From the Guidelines
The recommended surveillance protocol for a rectal cuff in patients with Crohn's disease (CD) involves annual endoscopic examination with multiple biopsies, particularly for those at high risk of developing colorectal dysplasia, such as those with prior colorectal cancer or dysplasia, primary sclerosing cholangitis, persistent moderate to severe pouchitis, and/or pre-pouch ileitis. This approach is supported by the American Society of Gastrointestinal Endoscopy, British Society of Gastroenterology, and European Crohn’s and Colitis Organisation, as outlined in the 2021 clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases 1.
Key considerations for surveillance include:
- Annual surveillance for high-risk patients, including those with prior colorectal dysplasia or cancer, primary sclerosing cholangitis, and those with persistent pouchitis or type C (atrophic and inflamed) mucosa
- Individualized surveillance intervals for those at lower risk, with some guidelines suggesting surveillance every 5 years for those without risk factors, as recommended by the British Society of Gastroenterology 1
- The importance of multiple biopsies during surveillance, with 4-6 biopsies taken from the rectal cuff or pouch at multiple levels, and additional targeted biopsies of any suspicious areas
- The need for lifelong surveillance, as the cancer risk persists over time, particularly in patients with retained rectal tissue after total colectomy with ileorectal anastomosis or ileoanal pouch.
The rationale for this protocol is based on the increased risk of colorectal dysplasia and cancer in patients with Crohn's disease, particularly those with a history of colorectal cancer or dysplasia, and the importance of early detection and intervention to prevent the progression to cancer, as highlighted in the 2021 clinical practice update 1.
From the Research
Surveillance of Rectal Cuff in Crohn's Disease
The recommended surveillance protocol for a rectal cuff in patients with Crohn's disease (CD) is not explicitly stated in the provided studies. However, some studies provide information on the management of dysplasia in Crohn's colitis and the risk of cancer in patients with CD.
- The study by 2 suggests that total proctocolectomy (TPC) is recommended in good-risk patients with multifocal dysplasia in Crohn's colitis.
- The study by 3 found no signs of malignancy or premalignant degeneration in a prospective series of IBD patients with a closed rectal stump, but noted the presence of moderate to severe inflammation in the majority of rectal stumps.
- The study by 4 found that 29% of high-grade dysplasia (HGD) or colorectal cancer (CRC) was undetected in patients with inflammatory bowel disease (IBD), and that the rectum was a common site for undetected lesions.
Risk of Cancer in Patients with CD
- The study by 2 confirms the risk of cancer in patients with CD dysplasia, and notes that the predictive value of high-grade dysplasia (HGD) for a final HGD or cancer diagnosis was 73%.
- The study by 4 found that patients with pancolitis and multifocal dysplasia were more likely to have undetected HGD/CRC.
Surveillance Methods
- The study by 5 suggests that capsule endoscopy may be a useful tool for detecting recurrence after surgery for Crohn's disease, and is better tolerated than colonoscopy.
- The study by 4 notes that the high proportion of undetected rectal and right-sided HGD/CRC suggests that these areas may need greater attention during surveillance.