Mistakes in ... 2021 - 40
ueg education
Mistakes in... 2021
lesion. A good endoscopy report should be
supplemented with good quality images (or
videos), which can be particularly helpful when
determining optimal patient management.
Mistake 6 Not obtaining a second, expert
histopathologist opinion when dysplasia
is detected
The histological diagnosis of dysplasia in
the context of colitis can be challenging for a
pathologist. This is particularly true when there
is active inflammation because inflammatory
and regenerative changes can mimic dysplasia,
which is another reason to try to suppress
disease activity as much as possible prior
to colonoscopy. Therefore, when a clinician
receives a pathology report describing dysplasia,
it is important to obtain a second opinion from
an expert gastrointestinal histopathologist. This
is a longstanding recommendation but is equally
important today and, in my experience, can
frequently change the management decision.
Mistake 7 Assuming that endoscopic
therapy in patients who have colitis is easy
Whereas in the past, panproctocolectomy was
recommended for patients with colitis-associated
dysplasia, it is now recognised that many
neoplastic lesions are amenable to endoscopic
therapy. However, before the decision to use
endoscopic therapy is made, a very careful review
is required. It is important to repeat a high-quality
colonoscopic assessment to ensure there are no
synchronous lesions. During these procedures,
I also take additional random biopsies from the
background mucosa to ensure there is no
endoscopically invisible neoplasia, as clearly this
would totally change the management plan.
When assessing the actual lesion, it is
important to assess its lateral margin - some
lesions are poorly circumscribed and therefore
Your colorectal cancer and IBD briefing
UEG Week
* 'Colorectal cancer screening' session at UEG Week Virtual
2020 [https://ueg.eu/library/session/
colorectal-cancer-screening/161/2666].
* 'Colorectal cancer' session at UEG Week
Virtual 2020 [https://ueg.eu/library/session/
colorectal-cancer/161/2752].
* 'Quality in screening colonoscopy' session at UEG Week
Virtual 2020 [https://ueg.eu/library/session/
quality-in-screening-colonoscopy/161/2715].
* 'Screening strategies in colorectal cancer:
What's new in 2020?' session at UEG Week Virtual 2020
[https://ueg.eu/library/session/screening-strategies
-in-colorectal-cancer-whats-new-in-2020/161/2777].
* 'Cancer and IBD' session at UEG Week 2018 [https://ueg.
eu/library/session/cancer-and-ibd/153/1979].
28
* 'Intestinal and extra-intestinal cancers in IBD' session at
UEG Week 2016 [https://ueg.eu/library/session/
intestinal-and-extra-intestinal-cancers-in-ibd/144/1613].
Standards and Guidelines
* Hassan C, East J, Radaelli F, et al. Bowel preparation for
colonoscopy: European Society of Gastrointestinal
Endoscopy (ESGE) Guideline - Update 2019. Endoscopy
2019; 51: 775-779 [https://ueg.eu/library/
bowel-preparation-for-colonoscopy-european-societyof-gastrointestinal-endoscopy-esge-guidelineupdate-2019/231355].
*
Cubiella J, Marzo-Castillejo M, Mascort-Roca J, et al.
Clinical practice guideline. Diagnosis and prevention of
colorectal cancer. 2018 Update. Gastroenterol Hepatol
2018; 41: 585-596 [https://ueg.eu/library/
clinical-practice-guideline-diagnosis-and-prevention-ofcolorectal-cancer-2018-update/203033].
*
Annese V, Beaugerie L, Egan L, et al. European
evidence-based consensus: inflammatory bowel disease
and malignancies. J Crohns Colitis 2015; 9: 945-965
[https://ueg.eu/library/european-evidence
-based-consensus-inflammatory-bowel-disease-andmalignancies/125370].
*
Laine L, Kaltenbach T, Barkun A, et al. SCENIC
international consensus statement on surveillance and
management of dysplasia in inflammatory bowel
disease. Gastroenterology 2015; 148: 639-651.e28
[https://www.gastrojournal.org/article/S00165085(15)00116-X/fulltext].
*
Langner C, Magro F, Driessen A, et al. The
histopathological approach to inflammatory bowel
disease: a practice guide. Virchows Arch 2014; 464:
511-527 [https://ueg.eu/library/
the-histopathological-approach-to-inflammatorybowel-disease-a-practice-guide/128280].
challenging
to remove endoscopically. Even if
the lesion is well circumscribed, if it is within a
segment of the colon that has either active
inflammation or has previously been inflamed,
there will often be submucosal fibrosis, which
renders the lesion difficult to lift and resect.
As with any endoscopic therapy, the best
opportunity to resect the lesion fully is at the first
attempt, so it is paramount that the resection of
such lesions is only attempted by endoscopists
experienced in complex polyp therapy.
That being said, the majority of dysplastic
lesions that are seen in colitis surveillance will be
small, well circumscribed, similar in appearance
to sporadic adenomas and easy to resect en bloc
with careful, standard polypectomy techniques.
For these lesions, the mistake to avoid is
overinterpreting their significance and subjecting
the patient to unnecessary life-changing surgery.
The importance of the assessment and
clinical decision is evident - get it wrong and a
patient may either be needlessly subjected to
major surgery or left with a high risk of
developing CRC.
Mistake 8 Focusing on the lesion rather
than managing the patient holistically
Finally, but importantly, clinicians must treat
the patient rather than the endoscopic lesion,
because the optimal management plans for
two patients with identical endoscopic lesions
might be completely different. For example, an
older patient with quiescent colitis who has a
well circumscribed, 15 mm sessile lesion in the
transverse colon might be best managed by
endoscopic resection of the lesion, whereas an
identical lesion in a young patient with PSC might
prompt a decision for early panproctocolectomy,
owing to that patient's high lifetime risk of CRC.
Multidisciplinary discussion and shared
decision-making are, therefore, important
cornerstones of optimal patient care.
References
1. Soderlund S, et al. Inflammatory bowel disease
confers a lower risk of colorectal cancer to females
than to males. Gastroenterology 2010; 138: 1697-1703.
2. Jess T, et. al. Risk of colorectal cancer in patients with
ulcerative colitis: a meta-analysis of populationbased
cohort studies. Clin Gastroenterol Hepatol
2012; 638: 639-645.
3. Lutgens MW, et al. Declining risk of colorectal cancer
in inflammatory bowel disease: an updated metaanalysis
of population-based cohort studies. Inflamm
Bowel Dis 2013; 19: 789-799.
4. Herrinton LJ, Liu L, Levin TR, et al. Incidence and
mortality of colorectal adenocarcinoma in persons
with inflammatory bowel disease from 1998 to 2010.
Gastroenterology 2012; 143: 382-389.
5. Burr NE, et al. Variation in post-colonoscopy
colorectal cancer across colonoscopy providers in
English National Health Service: population based
cohort study. BMJ 2019; 367: l6090.
6. Shah SC, et al. High risk of advanced colorectal neoplasia
in patients with primary sclerosing cholangitis
associated with inflammatory bowel disease. Clin
Gastroenterol Hepatol 2018; 16: 1106-1113.e3.
7. Jess T, et al. Decreasing risk of colorectal cancer in
patients with inflammatory bowel disease over 30
years. Gastroenterology 2012; 143: 375-381.e1.
8. Rutter M, et al. Severity of inflammation is a risk factor
for colorectal neoplasia in ulcerative colitis.
Gastroenterology 2004; 126: 451-459.
9. Rutter MD, et al. Cancer surveillance in longstanding
ulcerative colitis: endoscopic appearances help
predict cancer risk. Gut 2004; 53: 1813-1816.
10. Ekbom A, et al. Ulcerative colitis and colorectal
cancer. A population-based study. N Engl J Med 1990;
323: 1228-1233.
11. Annese V, et al. European evidence based consensus
for endoscopy in inflammatory bowel disease.
J Crohns Colitis 2013; 7: 982-1018.
12. Cairns SR, Scholefield JH, Steele RJ, et al. Guidelines
for colorectal cancer screening and surveillance in
moderate and high risk groups (update from 2002).
Gut 2010; 59: 666-689.
13. Laine L, Kaltenbach T, Barkun A, et al. SCENIC
international consensus statement on surveillance
and management of dysplasia in inflammatory bowel
disease. Gastroenterology 2015; 148: 639-651.e28.
14. Imperatore N, Castiglione F, Testa A, et al. Augmented
endoscopy for surveillance of colonic inflammatory
bowel disease: systematic review with network metaanalysis.
J Crohns Colitis 2019; 13: 714-724.
15. Travis SP, Schnell D, Krzeski P, et al. Developing an
instrument to assess the endoscopic severity of
ulcerative colitis: the Ulcerative Colitis Endoscopic
Index of Severity (UCEIS). Gut 2012; 61: 535-542.
16. The Paris endoscopic classification of superficial
neoplastic lesions: esophagus, stomach, and colon:
November 30 to December 1, 2002. Gastrointest
Endosc 2003; 58: S3-S43.
https://www.ueg.eu/library/session/intestinal-and-extra-intestinal-cancers-in-ibd/144/1613
https://www.ueg.eu/library/session/intestinal-and-extra-intestinal-cancers-in-ibd/144/1613
https://www.ueg.eu/library/session/colorectal-cancer-screening/161/2666
https://www.ueg.eu/library/european-evidence-based-consensus-inflammatory-bowel-disease-and-malignancies/125370
https://www.ueg.eu/library/session/colorectal-cancer-screening/161/2666
https://www.ueg.eu/library/european-evidence-based-consensus-inflammatory-bowel-disease-and-malignancies/125370
https://www.ueg.eu/library/european-evidence-based-consensus-inflammatory-bowel-disease-and-malignancies/125370
https://www.ueg.eu/library/session/colorectal-cancer/161/2752
https://www.ueg.eu/library/session/colorectal-cancer/161/2752
https://www.ueg.eu/library/bowel-preparation-for-colonoscopy-european-society-of-gastrointestinal-endoscopy-esge-guideline-update-2019/231355
https://www.ueg.eu/library/bowel-preparation-for-colonoscopy-european-society-of-gastrointestinal-endoscopy-esge-guideline-update-2019/231355
https://www.ueg.eu/library/session/quality-in-screening-colonoscopy/161/2715
https://www.ueg.eu/library/bowel-preparation-for-colonoscopy-european-society-of-gastrointestinal-endoscopy-esge-guideline-update-2019/231355
https://www.ueg.eu/library/session/quality-in-screening-colonoscopy/161/2715
https://www.gastrojournal.org/article/S0016
https://www.ueg.eu/library/bowel-preparation-for-colonoscopy-european-society-of-gastrointestinal-endoscopy-esge-guideline-update-2019/231355
https://www.ueg.eu/library/session/screening-strategies-in-colorectal-cancer-whats-new-in-2020/161/2777
https://www.ueg.eu/library/session/screening-strategies-in-colorectal-cancer-whats-new-in-2020/161/2777
https://www.ueg.eu/library/clinical-practice-guideline-diagnosis-and-prevention-of-colorectal-cancer-2018-update/203033
https://www.ueg.eu/library/the-histopathological-approach-to-inflammatory-bowel-disease-a-practice-guide/128280
https://www.ueg.eu/library/clinical-practice-guideline-diagnosis-and-prevention-of-colorectal-cancer-2018-update/203033
https://www.ueg.eu/library/session/cancer-and-ibd/153/1979
https://www.ueg.eu/library/the-histopathological-approach-to-inflammatory-bowel-disease-a-practice-guide/128280
https://www.ueg.eu/library/clinical-practice-guideline-diagnosis-and-prevention-of-colorectal-cancer-2018-update/203033
https://www.ueg.eu/library/session/cancer-and-ibd/153/1979
https://www.ueg.eu/library/the-histopathological-approach-to-inflammatory-bowel-disease-a-practice-guide/128280
Mistakes in ... 2021
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