Surveillance Guidelines

Guidelines have recently been published by authors from different expert centres [16-19]. Since duration and anatomic extent of the ulcerative colitis have been shown to be the two strong and independent risk factors regarding the development of cancer, special attention to these variables is crucial in the practice of surveillance. The UK guidelines for surveillance in ulcerative colitis [19] state that surveillance colonoscopy should preferably be performed in disease remission, it should be performed in all patients after 8-10 years of disease to clarify disease extent, and regular surveillance should begin after 8-10 years in those with pancolitis and after 10-15 years in those with left-sided colitis. Given that cancer risk increases with the duration of disease, the interval between colonoscopies should decrease in line with increased disease duration. In the second decade of disease, colonoscopy should be carried out every 3 years, in the third decade every 2 years and every year in the fourth decade. Based on the fact that interval cancers can develop within 2 years after an examination, patients with extensive (or left-sided) colitis who have a negative result should begin surveillance within 1-2 years. With a negative surveillance colonoscopy, subsequent examinations should be performed every 1-2 years. With two negative examinations, the next surveillance examination may be performed in 1-3 years until colitis has been present for 20 years.

To obtain 90% sensitivity for the detection of dys-plasia in patients with extensive disease, a minimum of 33 biopsies is suggested, taking 4 biopsies for every 10 cm around the colon. In those with less extensive microscopic disease, four quadrant biopsies taken from the proximal extent of disease and every 10 cm distally would be satisfactory. The commonly followed guideline is that any diagnosis of high-grade dysplasia (and low-grade dysplasia when associated with a DALM) should lead to consideration of colectomy, while low-grade dysplasia in flat mucosa should not be an indication for colectomy but for continuous surveillance with colonoscopy. The issue is controversial. While DALM or cancer in such cases has been proved to occur in more than half the patients at 5 years [20] other authors [21] considered low-grade dysplasia (unrelated to a DALM) less alarming and not sufficiently reliable as a marker to justify prophylactic colectomy.

Careful comparative studies by experienced pathologists show evidence that surveillance and screening programmes may carry a significant rate of histological error due to interobserver variation between the gastrointestinal pathologists when grading dysplasia in ulcerative colitis [22].

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