A 45-year-old man with longstanding ulcerative colitis (pancolitis for 12 years) comes for colonoscopy surveillance. The biopsy shows high-grade dysplasia in a flat mucosa without polypoid change. What is the most appropriate management?
- A Repeat colonoscopy in 3-6 months with increased biopsy sampling
- B Local endoscopic mucosal resection of the dysplastic area
- C Increase mesalazine dose and repeat biopsy in 1 year
- D Colectomy — high-grade dysplasia in flat mucosa is an indication for total proctocolectomy ✓
Explanation
High-grade dysplasia (HGD) in flat mucosa in the setting of long-standing ulcerative colitis carries a significant risk (30-40%) of synchronous colorectal cancer in the resected specimen and a high risk of progression. Per international guidelines (BSG, ECCO), HGD in flat/non-polypoid mucosa is an indication for total proctocolectomy. Polypoid dysplastic lesions (DALMs or adenoma-like masses) may be managed by polypectomy with close surveillance if clearly delineated and the surrounding flat mucosa is dysplasia-free. Increasing mesalazine or repeat surveillance is not appropriate for confirmed HGD.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.