A 55-year-old man with longstanding ulcerative colitis (pancolitis for 12 years) undergoes surveillance colonoscopy. Multiple biopsies from a raised irregular plaque near the hepatic flexure show high-grade dysplasia. The remainder of the colon shows no other dysplasia. What is the recommended management per current BSG/ACG surveillance guidelines for indefinite high-grade dysplasia in UC?
- A Repeat colonoscopy in 3 months with repeat biopsies before deciding on surgery
- B Endoscopic mucosal resection (EMR) of the dysplastic lesion if it is polypoid/pedunculated
- C Increase 5-ASA dose to maximum and repeat surveillance in 6 months
- D Colectomy (proctocolectomy) is recommended for confirmed high-grade dysplasia in UC ✓
Explanation
Per current ECCO and ACG guidelines, confirmed high-grade dysplasia (HGD) in inflammatory bowel disease — even when found in a single biopsy and even when associated with a visible lesion — is an indication for colectomy (usually proctocolectomy with ileal pouch-anal anastomosis). HGD in UC carries a very high risk of concurrent colorectal carcinoma (found in 40–50% of colectomy specimens after HGD diagnosis) and a high risk of progression to cancer. If the dysplasia is in a clearly delineated, polypoid, endoscopically resectable lesion without surrounding flat dysplasia, careful endoscopic resection with close surveillance is an alternative approach in some guidelines (for confirmed complete resection in expert centres), but outright HGD in a flat irregular plaque (as in this case) requires colectomy. Repeat colonoscopy is appropriate for indefinite dysplasia, not HGD.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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