After 8-10 years of colitis, annual surveillance colonoscopy with multiple biopsies at regular intervals should be performed. The finding of definite dysplasia of any grade, confirmed by expert pathologists’ review, is an indication for colectomy.

Patients with UC are at increased risk for colorectal cancer; the degree of risk is related to duration of disease and anatomic extent of colitis [110] [111] . After 10 yr of universal disease, the cancer risk is in the range of 0.5-1%/yr [110] [111] [112] [113] . Even patients with left-sided colitis reach similar levels of cumulative cancer risk after 3-4 decades of disease [111] [114] [115] ; patients with proctosigmoiditis are not at increased cancer risk. Although some data suggest a later onset of cancer risk in left-sided than in more extensive colitis [110] , this evidence is not sufficiently strong to justify different guidelines for surveillance in the two groups. Compared with noncolitis-associated colorectal cancer, colitis-associated cancers are more often multiple, broadly infiltrating, anaplastic, and uniformly distributed throughout the colon, and seem to arise from flat mucosa instead of following the usual adenoma-cancer sequence [114] [116] . Furthermore, colitis-associated colorectal cancer often occurs in a much younger patient population than does colorectal cancer in the general population [111] [113] .

Simply stated, the goal of any cancer surveillance program in UC is to prevent cancer and to save lives. There are no randomized studies comparing different surveillance protocols or for that matter, even surveillance versus no surveillance. Nonetheless, at present, the best practical recommendation for patients who are surgical candidates, based upon review of dysplasia surveillance series calls for annual colonoscopy, avoiding periods of clinical relapse, with multiple biopsies at 10-cm intervals [105] [117] . Examination every second yr would reduce cost but at the expense of reducing likelihood of early cancer detection [105] , especially in patients with longer disease duration because hazard rates increase with time [118] . Whatever schedule might be theoretically most advisable, being both frankly informative and programmatically flexible with patients is important to compliance. The standardization of “high grade” and “low grade” dysplasia published by the Inflammatory Bowel Disease-Dysplasia Morphology Group has been widely adopted and has served to make the diagnosis of dysplasia more stringent [117] . The cost of such a surveillance program has been estimated at approximately $93,000 for each successful detection of precancer or cancer, and compares favorably with the cost of population-wide screening by flexible sigmoidoscopy for all subjects at average risk for colorectal cancer [117] . Generic Zyban 150 mg

Guidelines for the patient found to have low grade or high grade dysplasia are discussed above (see Recommendation for Surgery). The guiding principle is that any degree of definite dysplasia should prompt colectomy. It is essential to obtain corroborating pathologic review to confirm the unequivocal distinction between definite neoplastic dysplasia and regenerative atypia due to inflammation and repair, but it is unwise to repeatedly attempt to demonstrate dysplasia on subsequent examinations before recommending colectomy. On the other hand, the patient whose biopsies are interpreted as “indefinite” for dysplasia should have the slides reviewed by an expert gastrointestinal pathologist and should undergo repeat surveillance colonoscopy at a briefer interval [119] . Generic Allegra 120mg


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