Gastroenterology: An unexpected discovery in hyper-expanded endoscopy monitoring ulcerative colitis. Case studies.

This article is compiled by yimaitong, please do not reprint without authorization.a 44 year old female patient with 24 years history of ulcerative colitis (UC) frequently visited our hospital in the past.UC is a total colon type and has been maintained in remission by oral mesalazine (4.8 g / D) for the past three years.the patient received routine endoscopic monitoring (once a year). It was found that the patient's total colonic UC achieved mucosal healing under endoscopy, but there was a slight red lesion protruding from the surface (about 5mm) in the lower part of the rectum.doctors used the endocytoscope (Olympus company) (supplemented by methylene blue and crystal violet staining) to further evaluate the lesions.the hyperextended cell endoscopy images showed large, round nuclei with irregular arrangement and irregular fissures (Fig. a).figure a: what is the diagnosis of hyperextended cell endoscopy? The correct diagnosis is ulcerative colitis associated colorectal cancer (uc-crc).according to the biopsy specimens, the disease was diagnosed as adenocarcinoma, and the results of ultra large cell endoscopy were consistent with the diagnosis (Fig. b).figure B: compared with healthy people, the risk of colorectal cancer (CRC) in UC patients is significantly increased.Olympus's extended cell endoscopy (EC) is a new type of endoscopic system, including a 520 fold contact optical microscope system, which is integrated into the end of colonoscopy.compared with conventional magnifying endoscopy, EC's super magnifying ability allows for cellular observation of gastrointestinal lesions and can be used for the diagnosis of CRC.however, its application in the diagnosis of colorectal cancer associated with colitis is rarely reported.the results of this study indicate that the extended cell endoscopy can be used to obtain the nuclear level information of colorectal cancer associated with colitis.most importantly, because of inflammation, colorectal cancer associated with colitis is often difficult to diagnose, and the use of extended cell endoscopy can reduce unnecessary biopsy.knowledge class: the incidence of canceration in uc-crc patients is 5-8 times higher than that in normal people, and the younger the patients are, the longer the course of disease will increase the risk of cancer.uc-crc is the most serious complication of UC, accounting for 10% - 15% of the causes of death in UC patients.a meta-analysis by eaden et al. Showed that the cancer risk of UC patients in 10, 20 and 30 years was 2.0%, 8.0% and 18.0%, respectively, and the total cancer risk was about 3.7%.uc-crc is younger than sporadic colorectal cancer, and its incidence pattern is "chronic inflammation ➝ atypical hyperplasia ➝ canceration", and it develops more rapidly than "adenoma ➝ adenocarcinoma". The average duration of uc-crc is about 16.3 years.the course of disease & gt; 10 years, the extent of lesions involving the whole colon, and colon polyps with atypical hyperplasia are independent risk factors for uc-crc. For UC patients with the above risk factors, regular colonoscopy review or preventive partial colectomy should be performed.prevention of uc-crc 1 endoscopic monitoring of dysplasia is of great significance in the process of ulcerative colitis canceration, and is an important observation index in the screening and monitoring of ulcerative colitis colonoscopy.currently, the generally accepted UC - CRC screening and monitoring guidelines are issued by the American College of Gastroenterology (ACG), which are as follows: (1) colonoscopy should be performed during remission; (2) colonoscopy should be carried out 8-10 years after the onset of ulcerative colitis; (3) the uc-crc screening and monitoring guidelines for uc-crc are published by the American College of Gastroenterology (ACG), respectively- The frequency of colonoscopy should be increased with the duration of the disease. For example, patients with total colitis should be examined once every 3 years, 2 years and 1 year in the second, third and fourth 10 years; (5) 2 samples per 10 cm segment were randomly selected- Four biopsy specimens should be biopsied in suspected cancerous areas; (6) patients with ulcerative colitis and primary sclerosing cholangitis (including liver transplantation) should be examined by colonoscopy every year.however, some scholars believe that all patients with inflammatory bowel disease should start endoscopic monitoring after 8-10 years.new endoscopic techniques, such as chromoendoscopy, confocal microscopy, magnifying endoscopy, narrow-band imaging and autofluorescence imaging, are helpful to improve the diagnosis of dysplasia and early cancer.2 chemoprevention (1) 5-aminosalicylic acid 5-aminosalicylic acid is the first-line drug for inducing and maintaining remission of mild to moderate ulcerative colitis. It has good tolerance, small adverse reactions and definite anti-inflammatory effect.it can reduce the incidence of uc-crc by reducing inflammatory reaction, blocking NF KB pathway, stabilizing internal environment, inducing apoptosis, anti malignant proliferation, anti-oxidation and reducing abnormal crypt lesions. Ursodeoxycholic acid is mainly used in the treatment of primary biliary cirrhosis, cholelithiasis, primary sclerosing cholangitis and other hepatobiliary diseases. It can reduce the hepatotoxicity of endogenous bile acids, protect the liver cell membrane, and reduce HLA class I and ma The abnormal expression of class II antigen molecules on the liver cell membrane, and also has the immunomodulatory effect.ursodeoxycholic acid can prevent uc-crc in ulcerative colitis with primary sclerosing cholangitis.some data show that ursodeoxycholic acid can not reduce the incidence of atypical hyperplasia and uc-crc, but it can reduce the mortality rate and reduce the risk of low-grade atypical hyperplasia continuing to transform into highly atypical hyperplasia.(3) etanercept TNF - α is an important mediator in the occurrence and development of colon cancer associated with colitis.inacept is a new anti-tumor necrosis factor new drug, which belongs to the whole human soluble receptor fusion protein. Soluble anti-tumor necrosis factor fusion protein is a TNF - α antagonist. It can control inflammation and block the progress of disease by inhibiting TNF - α.(4) DNA methylation and cell proliferation activity of colonic epithelial cells in patients with folate ulcerative colitis were significantly increased.therefore, it is possible to develop colorectal cancer by Cytodynamic changes.folate can maintain the normal DNA methylation process and DNA precursor homeostasis level, and inhibit the proliferation of rectal mucosal epithelial cells.therefore, folic acid may have chemopreventive effect on colorectal cancer and can be used as a preventive drug for uc-crc. the absorption of folic acid in patients with ulcerative colitis is often affected by the disease itself, in addition to increased intestinal loss and the competitive inhibition of SULFAPYRIDINE. therefore, patients with ulcerative colitis often have insufficient or even lack of folic acid. Patients with ulcerative colitis need to supplement folic acid, which is also one of the methods to prevent and treat uc-crc. (5) other possible chemopreventive drugs include statins, calcium agents, steroids, etc. statins such as fluvastatin can reduce inflammatory response, simvastatin can promote cell apoptosis and inhibit angiogenesis, which may have the effect of inhibiting canceration; calcium can reduce the occurrence of adenomatous polyps, but there is no obvious evidence that it can reduce the incidence of uc-crc. oral or topical corticosteroids have antitumor effect, but there are many adverse reactions, so it is not suitable for chemoprevention. The incidence of uc-crc can be significantly reduced by prophylactic colorectal resection, but it may cause postoperative complications and affect the quality of life of patients. therefore, we should weigh the advantages and disadvantages and consider them comprehensively. References: [1] Fukunaga s, kusaba y, Tsuruta o, use of endocytocopy for acute colitis surveillance: a case study, Gastroenterology (2019), DOI: A, Sachar DB.Ulcerative colitis practice guideline in adults (update)：American College of Gastroenterology，Practice Parameters Committee [J]. Am J gastroenteml, 2004, 99 (7): 1371-1385. [3] Zhang Chunxia, Wu Xiaoping. research progress of ulcerative colitis related colorectal cancer [J]. Journal of clinical internal medicine. 2014, 31(2):85-87。 [4] Gu Yanhui, Han Guangsen, Zhang Shijia. analysis of risk factors of ulcerative colitis related colorectal cancer [J]. Chinese Journal of digestive surgery. 2017, 16(7) :736-740。 1. Professor Yang Hong: looking back on the development of IBD drug history and looking forward to a new era of treatment led by small molecule drugs. 2. For the Dragon Boat Festival, please keep this top 10 gift pack of digestive department clinical guidelines for the first half of 2020. 3. 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