1. Precancerous colorectal lesions in IBD should be described as either polypoid (≥2.5 mm tall), nonpolypoid (<2.5 mm) or invisible (detected on nontargeted biopsy), using a modified Paris Classification. The older terms dysplasia-associated lesion or mass, adenoma-like mass and flat dysplasia (when referring to dysplasia detected in nontargeted biopsies) should be abandoned.
2. Visible precancerous lesions should be described based on size, morphology, clarity of borders, presence of ulceration, location, presence within an area of past or current colitis, perceived completeness of resection, and whether any special techniques were used for visualization.
3. Initial colonoscopy screening for dysplasia should be performed at 8-10 years after disease diagnosis in all people with colonic IBD, and immediately on diagnosis of primary sclerosing cholangitis. Staging biopsies should be taken from multiple colonic segments to assess histologic disease activity and extent and to help guide future surveillance intervals.
4. Conditions and practices for dysplasia detection should be optimized, including control of inflammation, use of high-definition endoscopes, bowel preparation, careful washing and inspection of all colorectal mucosa and targeted sampling of any suspicious mucosal irregularities.
5. Targeted biopsies should be performed where mucosal findings are suspicious for dysplasia or are inexplicably different from the surrounding mucosa. Endoscopic resection is preferred to biopsies when lesions are clearly demarcated without stigmata of invasive cancer or submucosal fibrosis. Mucosal biopsies surrounding a resected lesion are not required unless there are concerns about resection completeness.
6. Dye spray chromoendoscopy, performed by appropriately trained endoscopists, should be considered in all persons with colonic IBD undergoing surveillance colonoscopy, particularly if a standard definition endoscope is used or if there is a history of dysplasia.
7. Virtual chromoendoscopy is a suitable alternative to dye spray chromoendoscopy for dysplasia detection in persons with colonic IBD when using high-definition endoscopy.
8. Extensive nontargeted biopsies (roughly 4 adequately spaced biopsies every 10 cm) should be taken from flat colorectal mucosa in areas previously affected by colitis when white light endoscopy is used without dye spray chromoendoscopy or virtual chromoendoscopy. Additional biopsies should be taken from areas of prior dysplasia or poor mucosal visibility. Nontargeted biopsies are not routinely required if dye spray chromoendoscopy or virtual chromoendoscopyis performed using a high-definition endoscope, but should be considered if there is a history of dysplasia or primary sclerosing cholangitis.
9. All clearly delineated dysplastic-appearing lesions without stigmata of invasive cancer or significant submucosal fibrosis should be considered for endoscopic resection. If the resectability of a lesion is in question, referral to a specialized endoscopist or IBD center is suggested.
10. A finding of invisible dysplasia should prompt repeat examination by an experienced endoscopist using high-definition dye spray chromoendoscopy under optimized viewing conditions, with extensive nontargeted biopsies in the area of prior dysplasia if no lesion is seen. A finding of unresectable visible dysplasia or of invisible multifocal or high-grade dysplasia on histology should prompt colectomy. For visible lesions that can be resected or if histologic dysplasia is not confirmed on a high-quality dye spray chromoendoscopy examination, continued endoscopic surveillance at frequent intervals is appropriate.
11. After a negative screening colonoscopy, surveillance colonoscopy should be performed every 1-5 years based on risk factors for colorectal cancer, considering current and prior burden of colonic inflammation, family history of colorectal cancer, primary sclerosing cholangitis, history of colorectal dysplasia, and frequency and quality of prior surveillance examinations.
12. Pouch surveillance should be performed at least annually in those at high risk for developing colorectal dysplasia (prior colorectal cancer or dysplasia, primary sclerosing cholangitis), as well as in those with persistent moderate to severe pouchitis and/or pre-pouch ileitis (to assess for treatment response). Surveillance intervals in those at lower risk should be individualized.
13. Targeted biopsies of representative or concerning pseudopolyps is appropriate during colonoscopy. Removal and sampling of all lesions is neither required nor practical. Surgery should be a last resort to manage colorectal cancer risk in the setting of severe pseudopolyposis. Dye spray chromoendoscopy should not be used to detect flat or subtle lesions within a field of pseudopolyps.
14. Optimal disease control with medical therapy is imperative to minimizing an individual’s lifetime risk of developing colorectal cancer. There is uncertainty regarding the independent chemotherapeutic benefit of mesalamine therapy in people with colonic IBD.
