From the Guidelines
Patients with ulcerative colitis and pouchitis have a small but increased risk of pouch-related cancers, and regular endoscopic surveillance is recommended, particularly for those at high risk, such as those with prior colorectal cancer or dysplasia, primary sclerosing cholangitis, or persistent moderate to severe pouchitis. The risk of pouch cancer is significantly lower than the colorectal cancer risk in untreated ulcerative colitis, with a cumulative incidence of cancers of the pouch and cuff of 3.4% at 25 years in those without risk factors 1. Risk factors for pouch-related cancers include chronic pouchitis, pre-operative dysplasia or cancer, primary sclerosing cholangitis, and longer duration of pouch presence.
Key considerations for management include:
- Regular endoscopic surveillance, at least annually for those at high risk, to assess for treatment response and detect dysplasia or cancer early 1
- Management of chronic pouchitis with antibiotics, such as ciprofloxacin or metronidazole, and anti-inflammatory treatments, like mesalamine suppositories or enemas, to reduce inflammation and potentially lower cancer risk
- Monitoring for symptoms of pouchitis, including increased stool frequency, bleeding, urgency, and abdominal pain, and maintaining regular follow-up with a gastroenterologist experienced in IBD management for early detection of concerning changes and appropriate intervention.
The American Society of Gastrointestinal Endoscopy, British Society of Gastroenterology, and European Crohn’s and Colitis Organisation recommend annual surveillance for those at high risk of dysplasia, and the British Society of Gastroenterology further recommends surveillance every 5 years for those without risk factors 1.
From the Research
Risk of Cancer in Patients with Ulcerative Colitis and Pouchitis
- Patients with ulcerative colitis (UC) have an increased risk of developing colorectal cancer (CRC) due to chronic inflammation, which induces changes in epithelial proliferation, survival, and migration via the induction of chemokines and cytokines 2.
- The risk of CRC in patients with UC is 2.4-fold higher than in the general population, with men having a greater risk than women 3.
- Extensive colitis and young age at diagnosis with UC are also risk factors for CRC, with a pooled standardized incidence ratio (SIR) of 4.8 for extensive colitis and 8.6 for young age 3.
Surveillance and Management of Dysplasia in UC
- Surveillance colonoscopies are necessary to monitor for the development of cancer and its precursor, dysplasia, in patients with UC 4, 5.
- High-definition colonoscopes and advanced endoscopic techniques, such as chromoendoscopy, endoscopic mucosal resection, and endoscopic submucosal dissection, have improved the detection and removal of dysplastic tissue 4.
- If dysplasia is detected, management strategies include endoscopic resection, colectomy, or a combination of both, depending on the severity and location of the dysplasia 2, 4.
Pouchitis and Risk of Cancer
- Patients who undergo pouch surgery, such as ileal pouch-anal anastomosis, must continue surveillance for dysplasia of the rectal cuff and the pouch 4.
- However, there is limited evidence on the specific risk of cancer in patients with pouchitis, and further studies are needed to determine the risk and optimal management strategies for these patients.
Additional Risk Factors
- Primary sclerosing cholangitis is an independent risk factor for the development of colorectal dysplasia or cancer in patients with UC, particularly in the proximal part of the colon 6.
- Sulfasalazine treatment does not appear to have a significant protective effect on the development of colorectal dysplasia or cancer in patients with UC 6.