From the Guidelines
The latest British Society of Gastroenterology (BSG) guidelines on inflammatory bowel disease (IBD) surveillance recommend risk stratification of patients into high, intermediate, and low-risk categories, with surveillance intervals modified accordingly, as supported by the most recent evidence 1. The guidelines now emphasize the use of chromoendoscopy with targeted biopsies as the preferred surveillance technique rather than random biopsies, as dye-based chromoendoscopy enhances detection of dysplastic lesions. Some key points to consider when determining the next surveillance interval include:
- Patient preference
- Presence of multiple post-inflammatory polyps
- Age and comorbidity
- Accuracy and completeness of examination The guidelines suggest the following surveillance intervals:
- High-risk patients: annual colonoscopy
- Intermediate-risk patients: surveillance every 2-3 years
- Low-risk patients: colonoscopy every 5 years, as suggested by the 2021 AGA clinical practice update 1 It is also important to note that patients with Crohn’s disease isolated to the small bowel do not appear to harbor a greater risk of CRC than comparable non-IBD patients, thus average-risk CRC surveillance recommendations appear appropriate 1. Surveillance should begin 8 years after symptom onset for patients with extensive colitis and 10 years for those with left-sided colitis, with the next surveillance interval determined based on the risk level, as outlined in the 2019 BSG consensus guidelines 1. Some of the key factors that determine the risk level include:
- Disease extent
- Duration
- Severity of inflammation
- Family history of colorectal cancer
- Presence of primary sclerosing cholangitis
The 2019 BSG consensus guidelines provide a summary of the next surveillance interval based on the risk level, with the following conditions:
Risk Level Next Surveillance Interval Conditions Lower risk 5 years Extensive colitis with no active endoscopic or histological inflammation or left sided colitis or Crohn’s colitis affecting <50% of colon Intermediate risk 3 years Extensive colitis with mildly active endoscopic or histological inflammation or post-inflammatory polyps (often termed ‘pseudopolyps’) or family history of colorectal cancer in first degree relative aged ≥50 years Higher risk 1 year Extensive colitis with moderate/severely active endoscopic or histological inflammation or if stricture or dysplasia in last 5 years or primary sclerosing cholangitis (including post-orthotopic liver transplant) or family history of colorectal cancer in first degree relative aged <50 years
From the Research
Changes in IBD Surveillance Guidelines
There are no direct references to the latest BSG guidelines on IBD surveillance in the provided studies. However, the studies provide information on the disease phenotype and course of ulcerative colitis in patients with primary sclerosing cholangitis, which may be relevant to surveillance guidelines.
Disease Phenotype and Course
- Patients with ulcerative colitis and primary sclerosing cholangitis have a distinct disease course characterized by an earlier disease onset and lower disease activity, but more frequent extensive disease manifestation and higher risk for colorectal cancer 2.
- The clinical course and endoscopic features of colitis associated with primary sclerosing cholangitis have not been well documented, but studies suggest that it may represent a subset of ulcerative colitis with atypical colonoscopic findings and milder disease activity 3.
- Patients with primary sclerosing cholangitis and ulcerative colitis have a higher risk of developing colorectal dysplasia/carcinoma than patients with ulcerative colitis alone 4, 5.
Risk Factors for Colorectal Neoplasia
- Primary sclerosing cholangitis is a risk factor for the development of colorectal neoplasia in patients with ulcerative colitis 4, 5.
- The risk of colorectal neoplasia is higher in patients with ulcerative colitis and primary sclerosing cholangitis than in patients with Crohn's disease and primary sclerosing cholangitis 6.
Surveillance Recommendations
Although the provided studies do not directly address the latest BSG guidelines on IBD surveillance, they suggest that patients with primary sclerosing cholangitis and ulcerative colitis may require more frequent and intensive surveillance due to their higher risk of developing colorectal neoplasia 4, 5, 2, 6.