Management of Colonic Dysplasia

Introduction to Colonic Dysplasia Management

Patients with Primary Sclerosing Cholangitis (PSC) and high-grade colonic dysplasia or neoplasia are recommended to undergo total proctocolectomy due to the high risk of malignant progression and multifocal nature of dysplasia, as per the European Association for the Study of the Liver (EASL) guidelines 1
PSC patients with inflammatory bowel disease (IBD) have a significantly elevated risk of colorectal cancer, with a 9-fold increased risk compared to the general population and a 10-fold increased risk compared to ulcerative colitis patients without PSC, as reported by 2

The American Gastroenterological Association (AGA) recommends attempting endoscopic resection of visible lesions, assessing surrounding mucosa with chromoendoscopy and targeted biopsies, and considering proctocolectomy if dysplasia is found in surrounding mucosa, complete endoscopic resection is not possible, or high-grade dysplasia is present 2
High-grade dysplasia is an indication for proctocolectomy, as strongly recommended by the American College of Gastroenterology (ACG) 2
Low-grade dysplasia confirmed by two expert pathologists requires repeat colonoscopy with chromoendoscopy within 3 months, and if persistent or multifocal, proctocolectomy should be considered, as per the EASL guidelines 1, 2

The EASL clinical practice guidelines (2022) strongly recommend colectomy for high-grade colonic dysplasia, neoplasia, persistent symptomatic colonic inflammation despite optimal medical therapy, and low-grade dysplasia that is confirmed on multiple occasions and/or at multiple locations 1
Total proctocolectomy is the standard of care for PSC patients with colonic dysplasia due to the high risk of malignant progression and the multifocal nature of dysplasia in this patient population, as recommended by the American Society of Colon and Rectal Surgeons (ASCRS) and the EASL guidelines 1
PSC-IBD patients have a higher risk of pouchitis and pouch failure compared to IBD alone, and continued surveillance is necessary if any rectal mucosa remains, as per the Crohn's and Colitis Foundation guidelines and the EASL guidelines 1, 2
Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical approach over ileostomy, offering better functional results and fewer complications in PSC patients, as reported by 3, 4

Liver function assessment is crucial before surgery, as patients with significant PSC may experience hepatic decompensation after colectomy, and the timing of surgery should be carefully considered for patients with advanced liver disease requiring both liver transplantation and colectomy, as recommended by the American Association for the Study of Liver Diseases (AASLD) and the EASL guidelines 1
Surveillance after surgery is necessary to monitor for potential complications, such as pouchitis and pouch failure, and to assess for biliary dysplasia, as per the EASL guidelines 1, 2
For PSC-UC patients with dysplasia, surveillance intervals should be more frequent than the standard 1-2 years, with recommendations for every 3-6 months using high-definition endoscopy and chromoendoscopy, as reported by 3, 5, 1
The "five S" features (shape, size, site, surface, and surrounding mucosa) should be documented for all lesions during surveillance, as recommended by 5
Regular monitoring for cholangiocarcinoma with serum markers and imaging studies is essential for patients with PSC, and consideration for referral to a liver transplant center is recommended, as PSC is a progressive disease that may eventually require transplantation, as reported by 3, 1
Ursodeoxycholic acid (UDCA) is not recommended for chemoprevention of colorectal cancer in PSC-UC patients, despite potential benefits in reducing colorectal dysplasia risk, as reported by 3