A 45-year-old woman with primary sclerosing cholangitis (PSC) and concomitant ulcerative colitis undergoes surveillance colonoscopy. A flat dysplastic lesion 15 mm in diameter is found in the descending colon. Histology confirms low-grade dysplasia (LGD) without visible mass. Per BSG/ECCO 2022 guidelines on dysplasia in IBD, the management is:
- A Proctocolectomy — any dysplasia in PSC-IBD mandates immediate colectomy regardless of extent
- B Repeat colonoscopy in 3 months with chromoendoscopy — LGD in PSC-IBD does not require resection
- C High-dose mesalazine for 6 months and repeat biopsy — topical anti-inflammatory will regress LGD
- D Endoscopic resection with subsequent close surveillance — if completely resected with negative margins, colectomy is not required ✓
Explanation
BSG IBD dysplasia guidelines (2022) state that visible dysplastic lesions that are completely endoscopically resectable (flat or polypoid, clear margins, no synchronous invisible LGD on surrounding biopsies) can be managed by endoscopic resection (EMR/ESD) followed by intensive surveillance rather than immediate colectomy. PSC-associated IBD carries higher colorectal cancer risk requiring annual surveillance colonoscopy with chromoendoscopy. However, prophylactic colectomy for endoscopically resectable LGD is no longer mandatory if resection is complete. Multidisciplinary review is essential given PSC co-existing.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.