Clinical question list

From Clinical Guidelines Wiki


This page lists the questions answered by systematic review and modelling. For full details about the reviews, including the inclusion and exclusion criteria, please see the Technical report.

Advances in colonoscopy, CT colonography and other methods (section lead: Gregor Brown)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

Colonoscopic surveillance after polypectomy (section lead: Karen Barclay)

Clinical Question SAD1: What should be the surveillance colonoscopy for patients at low risk (1-2 small <10mm tubular adenomas)?

Population Intervention Comparator Outcomes Study Type Study Design
Patients diagnosed with 1 or 2 tubular adenomas <10mm in size which have been removed Surveillance colonoscopy follow up schedule – 5 to 10 years colonoscopy
  • Alternative colonoscopy frequency schedule(s) – <5 years; or
  • No schedule; or
  • No comparator
  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Complications
Intervention, aetiology Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Population Risk factor Outcomes Study Type Study Design
Low risk population:

Patients diagnosed with 1 or 2 tubular adenomas <10mm in size which have been removed

  • Surveillance time
  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
Prognostic Systematic reviews of Level II evidence, cohort studies
Clinical Question SAD2:

What should be the surveillance colonoscopy for patients at high risk (size ≥10mm, HGD, villosity and/or 3-4 adenomas)?

Population Intervention Comparator Outcomes Study Type Study Design
Patients who have had a polypectomy to remove:
  • three or more adenomatous polyps; or
  • at least one adenoma is ≥10mm in size; or
  • the adenomas exhibit villous or tubulovillous histology or high-grade dysplasia
Surveillance colonoscopy follow up schedule – 3 yearly colonoscopy (or any schedule given no comparator)
  • Alternative colonoscopy frequency schedule(s) - 5 years or 5–10 years; or
  • No comparator
  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Complications
Intervention, aetiology Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Population Risk factor Outcomes Study Type Study Design
High risk population:

Patients who have had a polypectomy to remove:

  • three or more adenomatous polyps; or
  • at least one adenoma is ≥10mm in size; or
  • the adenomas exhibit villous or tubulovillous histology or high-grade dysplasia
  • High risk population (compared to low risk population*)
  • Surveillance time

* Patients with 1 or 2 tubular adenomas <10mm in size

  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
Prognostic Systematic reviews of Level II evidence, cohort studies
Clinical Question SAD3:

What is the appropriate colonoscopic surveillance after the removal of large sessile or laterally spreading adenomas?

Population Intervention Comparator Outcomes Study Type Study Design
Patients diagnosed with adenomas ≥20mm including:
  • large sessile adenomas; or
  • laterally spreading adenomas

which were removed by:

  • en bloc resection

Procedure performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)

Surveillance colonoscopy follow up schedule with colonoscopy Alternative colonoscopy frequency schedule(s)

or

  • No comparator
*Residual/Recurrent adenoma
  • Cancer incidence
Intervention, aetiology Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Patients diagnosed with adenomas ≥20mm including:
  • large sessile adenomas; or
  • laterally spreading adenomas

which were revmoed by

  • piecemeal

Procedure performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)

Surveillance colonoscopy follow up schedule with colonoscopy – <6 months Alternative colonoscopy frequency schedule(s)

or

  • No comparator
Population Risk factor Outcomes Study Type Study Design
Patients diagnosed with adenomas ≥20mm including large sessile adenomas or laterally spreading adenomas
  • en bloc resection
  • piecemeal resection
  • endoscopic mucosal resection (EMR)
  • endoscopic submucosal resection (ESD)
  • surveillance time
Residual/Recurrent adenoma
  • Cancer incidence
Prognostic Systematic reviews of Level II evidence, cohort studies
Clinical Question SAD4:

What is the appropriate colonoscopic surveillance after the identification of sessile serrated adenomas and traditional serrated adenomas?

Population Intervention Comparator Outcomes Study Type Study Design
Patients diagnosed with
  • traditional serrated adenomas/polyps or;
  • sessile serrated adenomas/polyps or sessile serrated polyps proximal to the splenic flexure

+/- dysplasia +/- ≥ 10mm which have been removed

Surveillance colonoscopy follow up schedule with colonoscopy – 3 years (or any schedule given no comparator) Alternative colonoscopy frequency schedule(s) – <3, 5 or 5-10 years; or
  • No comparator
  • Incidence and location of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Incidence of SSA/TSA
  • Incidence of advanced SSA/TSA
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of TSA/SSA
  • Risk of advanced TSA/SSA
Intervention, aetiology Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Population Risk factor Outcomes Study Type Study Design
Patients diagnosed with sessile serrated adenomas/polyps or traditional serrated adenomas/polyps which have been removed and are undergoing surveillance colonoscopy Patients with
  • traditional serrated adenomas/polyps or;
  • sessile serrated adenomas/polyps or sessile serrated polyps proximal to the splenic flexure

+/- dysplasia +/- ≥ 10mm

  • Incidence and location of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Incidence of SSA/TSA
  • Incidence of advanced SSA/TSA
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of TSA/SSA
  • Risk of advanced TSA/SSA
Prognostic Systematic reviews of Level II evidence, cohort studies
Clinical Question SAD5:

What should be the surveillance colonoscopy for patients with adenoma multiplicity?

Population Intervention Comparator Outcomes Study Type Study Design
Patients diagnosed with multiple (5-19):
  • adenomas and/or
  • low risk adenomas and/or
  • high risk adenomas and/or
  • serrated adenomas

which have been removed

Surveillance colonoscopy follow up schedule with colonoscopy
  • 1 year for five to nine adenomatous polyps
  • ≤1 year for ≥10 adenomatous polyps
  • Any schedule given no comparator
Alternative colonoscopy frequency schedule(s)
  • No comparator
  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Complications
Intervention, aetiology Systematic reviews of Level II evidence, randomised controlled trials, cohort studies or case-control studies
Population Risk factor Outcomes Study Type Study Design
Patients diagnosed with adenomas that have been removed and are undergoing surveillance colonoscopy Patients with multiple (5-19):
  • adenomas and/or
  • low risk adenomas and/or
  • high risk adenomas and/or
  • serrated adenomas
  • Incidence of colorectal cancer
  • Incidence of adenoma
  • Incidence of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
  • Risk of colorectal cancer
  • Risk of adenoma
  • Risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
Prognostic Systematic reviews of Level II evidence, cohort studies
Clinical Question SFH1:

Is the surveillance colonoscopy recommendation different for patients with adenomas who also have a family history of CRC?

Intervention studies

Population Intervention Comparator Outcomes Study Type + Design
Patients diagnosed with adenomas which have been removed

AND Presence of a family history of colorectal cancer:

  • 1 first degree relative (FDR) or second degree relative (SDR) and age (≥55 or ≥60) years at diagnosis; or
  • 1 FDR age (<55 or <60) years at diagnosis or 2 FDR or 1 FDR and 1 SDR on the same side of the family, at any age at diagnosis

Colonoscopy after 2002

Following a defined surveillance colonoscopy schedule Alternative surveillance colonoscopy frequency schedule(s)

or No comparator

Incidence of:
  • colorectal cancer
  • adenoma
  • advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.

Risk of:

  • colorectal cancer
  • adenoma
  • advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.

Complications

Intervention studies of level I to III-2 evidence
Prognostic studies
Population Risk factor Outcomes Study Type + Design
Patients diagnosed with adenomas which have been removed and are undergoing surveillance colonoscopy Presence of a family history* of colorectal cancer
  • 1 first degree relative (FDR) or second degree relative (SDR) and age (≥55 or ≥60) years at diagnosis; or
  • 1 FDR age (<55 or <60) years at diagnosis or 2 FDR or 1 FDR and 1 SDR on the same side of the family, at any age at diagnosis
Risk of:
  • colorectal cancer
  • adenoma
  • advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia.
Prognostic studies of level I to III-3 evidence
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The role of surveillance colonoscopy after curative resection for colorectal cancer (section leads: James Moore and Tarik Sammour)

Clinical Question COL1:

What is the role of pre or peri-operative colonoscopy in CRC patients?

Population Intervention Comparator Outcomes Study Design
Patients diagnosed with colorectal cancer and planned surgery Colonoscopy performed peri-operatively including
  • pre-operatively
  • post-operatively
N/A
  • Diagnostic yield
  • Adenoma detection rateThe proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected.
  • Synchronous cancer rate
  • Quality of life
  • Adenomas with advanced pathological features
Cohort studies

Case/controls

Clinical Question FUC1:

At what time points after CRC resection should surveillance colonoscopy be performed?

PICO Question FUC1:

In patients who have undergone resection for colorectal cancer what is the optimal follow-up colonoscopy frequency or schedule in relation to diagnostic yield, adenoma recurrence, adenomas with advanced pathological features, and quality of life?

Population Intervention Comparator Outcomes Study Design
Patients who have undergone resection for colorectal cancer Surveillance colonoscopy follow up frequency/ schedule An alternative surveillance colonoscopy follow up frequency/ schedule Diagnostic yield (what % of cancer was diagnosed), adenoma recurrence, adenomas with advanced pathological features, quality of life Comparative study with or without concurrent controls
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Colonoscopic surveillance and management of dysplasia in inflammatory bowel disease (IBD) (section lead: Rupert Leong)

IBD and risk of colorectal cancer

Clinical Question SUR1:

What is the appropriate time to commence surveillance in IBD patients (ulcerative colitis and Crohn’s patients, and effects of primary sclerosing cholangitis or family history of CRC)?

Population Intervention Comparator Outcomes Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease) with or without a family history of CRC, or primary sclerosing cholangitis Time to commence surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease) An alternative time to commence surveillance following a diagnosis of IBD
  • Colorectal cancer prevelance
  • Colorectal cancer mortality
  • Dysplasia prevelance
Intervention and aetiology studies of all study designs
Population Risk factors Outcomes Study Design/Type
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)
  • Family History of CRC
  • Ulcerative colitis
  • Crohn’s disease
  • primary sclerosing cholangitis
  • Duration of IBD
  • Extent of bowel involvement
  • Activity of disease (endoscopic)
  • Activity of disease (histological)
  • Intestinal damage
  • Colorectal cancer incidence
  • Colorectal cancer mortality
  • Dysplasia incidence
Prognostic studies of all design
Clinical Question SUR2:

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

Intervention studies

Population Intervention Comparator Outcomes Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)

with or without a family history of CRC, or primary sclerosing cholangitis

Frequency of surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease) An alternative frequency of surveillance following a diagnosis of IBD (Ulcerative colitis or Crohn’s disease)
  • Colorectal cancer prevalence
  • Colorectal cancer mortality
  • Dysplasia prevalence
Intervention studies of all study designs
Prognostic studies
Population Risk factors Outcomes Study Design/Type
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)
  • Family History of CRC
  • Ulcerative colitis
  • Crohn’s disease
  • primary sclerosing cholangitis
  • Duration of IBD
  • Extent of bowel involvement
  • Activity of disease (endoscopic)
  • Activity of disease (histological)
  • Intestinal damage
  • Colorectal cancer incidence
  • Colorectal cancer mortality
  • Dysplasia incidence
Prognostic studies of all design
Clinical Question SUR3:

What is the recommended surveillance strategies for surveillance in IBD patients?

Population Intervention Comparator Outcomes Study Design
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)
  • High-definition endoscopy (HDE)
  • Chromoendoscopy
  • Confocal laser Endomicroscopy
  • Narrow band imagingA specialised type of endoscopy that uses specific blue and green wavelengths of light to enhance visualisation of the mucosal layer of the colon. (NBI)
  • Autofluorescence imaging
  • Endoscopy with targeted biopsies
Standard white light, standard definition colonoscopy
  • Colorectal cancer prevalence, or
  • Dysplasia prevalence over a specific follow-up period
Intervention studies of all study design
  • Targeted biopsies
  • Random biopsies
Population Index Test 1 Index Test 2 Reference standard Outcomes
Patient diagnosed with Inflammatory Bowel Disease (Ulcerative colitis or Crohn’s disease)
  • Colonoscopy (white light endoscopy)
  • High-definition endoscopy (HDE)
  • Chromoendoscopy
  • Confocal Laser Endomicroscopy (CLE)
  • Narrow band imagingA specialised type of endoscopy that uses specific blue and green wavelengths of light to enhance visualisation of the mucosal layer of the colon. (NBI)
  • Autofluorescence imaging
  • Endoscopy with targeted biopsies
  • Endoscopy with random biopsies
An alternative endoscopy technique listed for Index test 2 or no 2nd index test Pathological histology Diagnostic performance related to the detection of colorectal cancer or dysplasia, including
  • sensitivity
  • specificity
  • PPV or NPV
  • accuracy
Targeted biopsies Random biopsies
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Management of elevated dysplasia in IBD

Clinical Question MNG1:

What should be the protocol to manage elevated dysplasia in IBD?

PICO MNG1:

In patients who have inflammatory bowel disease (IBD) and elevated dysplasia, which management protocol achieves the best outcomes in relation to the development of colorectal cancer?

Population Intervention Comparator Outcomes Study Design
Patients who have IBD and elevated dysplasia Management protocol for elevated dysplasia which may include:
  • endoscopic lesions
  • surgical interventions
An alternative management protocol Development of colorectal cancer Comparative studies with or without concurrent controls
Clinical Question MNG2:

What should be the protocol to manage high-grade dysplasia in IBD?

PICO MNG2:

In patients who have inflammatory bowel disease (IBD) and high-grade dysplasia, which management protocol achieves the best outcomes in relation to the development of colorectal cancer?

Population Intervention Comparator Outcomes Study Design
Patients who have IBD and high-grade dysplasia in flat musoca Management protocol for high-grade dysplasia which may include:
  • colectomyThe surgical removal of all or part of the colon.
An alternative management protocol Development of colorectal cancer Comparative studies with or without concurrent controls
Clinical Question MNG3:

What should be the protocol to manage low-grade dysplasia in IBD?

PICO MNG3:

In patients who have inflammatory bowel disease (IBD) and low-grade dysplasia, which management protocol achieves the best outcomes in relation to the prevention of progression to a higher grade of dysplasia?

Population Intervention Comparator Outcomes Study Design
Patients who have IBD and low-grade dysplasia in flat musoca Management protocol for low-grade dysplasia which may include:
  • colectomyThe surgical removal of all or part of the colon.
  • chromoendoscopy
  • surveillance
An alternative management protocol Prevent progression to a higher grade of dysplasia Comparative studies with or without concurrent controls
Clinical Question MNG4:

What should be the protocol to manage indefinite dysplasia in IBD?

PICO MNG4:

In patients who have inflammatory bowel disease (IBD) and indefinite dysplasia, which management protocol achieves the best outcomes in relation to the progression to colorectal cancer?

Population Intervention Comparator Outcomes Study Design
Patients with IBD and indefinite dysplasia Management protocol for low-grade dysplasia which may include:
  • chromoendoscopy
  • surveillance
An alternative management protocol Progression to colorectal cancer Comparative studies with or without concurrent controls
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Anxiety in colonoscopy: approaches to minimise anxiety and its adverse effects (section lead: Afaf Girgis)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

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Socio-economic factors (section lead: Anne Duggan)

Background chapter based on general literature summary. The 2011 content was reviewed and updated where required. Practice points were included as guidance.

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