Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Service d’Hépato-Gastroentérologie et d’Assistance Nutritive, 67098 Strasbourg Cedex
Unité INSERM U1113 IRFAC (Interface de Recherche Fondamentale et Appliquée en Cancérologie), Université de Strasbourg, Faculté de Médecine, 3 avenue Molière, 67200 Strasbourg
Patients with inflammatory bowel disease [IBD: ulcerative colitis (UC) or Crohn's disease (CD)] have an increased risk to develop colorectal cancer (CRC), small bowel adenocarcinoma, ileo-anal pouch cancer, anal cancer and finally cholangiocarcinoma.
In UC patients the risk for CRC is significantly higher in those having (or who had former) involvement above the left colonic flexure. In colonic CD patients those having pancolitis are the most at risk. Other factors than disease extension have been demonstrated to increase CRC occurrence: disease duration (and young age at diagnosis), association with primary sclerosing cholangitis (PSC), first degree familial history of CRC, and disease severity (sustained severe mucosal inflammation). In these patients a colonoscopic surveillance program is recommended depending from risk level: low, moderate or high risk. Patients considered at high risk have to undergo a yearly colonoscopy, those considered at moderate risk, a surveillance each two to three years, and those at low risk each five years. Colonoscopy has ideally to be performed in patients with quiescent disease using high definition colonoscopes, indigo carmine (or in several countries methylene blue) pan-chromoendoscopy combined to targeted biopsies on suspect lesions (for dysplasia or cancer).
In CD patients with small bowel involvement, small bowel adenocarcinoma risk is very significantly higher than in the general population, despite this complication remains rare. Small bowel adenocarcinoma should be suspected in CD patients with digestive symptoms appearing after a long period of disease remission or in those presenting an occlusion refractory to the usual medical treatments. No specific surveillance recommendation for early small bowel adenocarcinoma diagnosis has been currently proposed.
UC patients who needed total coloproctectomy have a slight risk to develop a cancer in ileoanal pouch. These patients should ideally have an annual endoscopic pouch surveillance.
In CD patients with severe perineal disease, an increase in anal cancer occurrence has been reported. Therefore, an annual proctological examination under general anesthesia should be performed, especially in those with anal stenosis.
Finally, in patients with both colonic IBD and primary sclerosing cholangitis, the risk to develop a CRC is significantly higher (and an annual colonoscopic surveillance is recommended), but, in addition, these patients have also an increased risk for cholangiocarcinoma, a cancer often difficult to diagnose in its early stages. Recommendations are difficult to made, but according to experts’ opinion, an annual surveillance associating either liver ultrasonography or magnetic resonance cholangiopancreatography and Ca 19.9 blood concentrations measurement, appears helpful for early cholangiocarcinoma detection.
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