A 55-year-old man with longstanding ulcerative colitis (pancolitis for 18 years) is found to have low-grade dysplasia in flat mucosa on surveillance colonoscopy. What is the recommended management?
- A Proctocolectomy with ileal pouch-anal anastomosis ✓
- B Repeat surveillance colonoscopy in 3 months
- C Increase mesalamine dose and repeat biopsy in 6 months
- D Argon plasma coagulation ablation of dysplastic areas
Explanation
Flat low-grade dysplasia (LGD) in long-standing UC (>8–10 years, pancolitis) carries significant risk of synchronous colorectal carcinoma (estimated 20–40% of colectomy specimens) and progression to high-grade dysplasia. Current BSG/ECCO/AGA guidelines recommend proctocolectomy for flat LGD identified by standard white-light endoscopy in the context of confirmed, reproducible pathology. Enhanced endoscopy (chromoendoscopy) can better delineate visible lesions amenable to endoscopic resection, but flat invisible LGD in long-standing UC warrants surgical referral. Surveillance alone is insufficient.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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