High Adherence to Surveillance Guidelines in Inflammatory Bowel Disease Patients Results in Low Colorectal Cancer and Dysplasia Rates, While Rates of Dysplasia are Low Before the Suggested Onset of Surveillance

British Society of Gastroenterology guidelines on colorectal surveillance in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) remain at increased risk for colorectal cancer and death from colorectal cancer compared with the general population despite improvements in inflammation control with advanced therapies, colonoscopic surveillance and reductions in environmental risk factors. This guideline update from 2010 for colorectal surveillance of patients over 16 years with colonic inflammatory bowel disease was developed by stakeholders representing UK physicians, endoscopists, surgeons, specialist nurses and patients with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological support.An a priori protocol was published describing the approach to three levels of statement: GRADE recommendations, good practice statements or expert opinion statements. A systematic review of 7599 publications, with appraisal and GRADE analysis of trials and network meta-analysis, where appropriate, was performed. Risk thresholding guided GRADE judgements.We made 73 statements for the delivery of an IBD colorectal surveillance service, including outcome standards for service and endoscopist audit, and the importance of shared decision-making with patients.Core areas include: risk of colorectal cancer, IBD-related post-colonoscopy colorectal cancer; service organisation and supporting patient concordance; starting and stopping surveillance, who should or should not receive surveillance; risk stratification, including web-based multivariate risk calculation of surveillance intervals; colonoscopic modalities, bowel preparation, biomarkers and artificial intelligence aided detection; chemoprevention; the role of non-conventional dysplasia, serrated lesions and non-targeted biopsies; management of dysplasia, both endoscopic and surgical, and the structure and role of the multidisciplinary team in IBD dysplasia management; training in IBD colonoscopic surveillance, sustainability (green endoscopy), cost-effectiveness and patient experience. Sixteen research priorities are suggested.

Autoimmune diseases and risk of gastrointestinal cancer: an umbrella review of meta-analyses of observational studies

BACKGROUND

Several autoimmune diseases (ADs) are considered risk factors for gastrointestinal (GI) cancers. This study pooled and appraised the evidence associating ADs with GI cancer risks.

METHODS

Three databases were examined from initiation through 26 January 2024. Evidence was determined by the criteria including the P -value of random-effects, small-study effects, excess significance bias, heterogeneity, and 95% prediction interval.

RESULTS

Fourteen meta-analyses including 211 primary studies describing 31 associations were selected. Inflammatory bowel disease (IBD) and Crohn's disease (CD) are strong risk factors (with effect sizes of 10.33 and 12.12, respectively) for small bowel cancer (SBC), as indicated by highly suggestive evidence. Another highly suggestive evidence is that gastric cancer (GC) risk was elevated in individuals suffering from pernicious anemia (PA, effect size: 2.80). Suggestive evidence emerged that the risks of colorectal cancer (CRC) were decreased in patients with rheumatoid arthritis (RA, effect size: 0.79) but increased in patients with IBD (effect size: 1.82).

CONCLUSIONS

This study finds three highly suggestive pieces of evidence of IBD and CD patients with higher SBC risk and PA patients with higher GC risk. Future studies should identify these associations to provide more personalized cancer screenings for patients with ADs.

Adherence to endoscopic surveillance guidelines for patients with inflammatory bowel disease: An Australian cohort study

BACKGROUND AND AIM

Patients with inflammatory bowel disease have an increased risk of developing colorectal cancer as compared with the general population. Endoscopic surveillance to detect early dysplastic changes is advised by several published clinical guidelines, which provide recommendations as to the timing and performance of surveillance procedures. There is a paucity of data as to adherence with these guidelines in clinical practice.

METHODS

A longitudinal inception cohort study of all new patients diagnosed with inflammatory bowel disease across a service network of Australian hospitals between January 2005 and June 2014, with continuous follow-up in a gastroenterology clinic until December 31, 2022. Patients were included if they warranted surveillance according to the Australian guidelines. Adherence to guidelines and technical and quality measures were reported.

RESULTS

A total of 136 patients were included, and a total of 263 surveillance procedures were performed. Ninety-five patients (70%) had their first surveillance colonoscopy within the correct time interval. Fifty patients (37%) were completely adherent to guidelines with respect to timing of all surveillance procedure. The overall dysplasia detection rate for surveillance procedures was 10%. Chromoendoscopy was only performed in 16% of procedures.

CONCLUSIONS

Adherence to endoscopic surveillance guidelines with regard to timing of procedures and the utilization of chromoendoscopy is poor. Further clinician education, promotion of the surveillance guidelines and incorporation of chromoendoscopy training as part of the national colonoscopy training program may improve adherence to guidelines.

Quality of Surveillance Impacts the Colitis-Associated Advanced Neoplasia Risk: A Multicenter Case-Control Study

BACKGROUND AND AIMS

Although colorectal cancer (CRC) surveillance is embedded in clinical inflammatory bowel disease (IBD) practice, a subset of patients still develops advanced neoplasia (AN) (high-grade dysplasia [HGD] and/or CRC). We aimed to assess the impact of surveillance quality on AN risk in IBD.

METHODS

In this multicenter case-control study, we searched the Dutch nationwide pathology databank to identify IBD cases with AN and controls with indefinite or low-grade dysplasia. The surveillance colonoscopy preceding the index lesion (first indefinite for dysplasia [IND]/low-grade dysplasia [LGD] or AN) was used to assess the impact of surveillance quality. We assessed intervals, bowel preparation, cecal intubation, and absence of inflammation as primary quality indicators. In addition, we assessed chromoendoscopy, endoscopist expertise, hospital setting, and biopsy strategy. Associations of quality indicators with AN risk were determined with multivariable logistic regression analyses with Firth's correction.

RESULTS

We included 137 cases and 138 controls. Delayed intervals (58.2% vs 39.6%) and active inflammation (65.3% vs 41.8%) were frequently present in cases and controls and were associated with AN (delayed interval: adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.07-3.81; P = .03; active inflammation: aOR, 2.46; 95% CI, 1.33-4.61; P < .01). Surveillance compliant with primary quality indicators was associated with a reduced AN risk (aOR, 0.43; 95% CI, 0.22-0.91; P = .03), similar to chromoendoscopy (OR, 0.11; 95% CI, 0.01-0.89; P = .01). Other indicators were not significantly associated with AN.

CONCLUSIONS

Surveillance compliant with primary quality indicators is associated with a reduced colitis-associated AN risk. Delayed surveillance intervals and active inflammation were associated with an increased AN risk. This underlines the importance of procedural quality, including endoscopic remission to optimize the effectiveness of endoscopic surveillance.

Interval Colorectal Cancer in Inflammatory Bowel Disease: A Review

Inflammatory bowel disease (IBD) increases the risk of dysplasia and colorectal cancer (CRC). Moreover, colitis-associated CRC is responsible for a disproportionate number of CRC-related mortality. For this reason, societies recommend screening and surveillance colonoscopy as the standard of care for patients with ulcerative colitis and Crohn's colitis. Nonetheless, interval cancer defined as CRC detected within the appropriate surveillance interval might still occur despite following guideline recommendations. Even though there is limited data on risk factors associated with interval CRC in IBD, patient and disease-associated factors and technical aspects of the surveillance might play a role. This review aims to provide information on the epidemiology of interval CRC in IBD, the factors that might be associated with its occurrence, and the challenges of CRC screening and dysplasia management in patients with IBD.

Performance measures for colonoscopy in inflammatory bowel disease patients: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) presents a short list of performance measures for colonoscopy in inflammatory bowel disease (IBD) patients. Current performance measures for colonoscopy mainly focus on detecting (pre)malignant lesions. However, these performance measures are not relevant for all colonoscopy indications in IBD patients. Therefore, our aim was to provide endoscopy services across Europe and other interested countries with a tool for quality monitoring and improvement in IBD colonoscopy. Eight key performance measures and one minor performance measure were recommended for measurement and evaluation in daily endoscopy practice.

High-Volume Colonic Lavage Is a Safe and Preferred Colonoscopy Preparation for Patients With Inflammatory Bowel Disease

BACKGROUND

Colonoscopies provide a crucial diagnostic and surveillance tool for inflammatory bowel disease (IBD). Accordingly, IBD patients undergo repeated and frequent colonoscopies. The oral purgative bowel prep (BP) is often burdensome on patients, resulting in delayed or missed colonoscopies due to patient noncompliance. Additionally, oral BP has been noted to possibly induce colon mucosal inflammatory changes in some patients, which may be misleading when assessing actual disease activity.

METHODS

In this retrospective clinical study, we evaluated the use of an FDA cleared, defecation-inducing high-volume colon irrigation (>40 L) BP to prepare IBD patients for colonoscopy. Data were collected at 4 US Hygieacare centers from September 2016 to March 2021. The IBD patient population consisted of 314 patients that underwent 343 BPs. The BPs were prescribed by 65 physicians and performed by 16 nurses and technicians.

RESULTS

Patient ages were 20-85 years old, 76% females, 24% males, and 97% of the patients were adequately prepared for their colonoscopy (n = 309). Patient satisfaction with the BP was very high, as reflected in postprocedure surveys and open-ended responses text analyses, and there were no serious adverse events.

CONCLUSIONS

We present data supporting that the defecation-inducing high-volume colon irrigation BP for colonoscopy is safe, effective, and preferred for IBD patients. Using this BP for IBD patients can allow earlier interventions, significantly impacting disease management and future outcomes.

Adherence to endoscopic surveillance for advanced lesions and colorectal cancer in inflammatory bowel disease: an AEG and GETECCU collaborative cohort study

BACKGROUND AND AIMS

Patients with colonic inflammatory bowel disease (IBD) have a high risk of colorectal cancer (CRC). Current guidelines recommend endoscopic surveillance, yet epidemiological studies show poor compliance. The aims of our study were to analyse adherence to endoscopic surveillance, its impact on advanced colorectal lesions, and risk factors of non-adherence.

METHODS

A retrospective multicentre study of IBD patients with criteria for CRC surveillance, diagnosed between 2005 and 2008 and followed up to 2020, was performed. Following European guidelines, patients were stratified into risk groups and adherence was considered when surveillance was performed according to the recommendations (±1 year). Cox-proportional regression analyses were used to compare the risk of lesions. p-values below 0.05 were considered significant.

RESULTS

A total of 1031 patients (732 ulcerative colitis, 259 Crohn's disease and 40 indeterminate colitis; mean age of 36 ± 15 years) were recruited from 25 Spanish centres. Endoscopic screening was performed in 86% of cases. Adherence to guidelines was 27% (95% confidence interval, CI = 24-29). Advanced lesions and CRC were detected in 38 (4%) and 7 (0.7%) patients respectively. Adherence was associated with increased detection of advanced lesions (HR = 3.59; 95% CI = 1.3-10.1; p = 0.016). Risk of delay or non-performance of endoscopic follow-up was higher as risk groups increased (OR = 3.524; 95% CI = 2.462-5.044; p < 0.001 and OR = 4.291; 95%CI = 2.409-7.644; p < 0.001 for intermediate- and high- vs low-risk groups).

CONCLUSIONS

Adherence to endoscopic surveillance allows earlier detection of advanced lesions but is low. Groups at higher risk of CRC are associated with lower adherence.

Colorectal Dysplasia and Cancer Surveillance in Ulcerative Colitis

Ulcerative colitis (UC) is a risk factor for the development of inflammation-associated dysplasia or colitis-associated neoplasia (CAN). This transformation results from chronic inflammation, which induces changes in epithelial proliferation, survival, and migration via the induction of chemokines and cytokines. There are notable differences in genetic mutation profiles between CAN in UC patients and sporadic colorectal cancer in the general population. Colonoscopy is the cornerstone for surveillance and management of dysplasia in these patients. There are several modalities to augment the quality of endoscopy for the better detection of dysplastic or neoplastic lesions, including the use of high-definition white-light exam and image-enhanced colonoscopy, which are described in this review. Clinical practice guidelines regarding surveillance strategies in UC have been put forth by various GI societies, and overall, there is agreement between them except for some differences, which we highlight in this article. These guidelines recommend that endoscopically detected dysplasia, if feasible, should be resected endoscopically. Advanced newer techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have been utilized in the treatment of CAN. Surgery has traditionally been the mainstay of treating such advanced lesions, and in cases where endoscopic resection is not feasible, a proctocolectomy, followed by ileal pouch-anal anastomosis, is generally recommended. In this review we summarize the approach to surveillance for cancer and dysplasia in UC. We also highlight management strategies if dysplasia is detected.

Colonoscopy and artificial intelligence: Bridging the gap or a gap needing to be bridged?

Research in artificial intelligence (AI) in gastroenterology has increased over the last decade. Colonoscopy represents the most widely published field with regards to its use in gastroenterology. Most studies to date center on polyp detection and characterization, as well as real-time evaluation of adequacy of mucosal exposure for inspection. This review article discusses how advances in AI has bridged certain gaps in colonoscopy. In addition, the gaps formed with the development of AI that currently prevent its routine use in colonoscopy will be explored.

Endoscopic surveillance of colorectal cancer in inflammatory bowel diseases: a review of the literature

INTRODUCTION

The risk of colorectal cancer (CRC) in patients with inflammatory bowel diseases (IBD) is higher compared to the general population and it is related to the type, severity, duration, and extension of the disease.

AREAS COVERED

This review aims to highlight current evidence from the literature supporting the role of endoscopic surveillance of CRC in patients with IBD.

EXPERT OPINION

Even in the absence of randomized controlled trials (RCTs), evidence from the literature supports the effectiveness of endoscopic surveillance in reducing IBD-related CRC incidence and mortality. As a consequence, current guidelines recommend colonoscopy 8-10 years after disease or symptom onset in all patients with ulcerative colitis (UC) and Crohn's disease (CD) involving at least one-third of the colon and agree on the necessity of annual surveillance in high-risk patients. Nevertheless, an overall agreement on the optimal intervals for surveillance of low-intermediate risk patients is absent and 2-5 year intervals have been proposed. In the near future, further studies are needed to assess the most effective intervals and tailor the surveillance based on the personal risk profile. Additionally, further efforts should be made to evaluate the role of noninvasive tests as primary screening, thus avoiding unnecessary colonoscopies.

Endoscopic surveillance strategies for dysplasia in ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder with an increased risk of colorectal cancer (CRC). This has led to the implementation of surveillance programmes to minimise this risk. Overall, these proactive programmes in association with better medical therapies have reduced the incidence of CRC in this population. Specific populations remain at increased risk, such as younger age at diagnosis, primary sclerosing cholangitis, colonic strictures and pseudopolyps. The majority of gastrointestinal international societies favour chromoendoscopy with targeted biopsies or random biopsies. The aim of this review is to present the current literature on dysplasia surveillance, the methodology and endoscopic technology available to assess dysplasia in UC.