Endoscopy 2006; 38(5): 477-482
DOI: 10.1055/s-2006-925165
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Low Frequency of Colorectal Dysplasia in Patients with Long-Standing Inflammatory Bowel Disease Colitis: Detection by Fluorescence Endoscopy

T.  Ochsenkühn1 , C.  Tillack1 , H.  Stepp2 , J.  Diebold3 , S.  J.  Ott1 , R.  Baumgartner2 , S.  Brand1 , B.  Göke1 , M.  Sackmann1
  • 1Department of Medicine II, Klinikum Grosshadern, University of Munich, Germany
  • 2Laser Research Institute, Klinikum Grosshadern, University of Munich, Germany
  • 3Institute of Pathology Munich, Klinikum Grosshadern, University of Munich, Germany
Further Information

Publication History

Submitted 2 September 2004

Accepted after revision 5 September 2005

Publication Date:
09 May 2006 (online)

Background and Study Aim: Patients with long-standing inflammatory bowel disease (IBD) have an increased risk of developing colonic dysplasias. Dysplastic changes in flat mucosa are likely to be missed by conventional colonoscopy. Endoscopic fluorescence imaging, using 5-aminolevulinic acid (5-ALA) as photosensitizer, has evolved as a new technique to differentiate between normal colonic mucosa and dysplasia. We combined this technique with random biopsies to prospectively evaluate the occurrence of dysplasias in patients with long-standing IBD.
Patients and Methods: 52 colonoscopies were performed in 42 consecutive patients (n = 28 with ulcerative colitis, n = 11 with Crohn’s colitis, n = 3 with indeterminate colitis; mean age 43 years, range 21 - 78) with long-standing IBD colitis (median disease duration 14 years, range 3 - 40). All patients were in clinical remission. Patients were examined using both conventional white light and by fluorescence colonoscopy using oral 5-ALA. Four biopsies were taken every 10 cm from mucosa of normal appearance. In addition, macroscopically suspicious and fluorescence-positive areas were biopsied.
Results: A total of 688 biopsies of red-fluorescent (n = 20) and nonfluorescent (n = 662) areas of mucosa were taken. Dysplasia was detected histopathologically in only two of the biopsies. These biopsies were taken from two polypoid lesions which were fluorescence-negative.
Conclusions: The rate of colonic dysplasia in patients with long-standing IBD colitis may be lower than previously reported.

References

  • 1 Farrell R J, Peppercorn M A. Ulcerative colitis.  Lancet. 2002;  359 331-340
  • 2 Rutter M, Saunders B, Wilkinson K. et al . Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis.  Gastroenterology. 2004;  126 451-459
  • 3 Greenstein A J, Sachar D B, Smith H. et al . A comparison of cancer risk in Crohn’s disease and ulcerative colitis.  Cancer. 1981;  48 2742-2745
  • 4 Weedon D D, Shorter R G, Ilstrup D M. et al . Crohn’s disease and cancer.  N Engl J Med. 1973;  289 1099-1103
  • 5 Gyde S N, Prior P, Macartney J C. et al . Malignancy in Crohn’s disease.  Gut. 1980;  21 1024-1029
  • 6 Ekbom A, Helmick C, Zack M, Adami H-O. Increased risk of large bowel cancer in Crohn’s disease with colonic involvement.  Lancet. 1990;  336 357-359
  • 7 Bernstein C N, Blanchard J F, Kliewer E, Wajda A. Cancer risk in patients with inflammatory bowel disease: a population-based study.  Cancer. 2001;  91 854-862
  • 8 Rhodes J M, Campbell B J. Inflammation and colorectal cancer: IBD-associated and sporadic cancer compared.  Trends Mol Med. 2002;  8 10-16
  • 9 Ullman T A, Loftus Jr E V , Kakar S. et al . The fate of low grade dysplasia in ulcerative colitis.  Am J Gastroenterol. 2002;  97 922-927
  • 10 Ransohoff D F, Riddell R H, Levin B. Ulcerative colitis and colonic cancer. Problems in assessing the diagnostic usefulness of mucosal dysplasia.  Dis Colon Rectum. 1985;  28 383-388
  • 11 Raithel M, Weidenhiller M, Schwab D. et al . Pathobiology of dysplasia in chronic inflammatory bowel disease: Current recommendations for surveillance of dysplasia [in German].  Z Gastroenterol. 2001;  39 861-875
  • 12 Messmann H. Fluorescence endoscopy in gastroenterology.  Z Gastroenterol. 2000;  38 21-30
  • 13 Stepp H, Sroka R, Baumgartner R. Fluorescence endoscopy of gastrointestinal diseases: basic principles, techniques and clinical experience.  Endoscopy. 1998;  30 379-386
  • 14 Sackmann M. Fluorescence diagnosis in GI endoscopy.  endoscopy. 2000;  32 1-9
  • 15 Messmann H, Endlicher E, Freunek G. et al . Fluorescence endoscopy for the detection of low and high grade dysplasia in ulcerative colitis using systemic or local 5-aminolaevulinic acid sensitisation.  Gut. 2003;  52 1003-1007
  • 16 Messmann H, Knüchel R, Bäumler W. et al . Endoscopic fluorescence detection of dysplasia in patients with Barrett’s esophagus, ulcerative colitis, or adenomatous polyps after 5-aminolevulinic acid-induced protoporphyrin IX sensitization.  Gastrointest Endosc. 1999;  49 97-101
  • 17 Messmann H, Kullmann F, Wild T. et al . Detection of dysplastic lesions by fluorescence in a model of colitis in rats after previous photosensitization with 5-aminolaevulinic acid.  Endoscopy. 1998;  30 333-338
  • 18 Best W R, Becktel J M, Singleton J W, Kern Jr F . Development of a Crohn’s disease activity index.  Gastroenterology. 1976;  70 439-444
  • 19 Lichtiger S, Present D H, Kornbluth A. et al . Cyclosporine in severe ulcerative colitis refractory to steroid therapy.  N Engl J Med. 1994;  330 1841-1845
  • 20 Shetty K, Rybicki L, Brzezinski A. et al . The risk for cancer or dysplasia in ulcerative colitis patients with primary sclerosing cholangitis.  Am J Gastroenterol.. 1999;  94 1643-1649
  • 21 Kornfeld D, Ekbom A, Ihre T. Is there an excess risk for colorectal cancer in patients with ulcerative colitis and concomitant primary sclerosing cholangitis? A population based study.  Gut. 1997;  41 522-525
  • 22 Marchesa P, Lashner B A, Lavery I C. et al . The risk of cancer and dysplasia among ulcerative colitis patients with primary sclerosing cholangitis.  Am J Gastroenterol.. 1997;  92 1285-1288
  • 23 Batlle A M. Porphyrins, porphyrias, cancer and photodynamic therapy - a model for carcinogenesis.  J Photochem Photobiol B. 1993;  20 5-22
  • 24 Kennedy J C, Pottier R H. Endogenous protoporphyrin IX, a clinically useful photosensitizer for photodynamic therapy.  J Photochem Photobiol B. 1992;  14 275-292
  • 25 Peng Q, Warloe T, Berg K. et al . 5-Aminolevulinic acid-based photodynamic therapy.  Cancer. 1997;  79 2282-2308
  • 26 Kiesslich R, Fritsch J, Holtmann M. et al . Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.  Gastroenterology. 2003;  124 880-888
  • 27 Winther K V, Vruun E, Horn T. et al . Screening for dysplasia in patients with 22 - 40 years of ulcerative colitis in a population-based cohort from Copenhagen County.  Gastroenterology. 2003;  124 (Suppl) A216
  • 28 Rutter M D, Saunders B P, Schofield G, Forbes A, Price A B, Talbot I C. Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis.  Gut. 2004;  53 256-260
  • 29 Peppercorn M A, Odze R D. Colorectal cancer surveillance in inflammatory bowel disease.  UpToDate. 2006.;  http://www.uptodate.com
  • 30 Arnott I D, Drummond H E, Ghosh S. Frequency of continuing mucosal inflammation in clinically inactive Crohn’s disease.  Scott Med J. 2001;  46 136-139
  • 31 Beattie R M, Nicholls S W, Domizio P. et al . Endoscopic assessment of the colonic response to corticosteroids in children with ulcerative colitis.  J Pediatr Gastroenterol Nutr. 1996;  22 373-379
  • 32 Riddell R H. Pathology of idiopathic inflammatory bowel disease. In: Kirsner JB (ed) Inflammatory bowel disease. 5th edn. Philadelphia; Saunders 2000: 427-448
  • 33 Connell W R, Lennard-Jones J E, Williams C B. et al . Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis.  Gastroenterology. 1994;  107 934-944
  • 34 Melville D M, Jass J R, Shepherd N A. et al . Dysplasia and deoxyribonucleic acid aneuploidy in the assessment of precancerous changes in chronic ulcerative colitis. Observer variation and correlations.  Gastroenterology. 1988;  95 668
  • 35 Dixon M F, Brown L J, Gilmour H M. et al . Observer variation in the assessment of dysplasia in ulcerative colitis.  Histopathology. 1988;  13 385
  • 36 Lewis J D. The many faces of low-grade dysplasia.  Gastroenterology. 2003;  125 1531-1533
  • 37 van Hogezand R A, Eichhorn R F, Choudry A. et al . Malignancies in inflammatory bowel disease: fact or fiction?.  Scand J Gastroenterol. 2002;  236 (Suppl) 48-53
  • 38 Fraser A G, Orchard T R, Robinson E M, Jewell D P. Long-term risk of malignancy after treatment of inflammatory bowel disease with azathioprine.  Aliment Pharmacol Ther. 2002;  16 1225-1232
  • 39 Lynch D A, Lobo A J, Sobala G M. et al . Failure of colonoscopic surveillance in ulcerative colitis.  Gut. 1993;  34 1075-1080
  • 40 Albert M B, Nochomovitz L E. Dysplasia and cancer surveillance in inflammatory bowel disease.  Gastroenterol Clin N Am. 1989;  18 83-97
  • 41 Axon A T. Cancer surveillance in ulcerative colitis: a time for reappraisal.  Gut. 1994;  35 587
  • 42 Ullman T, Croog V, Harpaz N. et al . Progression of flat low-grade dysplasia to advanced neoplasia in patients with ulcerative colitis.  Gastroenterology. 2003;  125 1311-1319
  • 43 Bernstein C N, Eaden J, Steinhart A H. et al . Cancer prevention in inflammatory bowel disease and the chemoprophylactic potential of 5-aminosalicylic acid.  Inflamm Bowel Dis. 2002;  8 356-361
  • 44 Mir-Madjlessi S H, Farmer R G, Easley K A, Beck G J. Colorectal and extracolonic malignancy in ulcerative colitis.  Cancer. 1986;  58 1569-1574
  • 45 Langholz E, Munkholm P, Davidsen M, Binder V. Colorectal cancer risk and mortality in patients with ulcerative colitis.  Gastroenterology. 1992;  103 1444-1451
  • 46 Brand S, Wang T D, Schomacker K T. et al . Detection of high-grade dysplasia in Barrett’s esophagus by spectroscopy measurement of 5-aminolevulinic acid-induced protoporphyrin IX fluorescence.  Gastrointest Endosc. 2002;  56 479-487

Thomas Ochsenkühn, M. D.

Department of Medicine II

University of Munich-Grosshadern · Marchioninistrasse 15 · 81 366 Munich · Germany

Fax: +49-89 70955291·

Email: thomas.ochsenkuehn@med.uni-muenchen.de

    >