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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

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Thank you

mumbaiendoscopy@gmail.com

53

Thank you

mumbaiendoscopy@gmail.com

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