gastrocon 2016 - dr pankaj dhawan on surveillance in gi diseases
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Pankaj Dhawan, MD, DNB, DMChief Interventional Gastroenterologist
Digestive Diseases & Endoscopy Center, Mumbai, IndiaConsultant Interventional Gastroenterologist
Jaslok, Bhatia & Breach Candy Hospitals, Mumbai
Surveillance (and screening) in GI Diseases
Two Issues• SURVEILLANCE• Periodic evaluation of a chronic inflammatory disease which has a potential to
turn malignant.
• SCREENING• Evaluation of normal [high risk] population to pick up pre malignant / early
tumors.
Definitions
Two Issues• SURVEILLANCE• Periodic evaluation of a chronic inflammatory disease which has a potential to
turn malignant.
• SCREENING• Evaluation of normal [high risk] population to pick up pre malignant / early
tumors.
Definitions
Two Issues• Early detection : Improved outcomes
Surveillance
Gut 2014
n=29,536
Two Issues• New endoscopic technology is very useful• Options [minimal access] now available• Aging population• Improved awareness• Society guidelines• Increasing workload in GI
Surveillance
Two Issues• Pre-existing disease considered “pre-malignant”• Treated patient follow up
Surveillance : Two Situations
Two Issues• Upper GI• Barrett’s esophagus• Esophageal cancer• Gastric cancer
• Lower GI• Colorectal polyps• Colorectal cancer
• Biliary Pancreatic• Hepato-biliary tumors• Pancreatic tumors
Surveillance for Treated Patients
Two Issues• Upper GI
• Barrett’s esophagus• Gastric atrophy• Corrosive esophagus
• Lower GI• Colorectal polyps• Inflammatory bowel disease• Celiac disease
• Biliary Pancreatic• Chronic pancreatitis• Pancreatic cysts• Gallbladder polyps• Gallstones • Choledochal cyst
• Syndromes
Surveillance for Pre-existing Disease
Two Issues• Upper GI
• Barrett’s esophagus• Gastric atrophy• Corrosive esophagus
• Lower GI• Colorectal polyps• Inflammatory bowel disease• Celiac disease
• Biliary Pancreatic• Chronic pancreatitis• Pancreatic cysts• Gallballder polyps• Gallstones • Choledochal cyst
• Syndromes
Surveillance for Pre-existing Disease
Two IssuesBarrett’s Esophagus
Two IssuesBarrett’s Esophagus
• Mr. AS, 54 years, non smoker• GERD since 5 years.• Multiple upper GI endoscopy• Diagnosed : Barrett’s esophagus with hiatal henria
• OUR EVALUATION :• First patient to have NBI• WLE : Barrett’s esophagus [c-3, M-5], Hiatal hernia [3 cm]• NBI : Uniform BE• Biopsy [Seattle protocol] : No dysplasia
2008Barrett’s Esophagus
2009Barrett’s Esophagus
2010Barrett’s Esophagus
2011 [Mar]Barrett’s Esophagus
2011 [Mar]Barrett’s Esophagus
2011 [Jul]Barrett’s Esophagus
2011 [Jul]Barrett’s Esophagus
• Esophagectomy• R0 resection• T1, N0 lesion
2011 [Aug]Barrett’s Esophagus
Two IssuesBarrett’s Esophagus
Two IssuesBarrett’s Esophagus
SEATTLE PROTOCOL• A 4-quadrant biopsy sampling should be performed every 2 cm or
every 1 cm (if known or suspected dysplasia). • Additionally, specific biopsies of any suspicious lesions should be
submitted separately.
Note : Treat any inflammation prior
Two IssuesAtrophic Gastritis
Two IssuesAtrophic Gastritis
Two IssuesAtrophic Gastritis
Two IssuesColon Cancer : Screening
Two IssuesColon Cancer : Screening
High Risk Group• Male• > 70 years• Family history of CRC• Smoking• High BMI• NAFLD
Two IssuesColonic Polyps
Two Issues• Size• Number• Histology type• Serrated polyp
Colonic Polyps
Two IssuesColonic PolypsBaseline [high quality] colonoscopy
Low Risk
1-2 adenomasand both small < 1 cm
Intermediate Risk
3-4 small adenomasOr atleast one > 1 cm
High RiskAdenoma ≥10 mm; or with high
grade dysplasia; or a villous component or ≥3 adenomas; serrated polyp≥10mm or with
dysplasia
A5 years 3 years 1 years
Findings at follow up
B C
No adenoma Stop follow upLow risk adenoma AIntermediate risk adenoma BHigh risk adenoma C
Negative, Low or Intermediate risk adenoma BHigh risk adenoma C
1 neg exam B2 neg exams Stop FuLow or Inter risk adenoma BHigh risk adenoma C
Findings at follow up Findings at follow up
Two Issues• Disease duration and extent• Activity and severity of inflammation• Strictures • Primary sclerosing cholangitis• Family history of CRC• Dysplasia
Inflammatory Bowel Disease
Two IssuesRecommendation [Past]Random biopsies from all segments of colon [atleast 32 specimens] [to pick up “invisible” lesions] + “visible” lesion biopsy
Farraye FA, et al. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010
Inflammatory Bowel Disease
Two IssuesIssues :• Sample <0.1% of mucosa• Rate of dysplasia detection : 1/1000 biopsies • Only 9% of dysplasia patients diagnosed• Rate of interval CRC in IBD x 3 fold higher than those without IBD
Inflammatory Bowel Disease
Wang YR, et al. Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States. Am. J. Gastroenterol. 2013
Two IssuesChromoendoscopy Compared to WLE
• Likelihood to find any dysplasia : OR 8.9x (3.4 – 23)• Likelihood to find flat dysplasia : OR 5.2x (1.5 – 15.9)
Inflammatory Bowel Disease
Rutter M, et al. Endoscopic appearance of dysplasia in ulcerative colitis and the role of staining. Endoscopy 2004
Two IssuesSCENIC INTERNATIONAL CONSENSUS STATEMENT(Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients)
• HD WLE + Chromoendoscopy with targeted biopsy
Inflammatory Bowel Disease
Two Issues
Type Is
Inflammatory Bowel Disease
Two IssuesInflammatory Bowel Disease
Type IIa
Two IssuesInflammatory Bowel Disease
Type IIa
Two IssuesInflammatory Bowel Disease
Type IIb
Two IssuesInflammatory Bowel Disease
Type IIc
Two IssuesLIMITATIONS
• Active inflammation• Multiple pseudopolyps
Inflammatory Bowel Disease
Two IssuesPancreatic Cysts
Two IssuesPancreatic Cysts
Two IssuesPancreatic Cysts
Two Issues• Size < 3 cm• Non dilated main pancreatic duct• No intramural nodule / solid component
Pancreatic Cysts
Two IssuesPancreatic Cysts
Size Modality Interval
< 1 cm CT/MRI 2-3 yr
1-2 cm CT/MRI 1 yr (lengthen if no change after 2 yr)
2-3 cm EUS, MRIEUS in 3-6 mo, then lengthen interval thereafter alternating MRI and EUS
> 3 cm EUS, MRI Alternate MRI and EUS every 3-6 mo
Two IssuesChronic Pancreatitis
• Hereditary pancreatitis• “Tropical” pancreatitis• Alcohol related pancreatitis ?• Increasing pain• Weight loss• Jaundice• Head mass• Rising CA 19-9
Two IssuesChronic Pancreatitis
Two Issues• Gallbladder polyps (>13 mm)
Gallbladder Polyps
Two Issues• Thickened gallbladder wall on T-USG / CT scan• Obesity• Women
Gallstones
Two Issues• Thickened gallbladder wall on T-USG / CT scan• Obesity• Women
Gallstones
Two Issues• Surveillance for many chronic [pre-malignant] GI diseases is
recommended.• It has been shown to improve patient outcomes.• Utilization of advanced imaging [both endoscopic and radiologic] has
been made surveillance very useful• Newer minimal invasive therapies can be used to treat early lesions.• Protocols have been formulated.• May need modifications for Indian patients.• It will constitute increasing time resource for gastroenterologists.
Conclusion
Surveillance in GI Diseases• Colorectal cancer screening should begin at 50 years of age in average-risk individuals.• Average-risk patients with normal findings on colonoscopy should have repeat colonoscopy in
10 years.• Patients with small, distal hyperplastic polyps are considered to have a normal colonoscopy
result and should have repeat colonoscopy in 10 years.• Patients with 1 or 2 small (< 10 mm) tubular adenomas should have repeat colonoscopy in 5
to 10 years.• Patients with small (< 10 mm) serrated polyps without dysplasia should have repeat
colonoscopy in 5 years.• Patients with 3 to 10 tubular adenomas, a tubular adenoma or serrated polyp ≥ 10 mm, an
adenoma with villous features or high-grade dysplasia, a sessile serrated polyp with cytologic dysplasia, or a traditional serrated adenoma should have repeat colonoscopy in 3 years.
Two IssuesSurveillance