Clin Endosc.  2017 Sep;50(5):437-445. 10.5946/ce.2017.132.

Endoscopic Therapeutic Approach for Dysplasia in Inflammatory Bowel Disease

• Hong SN

• KMID: 2394743
• DOI: http://doi.org/10.5946/ce.2017.132

Abstract

Long-standing intestinal inflammation in patients with inflammatory bowel disease (IBD) induces dysplastic change in the intestinal mucosa and increases the risk of subsequent colorectal cancer. The evolving endoscopic techniques and technologies, including dye spraying methods and high-definition images, have been replacing random biopsies and have been revealed as more practical and efficient for detection of dysplasia in IBD patients. In addition, they have potential usefulness in detailed characterization of lesions and in the assessment of endoscopic resectability. Most dysplastic lesions without an unclear margin, definite ulceration, non-lifting sign, and high index of malignant change with suspicion for lymph node or distant metastases can be removed endoscopically. However, endoscopic resection of dysplasia in chronic IBD patients is usually difficult because it is often complicated by submucosal fibrosis. In patients with dysplasias that demonstrate submucosa fibrosis or a large size (≥20 mm), endoscopic submucosal dissection (ESD) or ESD with snaring (simplified or hybrid ESD) is an alternative option and may avoid a colectomy. However, a standardized endoscopic therapeutic approach for dysplasia in IBD has not been established yet, and dedicated specialized endoscopists with interest in IBD are needed to fully investigate recent emerging techniques and technologies.

Keyword

Inflammatory bowel disease; Dysplasia; Endoscopic resection

MeSH Terms

Biopsy
Colectomy
Colorectal Neoplasms
Fibrosis
Humans
Inflammation
Inflammatory Bowel Diseases*
Intestinal Mucosa
Lymph Nodes
Neoplasm Metastasis
SNARE Proteins
Ulcer
SNARE Proteins

Figure

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  Fig. 1. Carcinoma sequence pathways. (A) Sporadic colorectal cancer: adenoma-carcinoma sequence. (B) Inflammatory bowel disease-associated colorectal cancer: dysplasia-carcinoma sequence, Adapted from Matkowskyj et al. [8].

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  Fig. 2. Description of visible dysplasia on colonoscopic surveillance of patients with inflammatory bowel disease.

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  Fig. 3. Endoscopic mucosal resection of dysplasia in ulcerative colitis. (A) A 1.2-cm visible non-polypoid superficial elevated dysplasia. (B) The lesion was lifted after submucosal injection with normal saline mixed with indigo-carmine. (C) Mucosal resection performed using an endoscopic snare. (D) Visible dysplasia resected completely.

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  Fig. 4. Endoscopic submucosal dissection of dysplasia in ulcerative colitis. (A) A 2-cm visible polypoid dysplasia. (B, C) Mucosal incision and subsequent submucosal dissection. (D) Visible dysplasia resected completely.

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  Fig. 5. Endoscopic submucosal dissection of dysplasia in ulcerative colitis. (A) A 2.5-cm sessile polypoid visible dysplasia with a nodular surface feature on the chromoendoscopy. (B) Central nodular area showing a type IIIL pit pattern on magnifying endoscopy. (C, D) A depressive lesion beside the central nodularity, showing a type VI pit pattern on magnifying endoscopy and narrow band imaging. (E) Mucosal incision using a dual knife. (F) Submucosal fibrosis found during submucosal dissection. (G, H) Endoscopic complete resection. (I–L) Pathological examination result showing adenocarcinoma with multifocal submucosal invasion. The maximal depth of the submucosal invasion was >1,000 μm, and subsequent colectomy was performed. No residual neoplastic lesion on the endoscopic submucosal dissection site and no lymph node metastasis were observed.

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  Fig. 6. Endoscopic submucosal dissection with snaring. (A) An approximately 1.5-cm flat non-polypoid visible dysplasia with an indistinct border. (B) The border still indistinct on narrow band imaging. (C, D) The distinct border on chromoendoscopy with indigo-carmine. (E) Submucosal dissection was difficult because of the massive fibrosis. (F) Circumferential mucosal incision. (G) The lesion is snared along with the circumferential groove. (H) Endoscopic submucosal dissection with snaring for dysplasia. The four-quadrant biopsy specimens from the mucosa immediately adjacent to the resection site are free of dysplasia on histological examination.

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