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Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter.
Rationale
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.
Yearly MRCP is recommended to screen for cholangiocarcinoma.
References
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.
Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter.
Rationale
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.
Yearly MRCP is recommended to screen for cholangiocarcinoma.
References
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.
Q2. Correct answer: B. He should undergo surveillance colonoscopy now and annually thereafter.
Rationale
PSC diagnosis is the most consistent risk factor for colorectal cancer (CRC) in patients with inflammatory bowel disease. Other identified risk factors include endoscopic extent of the disease (pancolitis), duration of the disease (more than 8 years), age at diagnosis (young), presence of pseudopolyps, and family history of CRC. The current guidelines recommend first surveillance colonoscopy 8-10 years after the diagnosis of ulcerative colitis or Crohn's disease that involves more than one-third of the colon with subsequent surveillance intervals at 1-3 years. However, for patients with a concomitant diagnosis of PSC, the recommendation is to initiate surveillance as soon as the coexisting diagnosis is established, with annual surveillance colonoscopy thereafter.
High-dose UDCA (more than 28 mg/kg/day) is not recommended in patients with PSC because it was linked to adverse outcomes in this population including decompensated cirrhosis, death, and increased risk of colorectal neoplasia. On the other hand, low-dose UDCA may improve laboratory markers of cholestasis, but with no clear impact on survival or long-term outcomes, its role for chemoprophylaxis in colorectal cancer is still controversial.
Yearly MRCP is recommended to screen for cholangiocarcinoma.
References
Lindor KD et al. Am J Gastroenterol. 2015 May;110(5):646-59; quiz 660.
Lopez A et al. Best Pract Res Clin Gastroenterol. Feb-Apr 2018;32-33:103-109.
Q2. A 22-year-old man with a history of extensive ulcerative colitis diagnosed 3 years ago presents for evaluation. He is currently in clinical remission, maintained on oral mesalamine 2.4 g/day in divided doses. He was noted to have persistent elevation of serum alkaline phosphatase on blood samples drawn 3 months apart. Magnetic resonance cholangiopancreatography (MRCP) revealed alternating narrowed and dilated segments of the intrahepatic and extrahepatic biliary ducts consistent with primary sclerosing cholangitis (PSC).