or family history of CRC at age ≤50 years) should undergo yearly surveillance colonoscopy.


Consensus-based recommendationQuestion mark transparent.png

Patients with IBD at intermediate risk of CRC (those with quiescent disease, no high risk features or family history of CRC in a first-degree relative) should undergo surveillance colonoscopy every 3 years.


Consensus-based recommendationQuestion mark transparent.png

Patients with IBD at low risk of CRC (those with quiescent disease and no other risk factors, and with inactive disease on consecutive surveillance colonoscopies) may undergo surveillance colonoscopy every 5 years.


Practice pointQuestion mark transparent.png

Consider increased frequency of surveillance (intervals less than 3 years) in patients with a family history of CRC in a first-degree relative <50 years of age because this may be an additional risk factor for CRC.

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Notes on the recommendations

There are no prospective controlled studies on surveillance strategy with regard to surveillance intervals. Recommendations are based on risk factors identified by cohort studies and actual findings of dysplasia at the time of surveillance colonoscopy.

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References

  1. Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, et al. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders. J Crohns Colitis 2017 Jun 1;11(6):649-670 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28158501.
  2. 2.0 2.1 2.2 2.3 2.4 Averboukh F, Ziv Y, Kariv Y, Zmora O, Dotan I, Klausner JM, et al. Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn's and ulcerative colitis. Colorectal Dis 2011 Nov;13(11):1230-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21689324.
  3. 3.0 3.1 3.2 Baars JE, Looman CW, Steyerberg EW, Beukers R, Tan AC, Weusten BL, et al. The risk of inflammatory bowel disease-related colorectal carcinoma is limited: results from a nationwide nested case-control study. Am J Gastroenterol 2011 Feb;106(2):319-28 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21045815.
  4. 4.0 4.1 4.2 Choi CH, Rutter MD, Askari A, Lee GH, Warusavitarne J, Moorghen M, et al. Forty-Year Analysis of Colonoscopic Surveillance Program for Neoplasia in Ulcerative Colitis: An Updated Overview. Am J Gastroenterol 2015 Jul;110(7):1022-34 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25823771.
  5. 5.0 5.1 5.2 5.3 5.4 Navaneethan U, Kochhar G, Venkatesh PG, Lewis B, Lashner BA, Remzi FH, et al. Duration and severity of primary sclerosing cholangitis is not associated with risk of neoplastic changes in the colon in patients with ulcerative colitis. Gastrointest Endosc 2012 May;75(5):1045-1054.e1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22405258.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Nowacki TM, Brückner M, Eveslage M, Tepasse P, Pott F, Thoennissen NH, et al. The risk of colorectal cancer in patients with ulcerative colitis. Dig Dis Sci 2015 Feb;60(2):492-501 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25280558.
  7. 7.0 7.1 7.2 7.3 Selinger CP, Andrews JM, Titman A, Norton I, Jones DB, McDonald C, et al. Long-term follow-up reveals low incidence of colorectal cancer, but frequent need for resection, among Australian patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2014 Apr;12(4):644-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23707778.
  8. 8.0 8.1 8.2 Senanayake SM, Fernandopulle AN, Niriella MA, Wijesinghe NT, Ranaweera A, Mufeena MN, et al. The long-term outcomes of a cohort of Sri Lankan patients with ulcerative colitis: a retrospective study at two national referral centers and review of literature. Clin Exp Gastroenterol 2013;6:195-200 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24068873.
  9. 9.0 9.1 Stolwijk JA, Langers AM, Hardwick JC, Veenendaal RA, Verspaget HW, van Hogezand RA, et al. A thirty-year follow-up surveillance study for neoplasia of a dutch ulcerative colitis cohort. ScientificWorldJournal 2013;2013:274715 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24379739.
  10. 10.0 10.1 10.2 Wei SC, Shieh MJ, Chang MC, Chang YT, Wang CY, Wong JM. Long-term follow-up of ulcerative colitis in Taiwan. J Chin Med Assoc 2012 Apr;75(4):151-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22541142.

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Appendices

Jutta's magnifying glass icon.png PICO question SUR2 View Evidence statement form SUR2 Evidence statement form SUR2 View Systematic review report SUR2 Systematic review report SUR2

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