What’s the best approach for dysplasia surveillance in IBD?

High-definition white light endoscopy

Longstanding ulcerative colitis and Crohn’s colitis increase the risk for developing colorectal cancer. The majority of neoplastic lesions are visible endoscopically, and therefore, dye spraying chromoendoscopy (DCE) may not be necessary for all inflammatory bowel disease (IBD) patients undergoing a routine dysplasia surveillance colonoscopy.

High-definition white light (HDWL) endoscopes have higher magnification capacities and pixel density than the standard definition (SD) systems and provide sharper images with fewer artifacts. Although DCE has been proven to be superior to SD, there have been no differences in detection of dysplasia for routine surveillance with use of HDWL compared to DCE.

The SCENIC guidelines key recommendation for optimizing detection and management of dysplasia in IBD is to use a HD colonoscope. Further, based on the recent ACG Practice Guidelines for Dysplasia Screening and Surveillance in 2019, HD colonoscopes are also recommended.

In a network meta-analysis of eight parallel-group randomized controlled trials (RCT), there was very low quality of evidence to support the use of DCE over HDWL. This was contrary to prior, non-RCT studies which suggested that both SD and HDWL were inferior to DCE. More recently, Iacucci and colleagues conducted a randomized noninferiority trial to determine detection rates of neoplastic lesions in IBD patients with longstanding colitis who had inactive disease and enrolled in HDWL, DCE, or virtual chromoendoscopy (VCE) groups. The conclusion was that VCE and HDWL was not inferior to DCE, and HDWL was sufficient in detection of all neoplastic lesions including dysplasia and adenocarcinoma. In another large multicenter, prospective RCT of nine tertiary hospitals in South Korea, the detection rates of colitis-associated dysplasia or all colorectal neoplasia were comparable in HDWL versus high-definition chromoendoscopy. Lastly, a meta-analysis of six RCTs concluded that, although DCE is superior to SD in identification of dysplasia, there was no benefit of DCE compared to HDWL.

In summary, HDWL colonoscopy should be the standard of care for routine dysplasia surveillance in IBD. DCE should be considered in patients who are found to have a dysplastic lesion by HDWL in order to better delineate the lesion margins, endoscopically resect or remove, and for future dysplasia surveillance colonoscopies in the higher-risk IBD patient. Overall, a close and careful examination of the entire colon with use of HDWL is sufficient in detection of dysplasia and for routine surveillance in IBD patients.

Anita Afzali, MD, MPH, AGAF, is medical director of the Inflammatory Bowel Disease Center and program director of the Advanced Inflammatory Bowel Disease Fellowship at Ohio State University in Hilliard, Ohio. She has no relevant conflicts of interest.

These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2021.