We recommend that patients with ulcerative colitis
undergo a colonoscopy every one to three years. During these procedures, biopsy
samples should be taken every 10 cm along the length of the colon; and if any of
these samples reveals dysplasia, a total proctocolectomy should be considered.1
Persons with inflammatory bowel disease have a lifetime risk of colorectal
cancer at least three times as high as in the general population. Moreover, they
tend to develop colorectal cancer much earlier in their lives than do people
with sporadic colon cancer. The longer the person has had inflammatory bowel
disease and the more extensive it is, the greater the risk2–4. However, proctitis poses no increase in risk for rectal cancer.
Frequency of colonoscopies
Since the risk of dysplasia or cancer increases
with the duration of ulcerative colitis, testing should be done more frequently
as duration of disease increases.5 One method calls for testing every
three years for the first 15 years of disease, every two years for the next 10
years, and every year thereafter.1 Such an approach provides for at
least 20 examinations in 40 years of disease. Most of the evaluations would be
performed in the later years when the risk is the highest.
A history of primary sclerosing cholangitis, a liver
disease associated with ulcerative colitis, adds significantly to the already
high risk of dysplasia and colorectal cancer in patients with ulcerative
colitis. Therefore, at the same duration of disease, patients with primary
sclerosing cholangitis should be tested more often, perhaps every year.3, 5, 6
For these patients, prophylactic colectomy may offer the best alternative in
terms of life expectancy.7, 8
Because dysplasia can be present focally as well
as diffusely, biopsies must be taken throughout the colon. The sensitivity of
testing for detecting dysplasia is increased with a greater number of biopsies
taken. At least 32 biopsies should be taken of flat mucosa and of raised lesions.
Any biopsy that is positive for dysplasia poses an
inordinately high risk of colorectal cancer; the risk of concurrent cancer has
been reported to be as high as 19 percent in patients with low-grade dysplasia
and 42 percent in patients with high-grade dysplasia.10 Therefore, a
total proctocolectomy is usually recommended for all patients with low-grade
dysplasia, high-grade dysplasia or cancers found at colonoscopy.
Research is ongoing to determine whether alternative markers of malignancy or improved visualization of the colon with
chromoendoscopy, narrow band imaging, or autofluorescence can significantly
improve the sensitivity of the present surveillance techniques to detect dysplasia.
1. Lashner BA. Recommendations for colorectal cancer screening in ulcerative colitis: A review of research from a single
university-based surveillance program. Am J Gastroenterol 1992; 87:168-175.
2. Greenstein A, Sachar D, Pucillo A, et al. Cancer in universal and left sided ulcerative colitis: Clinical
and pathologic features. Mt Sinai J Med 1981; 46:25-32.
3. Gyde SN, Prior P, Allan RN, et al. Colorectal cancer in ulcerative colitis: A cohort study of primary referrals from three
centres. Gut 1988; 29:206-217.
4. Mir-Madilessi SH, Farmer RG, Easley KA, et al. Colorectal and extracolonic malignancy in ulcerative colitis. Cancer 1986;
5. Lashner BA, Hanauer SB, Silverstein MD. Optimal timing of colonoscopy to screen for cancer in ulcerative colitis. Ann Intern Med
6. Ekbom A, Helmick C, Zack M, et al. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med 1990;
7. Marchesa P, Lashner BA, Lavery IC, et al. The risk of cancer and dysplasia among ulcerative colitis
patients with primary sclerosing cholangitis. Am J Gastroenterol 1997; 92:1285-1288.
8. Loftus EV, Sandborn WJ, Tremaine WJ, et al. Risk of colorectal neoplasia in patients with primary sclerosing cholangitis.
Gastroenterology 1996; 110:432-440.
9. Provenzale D, Kowdley KV, Arora S, et al. Prophylactic colectomy or surveillance for chronic ulcerative colitis? A
decision analysis. Gastroenterology 1995; 109:1188-1196.
10. Shapiro BD, Lashner BA. Cancer biology in ulcerative colitis and potential use in endoscopic surveillance. Gast Endo Clin
North Am 1997; 7:453-468.
© Copyright 1995-2010 The Cleveland Clinic Foundation. All rights reserved.
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