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 (IBDInflammatory bowel disease), 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 IBDInflammatory bowel disease 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 CRCColorectal cancer at age ≤50 years.
Yearly
Intermediate All of:
  • quiescent disease
  • no high-risk features
  • no history of CRCColorectal cancer 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 IBDInflammatory bowel disease patients (SUR2)?

Systematic review evidence

No prospective controlled studies matching the (PICOPopulation, intervention, comparison, outcome 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 IBDInflammatory bowel disease diagnosis) outcomes indirectly relevant to the issue of risk stratification of IBDInflammatory bowel disease 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 (CRCColorectal cancer) prevalence in those with UCUlcerative colitis, Crohn’s disease or both IBDInflammatory bowel disease and primary sclerosing cholangitis (PSCPrimary sclerosing cholangitis), and CRCColorectal cancer rates according to duration of IBDInflammatory bowel disease or extent of Crohn’s disease. Studies also reported the prevalence of dysplasia among those with UCUlcerative colitis, and risk factors for CRCColorectal cancer in those with IBDInflammatory bowel disease (PSCPrimary sclerosing cholangitis, duration of IBDInflammatory bowel disease).

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

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

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

Evidence summary and recommendations

Evidence summary Level References
The cumulative risk of colorectal cancer (CRCColorectal cancer) increases with duration of IBDInflammatory bowel disease due to cumulative damage of the mucosa resulting from chronic inflammation. The median time to the development of CRCColorectal cancer 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 (PSCPrimary sclerosing cholangitis) is an additional risk factor for CRCColorectal cancer, beyond IBDInflammatory bowel disease. The duration of PSCPrimary sclerosing cholangitis was a risk factor for CRCColorectal cancer after 5 years. However, PSCPrimary sclerosing cholangitis and the colitis associated with PSCPrimary sclerosing cholangitis are often subclinical, meaning that they are diagnosed many years after disease onset. III-2, III-3 [5], [3]
The risk of CRCColorectal cancer arising in patients with proctitis or ileitis alone is low. III-3 [6]
Consensus-based recommendationA recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question.Question mark transparent.png

Patients with IBDInflammatory bowel disease at high risk of CRCColorectal cancer (those with PSCPrimary sclerosing cholangitis, ongoing chronic active inflammation, prior colorectal dysplasia, evidence of intestinal damage with colonic stricture, pseudopolyps or foreshortened tubular colon or family history of CRCColorectal cancer at age ≤50 years) should undergo yearly surveillance colonoscopy.

Consensus-based recommendationA recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question.Question mark transparent.png

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

Consensus-based recommendationA recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question.Question mark transparent.png

Patients with IBDInflammatory bowel disease at low risk of CRCColorectal cancer (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 pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

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

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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. 2.02.12.22.32.4 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. ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2011 Nov;13(11):1230-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21689324.
  3. 3.03.13.2 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. 4.04.14.2 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. 5.05.15.25.35.4 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. 6.06.16.26.36.46.5 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. 7.07.17.27.3 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. 8.08.18.2 Senanayake SM, Fernandopulle ANAdvanced neoplasia (advanced adenoma or colorectal cancer), Niriella MAMetachronous adenoma, Wijesinghe NT, Ranaweera A, Mufeena MNMetachronous neoplasia, 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. 9.09.1 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. 10.010.110.2 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.pngPICO question SUR2 View Evidence statement form SUR2Evidence statement form SUR2 View Systematic review report SUR2Systematic review report SUR2
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