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
Rationale
Persons with inflammatory bowel disease have a lifetime risk of colorectal cancer at least twice 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 risk. 2–4 (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 time goes on. 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. 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
Biopsy protocol
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. Therefore, biopsy samples should be taken every 10 cm.
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 alternative markers of malignancy to improve the sensitivity of the present surveillance regimens.
References
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; 58:1569-1574.
5. Lashner BA, Hanauer SB, Silverstein MD. Optimal timing of colonoscopy to screen for cancer in ulcerative colitis. Ann Intern Med 1988; 108:274-278.
6. Ekbom A, Helmick C, Zack M, et al. Ulcerative colitis and colorectal cancer. A population-based study. N Engl J Med 1990; 323:1228-1233.
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.
Reprinted with permission from the Cleveland Clinic Journal of Medicine, Volume 66, Number 5, May, 1999. All rights reserved.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 10/3/2006...#8097
