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Endoscopy in patients with IBD European School of Oncology Rome, Italy Dr James East Consultant Gastroenterologist, John R...
Overview <ul><li>Guidelines </li></ul><ul><ul><li>When </li></ul></ul><ul><ul><li>How </li></ul></ul><ul><li>Standard whit...
Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8...
Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8...
Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8...
British Society of Gastroenterology 2010 <ul><li>New 2010 BSG guidelines for colitis surveillance </li></ul><ul><ul><li>Re...
When to screen IBD – BSG 2010
How & When - Dysplasia detection in IBD <ul><li>How in 2011 </li></ul><ul><ul><li>Optimising standard technique </li></ul>...
Background <ul><li>Patients with colitis more likely to get CRC 1   </li></ul><ul><ul><li>Increases with colitis duration ...
Cost effectiveness <ul><li>Does surveillance work (cost effective)? 1,2 </li></ul><ul><ul><li>70% dysplasia/cancer detecte...
Standard white light exam
Standard white light exam <ul><li>Fibreoptic colonoscopy 1970-80s </li></ul><ul><li>Video colonoscopy 1980-90s </li></ul><...
Standard white light exam <ul><li>Bowel preparation </li></ul><ul><ul><li>Good prep to find polyps 1 </li></ul></ul><ul><u...
Standard white light exam R 2 =0.12, P=0.0066 Toruner M  et al.  Inflamm Bowel Dis 2005; 11 :428-34
Biopsy protocol <ul><li>UK (2002), ECCO and US guidelines recommend 2-4 biopsies every 10cm </li></ul><ul><ul><li>Samples ...
Biopsy protocol R 2 =0.02, P>0.05 Toruner M  et al.  Inflamm Bowel Dis 2005; 11 :428-34
Improved surface detail <ul><li>High definition (HDTV) + image enhance </li></ul><ul><ul><li>No evidence (anecdote) </li><...
Chromoendoscopy Study White Light Chromoscopy Marion 2008 9/102 (8.8%) 17/102 (16.7%) Kiesslich 2007 4/73 (5.5%) 13/84 (15...
Chromoendoscopy
Chromoendoscopy
Chromoendoscopy
SURFACE guidelines for chromoendoscopy in ulcerative colitis       (1)  S trict patient selection       (2)  U nmask the m...
Dye-spray <ul><li>10ml 1% Indigocarmine (i.e. one ampoule) </li></ul><ul><li>40ml Water for injection </li></ul><ul><li>A ...
Narrow band imaging <ul><li>Case report 1 </li></ul><ul><ul><li>NBI can detect dysplasia in UC </li></ul></ul><ul><ul><li>...
Narrow band imaging
Narrow band imaging
Autofluorescence imaging <ul><li>Case report 1 </li></ul><ul><ul><li>50% AFI +ve lesions dysplastic </li></ul></ul><ul><li...
Autofluorescence imaging
Autofluorescence imaging
Autofluorescence imaging
Multimodal imaging (ETMI)
Confocal endomicroscopy Kiesslich R  et al.  Gastroenterology 2007; 132 :874-882
Confocal endomicroscopy <ul><li>161 randomised to: </li></ul><ul><ul><li>1. Standard white light with quadrantic biopsies ...
Summary <ul><li>When to screen </li></ul><ul><ul><li>At 8-10 years post symptom start </li></ul></ul><ul><ul><li>Then pote...
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Endoscopy in Gastrointestinal Oncology - Slide 14 - J. East - Endoscopy in patients with IBD

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Endoscopy in Gastrointestinal Oncology - Slide 14 - J. East - Endoscopy in patients with IBD

  1. 1. Endoscopy in patients with IBD European School of Oncology Rome, Italy Dr James East Consultant Gastroenterologist, John Radcliffe Hospital 12 April 2011
  2. 2. Overview <ul><li>Guidelines </li></ul><ul><ul><li>When </li></ul></ul><ul><ul><li>How </li></ul></ul><ul><li>Standard white light exam </li></ul><ul><li>Chromoendoscopy </li></ul><ul><li>Advanced imaging </li></ul>
  3. 3. Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8-10 years Surveillance Extensive 2 yrly to 20yr then annually Left sided 2yrly starting at 15 yrs PSC: 1yrly By risk: Low 5 yrs Intermediate 3 yrs High 1yrs 1-3 years More often at high risk e.g. PSC 1-2 years Chromo Superior to WLE Recommended Special cases Not yet Biopsies 33+ if no chromo 33+ if no chromo 33+ 33+
  4. 4. Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8-10 years Surveillance Extensive 2 yrly to 20yr then annually Left sided 2yrly starting at 15 yrs PSC: 1yrly By risk: Low 5 yrs Intermediate 3 yrs High 1yrs 1-3 years More often at high risk e.g. PSC 1-2 years Chromo Superior to WLE Recommended Special cases Not yet Biopsies 33+ if no chromo 33+ if no chromo 33+ 33+
  5. 5. Current international guidelines ECCO 2008 BSG 2010 (and NICE) AGA 2010 ACG 2010 Screening 8-10 yrs 10 Years Max 8 years 8-10 years Surveillance Extensive 2 yrly to 20yr then annually Left sided 2yrly starting at 15 yrs PSC: 1yrly By risk: Low 5 yrs Intermediate 3 yrs High 1yrs 1-3 years More often at high risk e.g. PSC 1-2 years Chromo Superior to WLE Recommended Special cases Not yet Biopsies 33+ if no chromo 33+ if no chromo 33+ 33+
  6. 6. British Society of Gastroenterology 2010 <ul><li>New 2010 BSG guidelines for colitis surveillance </li></ul><ul><ul><li>Replace 2002 guidelines </li></ul></ul><ul><ul><li>Paradigm shift </li></ul></ul><ul><li>New How </li></ul><ul><ul><li>Random quadrantic biopsies abandoned </li></ul></ul><ul><ul><li>Pan-colonic chromoendoscopy </li></ul></ul><ul><li>New When </li></ul><ul><ul><li>“ Time served” based surveillance intervals abandoned </li></ul></ul><ul><ul><li>Intervals defined by endoscopic and histological features </li></ul></ul><ul><li>Cairns SR et al. Gut 2010; 59 :666-89 </li></ul><ul><li>NICE: Colonoscopic surveillance: full guideline DRAFT (May 2010) </li></ul>
  7. 7. When to screen IBD – BSG 2010
  8. 8. How & When - Dysplasia detection in IBD <ul><li>How in 2011 </li></ul><ul><ul><li>Optimising standard technique </li></ul></ul><ul><ul><li>Advanced imaging techniques </li></ul></ul><ul><li>When in 2011 </li></ul><ul><ul><li>Drivers of dysplasia risk </li></ul></ul><ul><ul><ul><li>Patient history </li></ul></ul></ul><ul><ul><ul><li>Endoscopic features </li></ul></ul></ul><ul><ul><ul><li>Histologic features </li></ul></ul></ul>
  9. 9. Background <ul><li>Patients with colitis more likely to get CRC 1 </li></ul><ul><ul><li>Increases with colitis duration </li></ul></ul><ul><ul><li>RFs: extensive colitis, PSC, family history, dysplasia, severe longstanding inflammation </li></ul></ul><ul><li>Colitis surveillance most difficult diagnostic task for colonoscopists </li></ul><ul><ul><li>flat dysplasia on inflamed background </li></ul></ul><ul><ul><li>18% cancer risk at 30 years </li></ul></ul><ul><li>1 Collins PD et al. Cochrane Database Syst Rev 2006;CD000279 </li></ul><ul><li>2 Eaden JA et al. Gut 2002; 51 (Suppl V):v10-v12 </li></ul>
  10. 10. Cost effectiveness <ul><li>Does surveillance work (cost effective)? 1,2 </li></ul><ul><ul><li>70% dysplasia/cancer detected on surveillance </li></ul></ul><ul><ul><li>£36,000 / dysplasia-early cancer </li></ul></ul><ul><ul><li>http://www.nice.org.uk/nicemedia/live/11877/48912/48912.pdf </li></ul></ul><ul><li>1 Collins PD et al. Cochrane Database Syst Rev 2006;CD000279 </li></ul><ul><li>2 Rutter MD et al. Gut 2003; 52 (Suppl I):A66 </li></ul>
  11. 11. Standard white light exam
  12. 12. Standard white light exam <ul><li>Fibreoptic colonoscopy 1970-80s </li></ul><ul><li>Video colonoscopy 1980-90s </li></ul><ul><li>High definition (HDTV) colonoscopy 2005- </li></ul><ul><li>(structure enhance) </li></ul>
  13. 13. Standard white light exam <ul><li>Bowel preparation </li></ul><ul><ul><li>Good prep to find polyps 1 </li></ul></ul><ul><ul><li>Almost no research into bowel prep in colitis </li></ul></ul><ul><ul><li>Known IBD: worse prep OR 0.63 (95%CI 0.40-0.98) 1 </li></ul></ul><ul><ul><li>Simethicone may help (bubbling) with PEG-ELS 2 </li></ul></ul><ul><li>Withdrawal time </li></ul><ul><ul><li>Longer time = more adenoma detection 3 </li></ul></ul><ul><ul><li>Similar for dysplasia in colitis 4 </li></ul></ul><ul><li>1 Froehlich F et al. Gastrointest Endosc 2005;61:378-84 </li></ul><ul><li>2 Lazzaroni M et al. Aliment Phamacol Ther 1993;7:655-9 </li></ul><ul><li>3 Barclay R et al. New Engl J Med 2006;355:2533-41 </li></ul><ul><li>4 Toruner M et al. Inflamm Bowel Dis 2005;11:428-34 </li></ul>
  14. 14. Standard white light exam R 2 =0.12, P=0.0066 Toruner M et al. Inflamm Bowel Dis 2005; 11 :428-34
  15. 15. Biopsy protocol <ul><li>UK (2002), ECCO and US guidelines recommend 2-4 biopsies every 10cm </li></ul><ul><ul><li>Samples 0.03% colonic surface 1 </li></ul></ul><ul><ul><li><2/1000 non-targeted biopsies dysplastic 2 </li></ul></ul><ul><li>No difference in dysplasia detection with more biopsies 3 </li></ul><ul><li>1 East JE et al. Am J Gastroenterology 2007; 102 :2529-35 </li></ul><ul><li>2 Hurlstone DP et al. Endoscopy 2005; 37 :1186-92 </li></ul><ul><li>3 Toruner M et al. Inflamm Bowel Dis 2005; 11 :428-34 </li></ul>
  16. 16. Biopsy protocol R 2 =0.02, P>0.05 Toruner M et al. Inflamm Bowel Dis 2005; 11 :428-34
  17. 17. Improved surface detail <ul><li>High definition (HDTV) + image enhance </li></ul><ul><ul><li>No evidence (anecdote) </li></ul></ul><ul><li>Chromoendoscopy </li></ul><ul><ul><li>Multiple large (n=100+)studies including RCT </li></ul></ul><ul><li>Narrow band imaging (NBI) </li></ul><ul><ul><li>Case report and tandem colonoscopy & RCT </li></ul></ul><ul><li>Autofluorescence endoscopy </li></ul><ul><ul><li>Case reports and back-to-back studies </li></ul></ul>
  18. 18. Chromoendoscopy Study White Light Chromoscopy Marion 2008 9/102 (8.8%) 17/102 (16.7%) Kiesslich 2007 4/73 (5.5%) 13/84 (15.5%) Hurlstone 2005 24/350 (6.9%) 69/350 (19.7%) Rutter 2004 2/100 (2%) 7/100 (7%) Kiesslich 2003 6/81 (7.4%) 11/80 (13.8%) SUMMARY 6.4% (45/706) 95% CI 4.6-8.2 16.3% (117/716) 95% CI 13.6-19.1
  19. 19. Chromoendoscopy
  20. 20. Chromoendoscopy
  21. 21. Chromoendoscopy
  22. 22. SURFACE guidelines for chromoendoscopy in ulcerative colitis      (1) S trict patient selection      (2) U nmask the mucosal surface =good bowel prep      (3) R educe peristaltic waves =antispasmodic      (4) F ull length staining of the colon (pan-chromoendoscopy)      (5) A ugmented detection with dyes      (6) C rypt architecture analysis      (7) E ndoscopic targeted biopsies =not random Kiesslich R et al. Gut 2004; 53 :165-76
  23. 23. Dye-spray <ul><li>10ml 1% Indigocarmine (i.e. one ampoule) </li></ul><ul><li>40ml Water for injection </li></ul><ul><li>A few drops of anti-foam (simethicone) </li></ul><ul><li>=50ml 0.2% Indigocarmine </li></ul><ul><li>Draw up in 20ml syringe </li></ul>
  24. 24. Narrow band imaging <ul><li>Case report 1 </li></ul><ul><ul><li>NBI can detect dysplasia in UC </li></ul></ul><ul><ul><li>NBI pit pattern assessment is possible to differentiate dysplasia from inflammation </li></ul></ul><ul><li>Two randomised tandem study (n=42 & 48) 2, 3 </li></ul><ul><ul><li>NBI = white light but fewer biopsies </li></ul></ul><ul><li>Randomised parallel group (n=112) 4 </li></ul><ul><ul><li>NBI 9% vs HDTV white light 9% </li></ul></ul><ul><li>1 East JE et al. Gut 2006; 55 :1432-35 </li></ul><ul><li>2 Dekker E et al. Endoscopy 2007; 39 :216-21 </li></ul><ul><li>3 van den Broek FJ et al. Endoscopy 2011; 43 :108-15 </li></ul><ul><li>4 Iganatovic A et al. BSG 2011 [abstract] </li></ul>
  25. 25. Narrow band imaging
  26. 26. Narrow band imaging
  27. 27. Autofluorescence imaging <ul><li>Case report 1 </li></ul><ul><ul><li>50% AFI +ve lesions dysplastic </li></ul></ul><ul><li>Randomised back-to-back study (n=50) 2 </li></ul><ul><ul><li>WLE miss rate 3/6 </li></ul></ul><ul><ul><li>AFI miss rate 0/10 p=0.036 </li></ul></ul><ul><li>Anecdotally inflammation a problem </li></ul><ul><li>1 Matsumoto T et al. Inflam Bowel Dis 2007; 13 :640-41 </li></ul><ul><li>2 van den Broek FJ et al. Gut 2008; 57 :1083-9 </li></ul>
  28. 28. Autofluorescence imaging
  29. 29. Autofluorescence imaging
  30. 30. Autofluorescence imaging
  31. 31. Multimodal imaging (ETMI)
  32. 32. Confocal endomicroscopy Kiesslich R et al. Gastroenterology 2007; 132 :874-882
  33. 33. Confocal endomicroscopy <ul><li>161 randomised to: </li></ul><ul><ul><li>1. Standard white light with quadrantic biopsies </li></ul></ul><ul><ul><li>2. Chromoendoscopy + confocal endomicroscopy </li></ul></ul><ul><li>3.5 fold increase in dysplasia </li></ul><ul><li>Up to 10-fold reduction in bx </li></ul><ul><li>Further 5-fold reduction in bx </li></ul><ul><li>Sensitivity 94.7% (95% CI 74-100%) </li></ul>Sensitivity 93% for zoom chromoendoscopy chromoendoscopy confocal +
  34. 34. Summary <ul><li>When to screen </li></ul><ul><ul><li>At 8-10 years post symptom start </li></ul></ul><ul><ul><li>Then potentially risk stratified according to findings </li></ul></ul><ul><ul><ul><li>Patient history </li></ul></ul></ul><ul><ul><ul><li>Histology </li></ul></ul></ul><ul><ul><ul><li>Endoscopy </li></ul></ul></ul><ul><li>How to screen </li></ul><ul><li>Optimised standard endoscopy </li></ul><ul><ul><li>Slow, clean, high definition, no random biopsies </li></ul></ul><ul><li>Pan-colonic chromoendoscopy </li></ul><ul><li>? Novel advanced imaging techniques </li></ul><ul><ul><li>None clearly better than chromoendoscopy at present </li></ul></ul>

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