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Patients with ulcerative colitis and Crohn's disease of the colon have an increased risk of developing colorectal cancer.
AGAAGA Medical Position Statement on the Diagnosis and Management of Colorectal Neoplasia in Inflammatory Bowel Disease
Section snippets
Literature Search Methodology
A search of the MEDLINE database was performed to identify relevant English language articles published in peer-reviewed journals. For this search, the terms dysplasia, colorectal cancer, surveillance, polyp, chemoprevention, chromoendoscopy, endoscopy, primary sclerosing cholangitis, risk factors, and children were searched in combination with the terms ulcerative colitis, Crohn's disease, Crohn's colitis, colitis, or inflammatory bowel disease. A manual search of the reference lists from the
Are Patients With IBD at Increased Risk for Colorectal Cancer?
Patients with IBD have an increased risk of developing colorectal cancer (CRC). The exact magnitude of the risk is uncertain due to wide variations in risk reported in many studies. Variations occur because some studies reported data only from tertiary referral centers, some were population based, and others represented only case reports or small series. Meta-analyses have
Are There Well-Substantiated Factors Other Than Dysplasia That Increase or Decrease the Risk of CRC in IBD?
Disease duration, more extensive disease, primary sclerosing cholangitis, and a positive family history of sporadic CRC are all associated with an increased risk of CRC. Colonic strictures in patients with UC and/or a shortened colon, and/or multiple postinflammatory pseudopolyps increase the risk of CRC. Inflammation is a risk factor for progression to colorectal neoplasia.
Increasing duration of disease is firmly established as one of the most important risk factors for the development of CRC in
What Is the Natural History of Dysplasia?
In most cases, CRC in IBD develops from dysplasia. Although imperfect, dysplasia is currently considered the best marker of CRC risk in IBD.
Dysplasia is currently considered the best marker of CRC risk in IBD, but there are limitations in predicting the natural history of dysplasia. Although dysplasia is present in 75% to 90% of patients with cancer, CRC can develop in patients without a prior history of dysplasia. Also, not all patients with low-grade dysplasia (LGD) will progress through a
Should Colectomy Be Performed for Raised Dysplasia?
Grade A: High certainty that the magnitude of net benefits is substantial. Patients with IBD and a non–adenoma-like dysplasia-associated lesion or mass should be treated with colectomy. Patients with IBD and an adenoma-like dysplasia-associated lesion or mass, and no evidence of flat dysplasia elsewhere in the colon, can be managed safely by polypectomy and continued surveillance.
Raised, endoscopically visible, dysplastic lesions in IBD have been referred to by the acronym “DALM”
Should Colectomy Be Performed for Flat Dysplasia?
Grade A: There is high certainty that colectomy for flat HGD treats undiagnosed synchronous cancer and prevents metachronous cancer. Grade Insufficient: The current evidence is insufficient to assess the balance of benefits and harms of colectomy for flat LGD.
“Flat dysplasia” is a term that has been applied to lesions that are not raised, minimally raised, or sometimes invisible. Not all studies have clearly defined what is meant by “flat dysplasia,” making comparisons between studies somewhat
Is There Sufficient Rationale for Performing Surveillance Colonoscopy in Patients With IBD?
Grade B: There is moderate certainty that surveillance colonoscopy results in at least moderate reduction of CRC risk in patients with IBD. Despite the lack of randomized controlled trials, surveillance colonoscopy is recommended for patients with IBD at increased risk for developing CRC. Patients with extensive UC or CD of the colon are most likely to benefit from surveillance.
Proof that surveillance colonoscopy is effective in patients with IBD requires demonstration of a reduction in mortality
How Should Surveillance Colonoscopy Be Performed?
The technique of surveillance colonoscopy in patients with IBD should include extensive biopsies of all anatomic segments of colorectal mucosa. Although there are inadequate data available to recommend optimal surveillance intervals, intervals of 1 to 3 years are suggested. Careful inspection of the mucosa along with a sufficient number of biopsy specimens should be obtained from all anatomic segments of the colon.
To date, our understanding of the efficacy of surveillance colonoscopy is based on
What Role Do the Newer Imaging Techniques Play in Identifying and Managing Dysplasia?
The sensitivity of chromoendoscopy for detecting dysplasia is higher than white light endoscopy in the hands of endoscopists who have expertise with this technique. The natural history of chromoendoscopically detected dysplasia is unknown. Additional studies are needed to evaluate the efficiency of other imaging methods, such as narrow band imaging and confocal endomicroscopy, in detecting dysplasia.
Several imaging modalities, such as chromoendoscopy with methylene blue or indigo carmine, narrow
Should Chemopreventive Agents Be Used to Lower the Risk of Developing Dysplasia or CRC in IBD?
Grade A: High certainty that the magnitude of net benefits is substantial. Ursodeoxycholic acid has demonstrated a significant reduction in CRC in patients with UC who also have PSC. Grade B: Moderate certainty that the magnitude of net benefits is moderate. Aminosalicylates are chemopreventive against CRC. Grade D: High certainty that the magnitude of net benefits is negative. Oral or topical corticosteroids, while demonstrating antineoplastic effects in 2 studies, are associated with too many side
Should Molecular Markers Be Applied to Help Stratify Patients Into Low-Risk and High-Risk Groups?
Grade Insufficient: No recommendation; insufficient evidence to recommend for or against the use of molecular markers. Molecular markers should not be applied to help stratify patients into low-risk and high-risk groups at this time.
The 3 major molecular pathways of colon carcinogenesis (chromosomal instability, microsatellite instability, and CpG island methylation pathway) also occur in colitis-associated CRC. Much of the data regarding types of molecular alterations in colitis-associated CRC
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AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease
Gastroenterology
(2010)
Cited by (431)
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Reprint requests Address requests for reprints to: Chair, Clinical Practice and Quality Management Committee, AGA National Office, 4930 Del Ray Avenue, Bethesda, Maryland 20814. Phone: (301) 272-1189; e-mail: [email protected].
Conflicts of interest The authors disclose the following: Dr Farraye has received research support from Prometheus Laboratories; is a consultant and a member of the speaker's bureau for Abbott, Centocor, Proctor & Gamble, Prometheus Laboratories, Salix, and Shire; and is a consultant for UCB. The remaining authors disclose no conflicts.