Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis

BACKGROUND AND AIMS: Because of the large number of biopsy specimens, surveillance colonoscopy in ulcerative colitis (UC) is currently time consuming and significant flat lesions still may be missed. In this study we assessed the value of combined chromoscopy and endomicroscopy for the diagnosis of intraepithelial neoplasias in a randomized controlled trial. METHODS: A total of 161 patients with long-term UC in clinical remission were randomized at a 1:1 ratio to undergo conventional colonoscopy or chromoscopy with endomicroscopy. Eight patients were excluded because of insufficient bowel preparation. In the conventional colonoscopic group (n = 73), random biopsy examinations and targeted biopsy examinations were performed. In the endomicroscopy group (n = 80), circumscribed mucosal lesions were identified by chromoscopy and evaluated for targeted biopsy examination by endomicroscopy. The primary outcome analysis was based on the detection of neoplasias. RESULTS: By using chromoscopy with endomicroscopy, 4.75-fold more neoplasias could be detected (P = .005) than with conventional colonoscopy, although 50% fewer biopsy specimens (P = .008) were required. If only circumscribed lesions would have been biopsied in the first group, the total number of biopsy specimens could have been reduced by more than 90%. A total of 5580 confocal endomicroscopic images from 134 circumscribed lesions were compared with histologic results. The presence of neoplastic changes could be predicted by endomicroscopy with high accuracy (sensitivity, 94.7%; specificity, 98.3%; accuracy, 97.8%). CONCLUSIONS: Endomicroscopy based on in vivo histology can determine if UC lesions identified by chromoscopy should undergo biopsy examination, thereby increasing the diagnostic yield and reducing the need for biopsy examinations. Thus, chromoscopy-guided endomicroscopy may lead to significant improvements in the clinical management of UC.     

Does colonoscopy cause increased ulcerative colitis symptoms?

BACKGROUND: Ulcerative colitis (UC) patients often report symptom flares after colonoscopy. However, this has not been documented in the literature. OBJECTIVES: 1. Determine whether colonoscopy is associated with increased UC symptoms. 2. Determine whether there is a need for escalation of UC medications after colonoscopy. 3. Identify baseline variables associated with increased symptoms after colonoscopy. METHODS: Fifty-five outpatients with a history of UC, intact colon, and quiescent disease were enrolled in a prospective case-crossover study. Subjects were evaluated with the Simple Clinical Colitis Activity Index (SCCAI) before colonoscopy, 1 week and 4 weeks after colonoscopy. A mixed model analysis was used to accommodate nonindependence of repeated measurements on the same patients. RESULTS: Fifty-one (91%) subjects completed the study. Six subjects had clinical relapse defined by a score of 5 or greater on the SCCAI during the week after colonoscopy. Five subjects increased their 5-aminosalicylic acid (5-ASA) medications immediately postcolonoscopy, two of whom had a SCCAI 5 or greater. Multivariate modeling demonstrated a clear association between the week immediately after colonoscopy preparation and increased disease activity, with the time period being predictive of increased SCCAI (week 1 vs. week 4, P = 0.0127). The baseline SCCAI (P value < 0.0001) and prednisone use (P = 0.0120) were predictive of increased SCCAI postcolonoscopy. Thiopurines (P < 0.001) were protective against increased symptoms. CONCLUSIONS: In our study, 1 in 8 subjects had UC relapse by SCCAI immediately postcolonoscopy, and 1 in 10 subjects required an increase in their 5-ASA medications. Clinicians should be cognizant of this effect of colonoscopy in patients with UC.     

Does autofluorescence imaging videoendoscopy system improve the colonoscopic polyp detection rate?--a pilot study

OBJECTIVES: Colonoscopy is considered the gold standard for the detection of colorectal polyps; however, polyps can be missed with conventional white light (WL) colonoscopy. The aim of this pilot study was to evaluate whether a newly developed autofluorescence imaging (AFI) system can detect more colorectal polyps than WL.
METHODS: A modified back-to-back colonoscopy using AFI and WL was conducted for 167 patients in the right-sided colon including cecum, ascending and transverse colon by a single experienced colonoscopist. The patient was randomized to undergo the first colonoscopy with either AFI or WL (group A: AFI-WL, group B: WL-AFI). The time needed for both insertion and examination for withdrawal and all lesions detected in the right-sided colon were recorded.
RESULTS: Eighty-three patients were randomized to group A and 84 to group B. The total number of polyps detected by AFI and WL colonoscopy was 100 and 73, respectively. The miss rate for all polyps with AFI (30%) was significantly less than that with WL (49%) ( P = 0.01).
CONCLUSIONS: AFI detects more polyps in the right-sided colon compared to WL colonoscopy.     

Risk factors for ulcerative colitis-associated colorectal cancer in a Hungarian cohort of patients with ulcerative colitis: results of a population-based study

BACKGROUND: There is an increased risk of colorectal cancer (CRC) in ulcerative colitis (UC). The prevalence of UC-associated CRC is different in various geographic regions. The risk depends primarily on the duration and extent of disease. The aim of this study was to identify the risk factors for and the epidemiology of CRC in Hungarian patients with UC. METHODS: We retrospectively evaluated the relevant epidemiological and clinical data of all patients with UC in Veszprem province in our 30-year IBD database (723 patients with UC; male/female, 380/343; non-CRC related colectomies, 3.7%). RESULTS: CRC was diagnosed in 13 patients (13/8564 person-year duration) during follow-up. Age at diagnosis of CRC was at a median of 51 (range 27-70) years. Eight patients are still alive, 4 died of CRC, and 1 died of an unrelated cause. Longer disease duration, extensive colitis, primary sclerosing cholangitis, and dysplasia found in the biopsy specimen were identified as risk factors for developing CRC. The cumulative risk of developing CRC after a disease duration of 10 years was 0.6% (95% confidence interval [CI] 0.2%-1.0%); 20 years, 5.4% (95% CI 3.7%-7.1%); and 30 years, 7.5% (95% CI 4.8%-10.2%). CRC diagnosed at surveillance colonoscopy was associated with a tendency for longer survival (P = 0.08). CONCLUSIONS: The cumulative risk of CRC was high in our patients with UC; however, it was lower compared with that reported in Western European and North American studies. CRC developed approximately 15 years earlier compared with sporadic CRC patients in Hungary. Longer disease duration, extensive colitis, dysplasia, and primary sclerosing cholangitis were identified as important risk factors for developing CRC.     

Two cases of inverted hyperplastic polyps of the colon and association with adenoma

Here we report two cases of inverted hyperplastic polyps of the colon. The first patient showed three inverted hyperplastic polyps in the ascending colon, one of which was associated with adenoma. We immunostained this adenoma-associated polyp using anti-beta-catenin antibody and found accumulation of beta-catenin in the cytoplasm of the adenomatous lesion but not in the inverted hyperplastic polyp. This suggested an adenomatous polyposis coli (APC) mutation in the adenomatous region but not in the inverted hyperplastic polyp. The inverted hyperplastic polyp in the second patient was located at the caecum and was studied using magnifying colonoscopy. The polyp appeared to be flat and elevated with a depressed pit in the centre. After spraying with methylene blue dye, the pit pattern of the lesion was observed and small asteroid pits on the polyp were found, consistent with a hyperplastic gland pattern. From these results, we diagnosed inverted hyperplastic polyp of the colon by colonoscopy.     

Clinical significance of expression of tissue factor and tissue factor pathway inhibitor in ulcerative colitis

AIM: To investigate the clinical significance of expression of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in ulcerative colitis (UC).METHODS: Thirty UC specimens taken by colonoscopy from patients with active UC treated at the Department of Pathology, Central Hospital Affiliated to Shenyang Medical College from February 2010 to January 2012 were included in an experimental group, and 30 normal colon tissue samples taken by colonoscopy from non-UC patients were included in a control group. Expression of TF and TFPI in UC and normal colon tissue samples was detected by immunohistochemistry.RESULTS: The positive rate of TF in UC was significantly higher than that in normal colon tissue (63% vs 33%, χ² = 5.41, P < 0.05). The positive rate of TFPI in UC was also significantly higher than that in normal colon tissue (43% vs 17%, χ² = 5.08, P < 0.05).CONCLUSION: Positive rates of TF and TFPI expression in UC are significantly higher than those in normal colon tissue. TF and TFPI may play an important role in the pathogenesis of UC.     

Distribution and prevalence of colorectal hyperplastic polyps using magnifying pan-mucosal chromoendoscopy and its relationship with synchronous colorectal cancer: prospective study

BACKGROUND AND AIM: Patients with multiple (hyperplastic polyposis) or large hyperplastic polyps (HPs) predominantly in the right-sided colon, have been reported to have an increased risk of colorectal cancer (CRC). This prospective study was conducted to clarify the distribution of various sized HPs using magnifying pan-mucosal chromoendoscopy and its relationship with synchronous CRC. METHODS: Patients eligible for this study had an initial total colonoscopy. Indigo carmine dye was sprayed throughout the whole colon and rectum, and diagnoses were made using magnifying colonoscopy. RESULTS: A total of 263 patients were enrolled, and a total of 3060 HPs were observed in 226 (86%) patients. The prevalence of patients with intermediate size (> or = 6 mm) HPs was 8.7% (n = 23) and that of patients with large HPs (> or = 10 mm) was 0.8% (n = 2). Of 3060 HPs, the numbers of diminutive (< 6 mm), intermediate size and large HPs were 3020, 38 and two, respectively, and 5.0%, 42.1% and 100% of these were located in the right-sided colon, respectively. Synchronous CRC was observed in 64 (24%) of 263 patients. Compared to patients without HPs, patients with intermediate size HPs showed a significant increase in odds ratio (OR) for synchronous CRC (OR = 4.9: 95% CI [1.3-18.2]), but there was no significant association between synchronous CRC and patients with diminutive or large HPs. CONCLUSIONS: Compared to diminutive HPs, intermediate size and large HPs were predominantly located in the right-side colon. Moreover, intermediate size HPs were significantly correlated with synchronous CRC.     

Increased risk of colorectal cancer in ulcerative colitis patients diagnosed after 40 years of age.

BACKGROUND: The association between ulcerative colitis (UC) and colorectal cancer (CRC) is well established. Retrospective data show a 5.4% CRC incidence rate among patients with pancolitis and suggest that cancer surveillance should be provided to patients following eight to 10 years of extensive UC. AIM: To identify premalignant risk factors for UC patients and to determine whether current recommendations for cancer surveillance need reviewing. PATIENTS AND METHODS: A retrospective audit was conducted of adult patients with UC who were diagnosed with CRC between 1991 and 2002 in five hospitals in Edmonton, Alberta. RESULTS: Thirty-one cases of CRC (68% male) were identified. In this group, the mean ages at diagnosis were 44.4 years for UC patients and 60.1 years for CRC patients. For patients in whom the initial data of diagnosis of UC could be determined (n=29), the median duration of UC at the time of CRC diagnosis was 16 years. Patients diagnosed with UC after 40 years of age (n=15, mean age 64 years) progressed more rapidly to CRC than patients diagnosed before 40 years of age (n=14, mean age 23 years). The median durations of UC before development of CRC were 22 years and 10 years, respectively, for patients with a diagnosis of UC before and after 40 years of age (OR 11.5, 95% CI 2.41 to 20.16; P=0.00029). Only four patients (13%) were enrolled in an appropriate cancer-screening program. Nine of these UC patients (29%) who were older than 40 years of age developed CRC before the 10-year point. CONCLUSIONS: In the present study, patients diagnosed with UC after 40 years of age developed CRC more rapidly than those diagnosed before 40 years of age. This finding suggests that patients who are diagnosed with UC after 40 years of age should undergo CRC surveillance earlier than current recommendations.     

Trends of ulcerative colitis-associated colorectal cancer in Korea: A KASID study

Background and Aim:  The number of patients with ulcerative colitis (UC) in Korea has increased. In addition, the number of patients with colorectal cancer (CRC) associated with UC has also increased. Therefore, this population-based nationwide study was conducted to investigate the incidence of CRC in patients with UC in Korea and compare these results to those of studies conducted in other countries.
Methods:  The Korean Association for the Study of Intestinal Diseases (KASID) reviewed 7061 cases of UC that occurred between 1970 and 2005 and found a total of 26 cases of CRC.
Results:  The overall prevalence of CRC in patients with UC was 0.37%. In addition, the estimated cumulative risk of UC-associated CRCs was 0.7% for patients that had UC for 10 years, 7.9% for patients that had UC for 20 years, and 33.2% for patients that had UC for 30 years. The mean age at the time of diagnosis with CRC was 49.6 years, and the mean duration of UC prior to the development of CRC was 11.5 years. Most UC-associated CRCs were diagnosed after they were already in advanced stages; however, the stage at diagnosis was lower in patients that had good compliance with medical treatment.
Conclusion:  The cumulative incidence of UC-associated CRCs in Korea was found to be comparable to that of western countries. The overall occurrence of UC-associated CRC in Korea may be growing, therefore, intensive surveillance colonoscopy and constructive chemoprevention should be encouraged to enable early detection and treatment of UC-associated CRCs in Korea.     

Inflammatory bowel disease as a risk factor for colorectal cancer

Patients with long-term inflammatory bowel disease (IBD), ulcerative colitis (UC) and Crohn's colonic disease (CD) have an increased risk of colorectal carcinoma (CRC). Eaden's meta-analysis has shown that the risk for CRC in UC patients is 2% at 10 years, 8% at 20 years and 18% at 30 years of disease duration. It is now accepted that the risk of colorectal cancer is equivalent in both (UC and CD) conditions. Duration of disease is recognized to be the most important risk factor for CRC development. Extent of disease in another major risk factor. Most cancers arise in patients with extensive disease, which is generally defined as extension of inflammation beyond the hepatic flexure. It was demonstrated that proctitis and proctosigmoiditis posed no increased risk for patients with UC. Recent data from case control studies suggests that greater degrees of colonoscopic or histologically active inflammation are associated with an increased risk of CRC. Recently, it has been proven that shortened tubular colon, colonic stricture and postinflammatory polyps should be considered strong risk factors for CRC development. Primary sclerosing cholangitis (PSC) in patients with UC is associated with substantial risk of CRC. Screening colonoscopy should be performed in patients with UC after 8-10 years of disease. The interval between surveillance examinations is dependent on each individual's personal risk factors. In patients with a previous history of PSC, ongoing active inflammation, previous history of dysplasia or strictures, and strong family history of bowel cancer, annual surveillance is recommended. Colectomy is strictly recommended for patients who were diagnosed with flat high-grade dysplasia (HGD) or CRC and where the diagnosis was confirmed by expert gastrointestinal pathologists. In patients with a biopsy specimen considered indefinite for dysplasia, guidelines suggest colonoscopy between 3 and 12 months. Multifocal low-grade dysplasia (LGD) is a stronger indication for colectomy. The optimal colonoscopic surveillance interval for patients who were diagnosed with a flat LGD is still unknown, but 3-6 months is often recommended. Chemopreventive agents should be used to minimize the risk of developing dysplasia or CRC in IBD patients. It has been shown that mesalazine has a preventive effect for CRC and dysplasia.     

SURVEILLANCE FOR DYSPLASIA AND COLITIC CANCER BY MAGNIFYING COLONOSCOPY IN PATIENTS WITH ULCERATIVE COLITIS

The aim of this study was to evaluate the macroscopic appearance and pit pattern of colitic cancer and dysplasia associated with ulcerative colitis (UC) by conventional and magnifying colonoscopy. Twelve lesions of dysplasia in nine patients and five colitic cancers in four patients were observed by magnifying colonoscopy. On conventional colonoscopy, most colitic cancers and dysplasias were protruded lesions. However, flat lesions were observed only in dysplasia, not in colitic cancer. All colitic cancers and 83% (10/12 lesions) of dysplasias presented reddish surface. On magnifying colonoscopy, most lesions of colitic cancer and dysplasia showed III_S to III_L or III_L to IV or IV type pit patterns. Tumorous pits associated with colitic cancers and dysplasias were similar to those seen in sporadic colorectal cancers and adenomas. Magnifying colonoscopy is expected to facilitate the qualitative diagnosis of colitic cancer and dysplasia associated with ulcerative colitis and to improve the efficiency of targeted biopsy.     

Chemoprevention of colorectal neoplasia in ulcerative colitis: the effect of 6-mercaptopurine.

BACKGROUND & AIMS: Evidence suggests that mesalamine-based anti-inflammatory medicines may prevent colorectal cancer (CRC) in ulcerative colitis (UC). If mesalamine exerts its chemopreventive effect by its anti-inflammatory activity, then other medications that reduce colitis activity also should possess chemopreventive properties. Our aim was to determine the effect of the immunomodulators 6-mercaptopurine (6MP) and azathioprine (AZA) in preventing the development of dysplasia or CRC in UC. METHODS: Patients with UC who underwent a surveillance colonoscopy in 1996-1997 were identified from a gastrointestinal pathology database. A proportional hazards analysis assessing 6MP/AZA use as a time-changing covariate was performed to evaluate the effect of 6MP/AZA on: (1) progression to any neoplasia (low-grade dysplasia, high-grade dysplasia, or CRC), and (2) progression to advanced neoplasia (high-grade dysplasia or CRC). RESULTS: A total of 315 subjects met inclusion criteria and were followed for an average of 8 years from their first surveillance examination. There were no significant differences in rates of progression to advanced neoplasia or to any neoplasia between 6MP/AZA users and never-users by log-rank testing. The proportional hazards analysis resulted in hazard ratios of 1.06 (95% confidence interval, .59-1.93) and 1.30 (95% confidence interval, .45-3.75) when considering the effect of exposure to 6MP/AZA on progression to any or to advanced neoplasia, respectively. The results were unaffected by known potential confounders. CONCLUSIONS: In UC patients with no initial history of dysplasia, 6MP/AZA use appears to have little or no effect on the rate of neoplastic transformation in the colon. Importantly, the use of 6MP/AZA did not increase malignant transformation in UC.     

Aminosalicylate therapy in the prevention of dysplasia and colorectal cancer in ulcerative colitis.

BACKGROUND & AIMS: Aminosalicylates have been suggested as chemopreventive agents for colorectal cancer (CRC) in ulcerative colitis (UC). We studied the effect of aminosalicylate use on dysplasia and CRC risk in chronic UC. METHODS: UC patients with dysplasia or CRC were matched with controls by disease duration, extent, and age at diagnosis. The total amount of aminosalicylates over the duration of the disease and the mean daily amount of drug was calculated. Conditional logistic regression was used to examine the relationship of aminosalicylates to the risk of neoplasia; potential confounders were controlled in a multivariable model. RESULTS: Twenty-six cases (8 CRC, 18 dysplasia) were matched with 96 controls. Cases and controls were similar in age (median, 43 vs 42.5 y), age at diagnosis of UC (median, 29.5 vs 30.5 y), duration of UC (median, 11.5 vs 9 y), and extent of disease (58% pancolitis), sex, family history of UC, history of primary sclerosing cholangitis, and smoking history. Cases were more likely to have a family history of CRC than controls (27% of cases, 9% of controls, P = .036). Conditional logistic regression adjusted for disease duration, age at diagnosis, and family history of CRC showed that aminosalicylate use of 1.2 g/day or more was associated with a 72% reduction in the odds of dysplasia/CRC (odds ratio, 0.28; 95% confidence interval, 0.09-0.85). As the total dose of aminosalicylates increased, the odds of dysplasia/CRC decreased (P = .056). CONCLUSIONS: This case-control study shows a significant risk reduction of dysplasia and CRC in UC patients exposed to aminosalicylate therapy.     

Serrated Adenoma is a Risk Factor for Subsequent Adenomatous Polyps

BACKGROUND: Serrated adenomas (SA) are histologically defined by the presence of both hyperplastic and adenomatous features. These uncommon polyps are thought to play an important role in the development of sporadic colorectal cancers (CRC) with microsatellite instability (MSI). There is paucity of data on the risk of progression of SA to CRC. This study was undertaken to define the relationship between SA and the future development of adenomatous polyps. METHODS: Colonoscopic biopsies that contained a pathologic diagnosis of SA were identified from a pathology database of a major urban academic medical center. Those patients with absence of concomitant malignancy, complete colonoscopy, good or adequate prep and presence of at least one follow-up procedures were identified. These were matched to controls by age, sex, indication for colonoscopy, polyp type and number and duration of follow-up. Outcomes of the follow-up procedures were compared. RESULTS: Between January 1997 and June 2005 17,226 colonoscopic biopsies and polypectomies were performed. Of these, 80 patients (0.5%) with SA were found, and of these SA, 80% were found in the left colon. The average age of patients undergoing colonoscopy was 58.5 years, and the average age of patients with SA was 68 years (P = 0.004). Of all patients with SA, 7 (9%) had concomitant CRC. The final groups contained 17 patients and 17 controls, respectively, and were well matched. The mean follow-up interval in the patient group was 29 months vs. 31 months in the control group (P = 0.82). On follow-up examination four patients (24%) and no controls had adenomatous polyps (P = 0.01). CONCLUSIONS: While SA are uncommon, they are commonly associated with colorectal cancer. Serrated adenomas appear to be found more commonly in the left colon and in older patients. This study found a significant association between SA and the subsequent development of adenomatous polyps. Further studies are needed to define appropriate preventive strategies for these patients.     

Risk factors for colorectal cancer in Crohn's colitis: a case-control study

BACKGROUND: Few data exist regarding exposures associated with colorectal cancer (CRC) in patients with Crohn's colitis. The aim of this study was to identify exposures that alter the risk of CRC in patients with Crohn's colitis. METHODS: The Research Patient Database Registry at Massachusetts General Hospital was searched to identify cases and controls. Cases had a confirmed diagnosis of Crohn's disease involving at least one third of the colon and a confirmed diagnosis of colorectal adenocarcinoma. Matched controls were randomly chosen from the same source population. Paired univariate analysis was performed to develop an odds ratio (OR) for each exposure. RESULTS: Twenty-seven patients were found to have Crohn's colitis and CRC. Colonoscopy performed for screening or surveillance was associated with an OR of 0.21 (95% CI 0.04-0.77; P=0.02). Nonsignificant trends for a protective effect included prior appendectomy (OR 0.30; 95% CI 0.05-1.17; P=0.10) and regular 5-aminosalicylate use (OR 0.30; 95% CI 0.05-1.17; P=0.10). Smoking history was associated with a 4-fold-increased risk for CRC, but this was not statistically significant (OR 4.00; 95% CI 0.80-38.67; P=0.11). CONCLUSIONS: We found that having a colonoscopy for an indication of surveillance or screening is associated with decreased risk of CRC in the setting of Crohn's colitis. These data underscore the importance of CRC surveillance for Crohn's colitis in addition to ulcerative colitis and should prompt further study in this area.     

Colorectal cancer screening, comorbidity, and follow-up in elderly patients

OBJECTIVE: We examined the relationship between comorbid disease and performance of complete colon examination by colonoscopy or double contrast barium enema (DCBE) after positive screening fecal occult blood test (FOBT) in patients 70 years of age or older. BACKGROUND: FOBT is an accepted form of colorectal cancer (CRC) screening. Factors that influence follow-up of positive FOBT have been largely unknown. METHODS: Patients aged 70 years and older with positive FOBT between March 1, 2000 and Feb 28, 2001 were included in this retrospective medical record review performed at a single center. Comorbidity was measured by the Charlson Comorbidity Scale. RESULTS:: In our sample of 266 subjects, 193 (73%) were referred for evaluation of positive FOBT and 109 (41%) underwent a colonoscopy or DCBE within 12 months. Using the Charlson score for comorbidity, 27% of our sample scored 0, 24% scored 1, and 23% scored 2 while 26% had a Charlson score of 3 or higher. There was no association between Charlson score (0, 1, 2, and > or =3) and referral for evaluation (chi test, P = 0.28) or performance of a complete colon examination (chi test, P = 0.38). CONCLUSIONS: In this sample, only 41% of patients with positive FOBT underwent a full colon examination within 12 months of a positive FOBT. Although comorbidity burden was considerable, there was no association between comorbidity score and referral for or performance of a full colon examination. These results suggest that inappropriate patients receive CRC screening, which may contribute to delays for screening appropriate patients and diagnostic delays for others with positive screening test findings.     

In vivo colonoscopic optical coherence tomography for transmural inflammation in inflammatory bowel disease.

BACKGROUND & AIMS: Transmural inflammation, a distinguishing feature of Crohn's disease (CD), cannot be assessed by conventional colonoscopy with mucosal biopsy. Our previous ex vivo study of histology-correlated optical coherence tomography (OCT) imaging on colectomy specimens of CD and ulcerative colitis (UC) showed that disruption of the layered structure of colon wall on OCT is an accurate marker for transmural inflammation of CD. We performed an in vivo colonoscopic OCT in patients with a clinical diagnosis of CD or UC using the previously established, histology-correlated OCT imaging criterion. METHODS: OCT was performed in 40 patients with CD (309 images) and 30 patients with UC (292 images). Corresponding endoscopic features of mucosal inflammation were documented. Two gastroenterologists blinded to endoscopic and clinical data scored the OCT images independently to assess the feature of disrupted layered structure. RESULTS: Thirty-six CD patients (90.0%) had disrupted layered structure, whereas 5 UC patients (16.7%) had disrupted layered structure (P < .001). Using the clinical diagnosis of CD or UC as the gold standard, the disrupted layered structure on OCT indicative of transmural inflammation had a diagnostic sensitivity and specificity of 90.0% (95% CI: 78.0%, 96.5%) and 83.3% (95% CI: 67.3%, 93.3%) for CD, respectively. The kappa coefficient in the interpretation of OCT images was 0.80 (95% CI: 0.75, 0.86, P < .001). CONCLUSIONS: In vivo colonoscopic OCT is feasible and accurate to detect disrupted layered structure of the colon wall indicative of transmural inflammation, providing a valuable tool to distinguish CD from UC.     

A Centralized Program with Stepped Support Increases Adherence to Colorectal Cancer Screening Over 9 Years: a Randomized Trial

BackgroundScreening over many years is required to optimize colorectal cancer (CRC) outcomes.ObjectiveTo evaluate the effect of a CRC screening intervention on adherence to CRC screening over 9 years.DesignRandomized trial.SettingIntegrated health care system in Washington state.ParticipantsBetween August 2008 and November 2009, 4653 adults in a Washington state integrated health care system aged 50–74 due for CRC screening were randomized to usual care (UC; N =1163) or UC plus study interventions (interventions: N = 3490).InterventionsYears 1 and 2: (arm 1) UC or this plus study interventions; (arm 2) mailed fecal tests or information on scheduling colonoscopy; (arm 3) mailings plus brief telephone assistance; or (arm 4) mailings and assistance plus nurse navigation. In year 3, stepped-intensity participants (arms 2, 3, and 4 combined) still eligible for screening were randomized to either stopped or continued interventions in years 3 and 5–9.Main MeasuresTime in adherence to CRC testing over 9 years (covered time, primary outcome), and percent with no CRC testing in participants assigned to any intervention compared to UC only. Poisson regression models estimated incidence rate ratios for covered time, adjusting for patient characteristics and accounting for variable follow-up time.Key ResultsCompared to UC, intervention participants had 21% more covered time over 9 years (57.5% vs. 69.1%; adjusted incidence rate ratio 1.21, 95% confidence interval 1.16–1.25, P<0.001). Fecal testing accounted for almost all additional covered time among intervention patients. Compared to UC, intervention participants were also more likely to have completed at least one CRC screening test over 9 years or until censorship (88.6% vs. 80.6%, P<0.001).ConclusionsAn outreach program that included mailed fecal tests and phone follow-up led to increased adherence to CRC testing and fewer age-eligible individuals without any CRC testing over 9 years.Trial RegistrationSystems of Support (SOS) to Increase Colon Cancer Screening and Follow-up (SOS), {"type":"clinical-trial","attrs":{"text":"NCT00697047","term_id":"NCT00697047"}}NCT00697047, clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00697047","term_id":"NCT00697047"}}NCT00697047Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06922-2.KEY WORDS: colorectal cancer, screening, mailed fecal tests, randomized trial, health care system     

Adherence to guidelines for surveillance colonoscopy in patients with ulcerative colitis at a Canadian quaternary care hospital

BACKGROUND:

Patients with ulcerative colitis (UC) are at high risk of colonic dysplasia. Therefore, surveillance colonoscopy to detect early dysplasia has been endorsed by many professional organizations.

OBJECTIVES:

To determine whether gastroenterologists at Hamilton Health Sciences (Hamilton, Ontario) adhere to recommendations for UC surveillance issued by the Canadian Association of Gastroenterology and to retrospectively assess the incidence and type of dysplasia found and the subsequent outcome of patients with dysplasia (ie, colorectal cancer [CRC], colectomy, dysplasia recurrence).

METHODS:

A retrospective chart review of all patients with UC undergoing colonoscopy screening at Hamilton Health Sciences from January 1980 to January 2005, was performed. Patients were classified by the extent of colonic disease: limited left-sided colitis (LSC), pancolitis and any disease extent with concurrent primary sclerosing cholangitis.

RESULTS:

A total of 141 patients fulfilled eligibility criteria. They underwent 921 endoscopies, including 453 for surveillance, which were performed by 20 endoscopists. Overall, screening was performed on 90% of patients, and surveillance at the appropriate time in 74%. There was a statistically significant increase in the mean number of biopsies per colonoscopy after the guidelines were published (P<0.01 for all categories). Colonic dysplasia was detected in 24 of 141 patients (17.0%), with 17 of 24 (70.8%) found at surveillance. Two patients (8.3%) had CRC successfully treated. The average age of patients with dysplasia was 56.1 years, with a mean disease duration of 10.9 years in LSC versus 11.8 years in pancolitis (P not significant). Colectomy was not recommended for any patient with flat dysplasia. No patients progressed to high-grade dysplasia or CRC. Patients with pancolitis had a higher incidence of neoplasia (21% [18 of 86]) than patients with LSC (12% [6 of 49]; P=0.24). Forty-one patients (29.5%) had at least one hyperplastic or inflammatory polyp.

CONCLUSIONS:

For the majority of patients who underwent surveillance colonoscopies, their procedures were performed within the recommended time intervals, and biopsy compliance has improved. Dysplasia tended to arise after approximately 10 years of disease duration and in middle age, with flat dysplasia being rare. Interventions resulted in no dysplasia progressing to CRC, implying successful prevention.