This transcript has been edited for clarity.
Hello. I’m Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
The colonoscopic surveillance of patients with inflammatory bowel disease (IBD) is a standard practice recommendation, given their increased risk for colorectal cancer.
The American Gastroenterological Association (AGA) recently provided guidance for refining the endoscopic surveillance and management of colorectal dysplasia in IBD. Most recently, Dr Uma Mahadevan, an expert in the field of IBD, provided her top 10 recommendations in this area, which I think provide some wonderful granularity that build on the AGA consensus recommendations. Here are the highlights from Dr Mahadevan’s work.
Consider a Smaller Colonoscope
The first recommendation is to use a pediatric colonoscope in patients with Crohn’s disease. The outside diameter of the adult colonoscope is 12.8 mm, compared with approximately 9.5-11.6 mm for the pediatric colonoscope. These changes in size may make it easier to pass through tight areas, giving clinicians greater flexibility in challenging cases.
When to Initiate Surveillance
Second is to begin IBD surveillance 8-10 years after the diagnosis but immediately after the patients have the diagnosis of primary sclerosing cholangitis.
Once these patients have been defined and have had an adequate exam, patients who have limited disease — meaning, limited to the rectum, proctitis, or involving less than one third of the colon — the recommendation is that these patients could then be advanced to a 5-year interval. This recommendation is the same as that from the AGA.
What Active Inflammation Tells Us
The third recommendation is that if the patient has active inflammation at the time of colonoscopy, it’s unlikely to have been an adequate examination. The reason is that inflammation can be confused with dysplasia.
Dr Mahadevan recommends that these patients be brought back once they’re adequately controlled. She may sometimes use a short burst of steroids to accelerate this control and then bring them back for further evaluation when the disease is in remission.
Phasing Out Certain Four-Quadrant Biopsy Tactics
Her fourth recommendation is that you don’t need to take the four-quadrant biopsies every 10 cm anymore. This is due to advances in the form of virtual chromoendoscopy involving narrow-band imaging, the i-scan from Pentax, or the advanced blue light imaging from Fuji, which will take the place of standard four-quadrant, random biopsies in some circumstances.
Instead, you can spend the time inspecting with the mucosal scrutinization using advanced imaging and high-definition colonoscope exam. If you don’t have high definition, you need to do the standard recommendation of quadrant biopsies. But high definition is used by most of us in clinical practice.
When to Say No to Dye Spray
The fifth recommendation is that, no, every IBD surveillance does not need dye spray chromoendoscopy. This is also due to the advantages of the enhanced imaging techniques I just mentioned, and even high-definition white-light endoscopy, which are comparable.
Again, the point here is to be familiar with the best surveillance strategies and have the expertise to comfortably define dysplasia in these patients. This will be easier going forward when you spend more time identifying lesions rather than conducting blind biopsies.
Use Proper Nomenclature
The sixth recommendation is to no longer call these lesions DALM (dysplasia-associated lesion or mass). When I was beginning my practice as a gastroenterologist, we had the identification of DALM, which was concordant with the next step for surgery — resection of the colon — because it was considered such a high-risk concern.
More recently, the modified Paris Classification describes the proper nomenclature for dysplastic lesions found in patients with IBD. These are described as polypoid visible lesions (≥ 2.5 mm tall, pedunculated or sessile), nonpolypoid (< 2.5 mm tall), or invisible, picked up on random biopsies for dysplasia. These lesions then warrant careful endoscopic definition and consideration for endoscopic resection.
I would add that a standard practice recommendation for these lesions would be to define the mucosal surface using a Kudo pit pattern, as we would for standard polyp resection assessment. This would determine whether or not these are endoscopically resectable.
Seeking Second Opinions
The seventh recommendation is that you do want to have a second opinion from a gastrointestinal pathologist if there’s a question of dysplasia, as we would in other organs. A lot of times an outside diagnosis by an expert pathologist may reevaluate these as a nondysplastic lesion or vice versa.
Tread Carefully for Difficult Lesions
The eighth recommendation is that if it looks like a difficult lesion and you don’t think you can remove it, then don’t try it. I think this would be the same recommendation for polyps in the colon of any sort.
Biopsies of these areas are also not recommended if you think it’s going to be an endoscopic resection. This is because partial resection by an attempt at polypectomy, or even extensive biopsies of the area, may tack it down and make it much more difficult for the endoscopic resection following a failed attempt.
An India ink tattoo is recommended to identify these clearly. You’ll want to define it where it is in the endoscopic report. You also want to place these at least 3-5 cm distal to the area. Do not place it adjacent because this infiltration of the India ink may tack down the polyp and make it less amenable to an endoscopic resection.
Performing Postoperative Surveillance for Crohn’s Disease
The ninth recommendation is that when performing postoperative surveillance for Crohn’s disease, make sure you intubate the ileum and use the recommended scoring system, which is the Rutgeerts scoring system.
If you go by the anastomosis, you may miss disease in the ileum, which if evidenced active disease would be reflective of inadequate therapy.
The Rutgeerts scoring system is something you should use in standard definitions. This is a four-tiered scoring system going from i0 to i4. There is a subset of i2a and i2b predicated on aphthous ulcerations in the ileum and/or disease limited to the anastomosis. A score of i0 to i2a would reflect generally good medical management and not need a medical change, whereas a score of i2b to i4 would reflect high likelihood for disease progression and recurrent surgery.
Annual Surveillance in High-Risk Patients
The final recommendation is to perform annual surveillance of the ileoanal pouch in high-risk patients. These are patients with a previous history of dysplasia, colon cancer, primary sclerosing cholangitis, or chronic pouchitis.
The recommendation is to do a retroflex of the pouch and to make sure you do biopsies of the pouch. Dr Mahadevan’s recommendation is two biopsies: proximal and distal. She puts them in the same jar, which I think is fine. She also provides an excellent recommendation to give a puff of air on the way out to make sure that, as you exit, you see the anal verge and the ileoanal anastomosis, areas where cancer can be indolent. That’s why it’s such an important recommendation to visualize these.
Key Points
These top 10 recommendations provide excellent granularity. I think the key points are to make sure we use standard language and the most appropriate definitions and technologies that we can to identify dysplasia. It needs to be done by people who are familiar with the technologies, nomenclature, and appropriate endoscopic resection, or at least who recognize when these patients should be referred to an expert center capable of doing these things.
Hopefully this discussion amplifies what you’re currently doing or exemplifies what we should be doing as the best-practice strategies in the surveillance of our patients with IBD.
I’m Dr David Johnson. Thanks for listening.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.
Follow Medscape on Facebook, Twitter, Instagram, and YouTube