Thread by @mchiorean4

1/
Important update for #IBD. The @AmerGastroAssn has issued updated clinical practice recommendations for neoplasia surveillance in #IBD. These are not the same as "guidelines" although the difference may be mostly semantics.
Several important highlights follow
Read on!

2/ Use the newest terminology to describe a suspicious lesions as per #SCENIC: polypoid (>2.5 mm tall), non-polypoid (<2.5 mm) or invisible (avoid "flat") if detected on random biopsies, see ⬇️
Describe size, morphology, borders (v important!) and location (within/out colitis)

3/ When to start: 8-10 years after dx. Disease extent (e.g. L-sided) no longer emphasized.
a. Exception are patients with #PSC #IBD in whom you should start immediately and repeat annually
b. Use the first c/scope as an opportunity to restage
c. target severely affected areas

4/ Three types of biopsies:
a. targeted (suspicious lesions) - also consider endoscopic resection if feasible
b. non-targeted (random) - of previously affected area (no point in doing surveillance of normal colon tissue)
c. staging (use to determine histo extent)

5/ When to use chromoendoscopy (dye or virtual):
a. you have experience with it
b. you use standard def endoscopes (uncommon)
c. patient with invisible dysplasia on non-targeted biopsies
d. primary sclerosing cholangitis (my personal bias)

6/ are non-targeted biopsies still required? Here the experts are shifting in the right direction:
No, if you use chromo and no complicating factors (PSC, severe inflammation, pseudopolyps, prior dysplasia)
Yes, if any of the above present, or using WLE

7/ Management of dysplasia:
A. Visible and resectable - resect
B. Visible but ? resectable - refer to #IBD center
C. Unresectable - surgery
D. Invisible w WLE - refer for chromo
E. Invisible w chromo - surveillance if focal, surgery if multi-focal

8/ Surveillance after index diagnosis of dysplasia:
A. High-grade or incomplete: 3-6 months
B. Large but low-grade: 12 months
C. Small (<1 cm), LGD, complete resection: 2 years
see ⬇️

9/ What to do when no dysplasia detected with chromo after previous dysplasia was detected on non-targeted biopsies. This is tricky but the experts are providing some clarity here ⬇️ Bottom line, high-risk ➡️ surgery.

10/ Surveillance intervals after negative c/s. New guidance, the interval can be extended to 5 years in low-risk patients. This is good bc in my opinion, "one size fits all" has been an overkill. This is endorsed by others as well @BritSocGastro

11/ What to do with pseudopolyps?
A. targeted bx for concerning ones (👀of the beholder)
B. look carefully in-between
C. Chromo should not be used (I am not sure I agree with this, as I find chromo useful in these pts)
D. Colectomy last resort (not automatic!)

12/ Pouch surveillance (also new-ish):
A. Annually for high-risk: history of cancer, neoplasia, PSC or severe pouchitis
B. Individualized for others (5 year intervals recommended by @BritSocGastro)

13/ Last but not least❗️ Optimal disease control is paramount for a good quality exam and to reduce the long-term risk of #ColonCancer in #IBD

14/ In summary, what's new in 2021:
a. ⬆️emphasis on targeted biopsies
b. ⬇️emphasis on "random" bx
c. emphasis on terminology (know your descriptors)
d. emphasis on risk
e. emphasis on endoscopic treatment
f. ⬆️quality
g. personalized surveillance intervals
@Realcecum #IBD 🔚