Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
-
Upload
apollogleaneagls -
Category
Health & Medicine
-
view
26 -
download
1
Transcript of Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
![Page 1: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/1.jpg)
1
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
![Page 2: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/2.jpg)
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
![Page 3: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/3.jpg)
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
![Page 4: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/4.jpg)
Two Issues• Early detection : Improved outcomes
Surveillance
Gut 2014
n=29,536
![Page 5: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/5.jpg)
Two Issues• New endoscopic technology is very useful• Options [minimal access] now available• Aging population• Improved awareness• Society guidelines• Increasing workload in GI
Surveillance
![Page 6: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/6.jpg)
Two Issues• Pre-existing disease considered “pre-malignant”• Treated patient follow up
Surveillance : Two Situations
![Page 7: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/7.jpg)
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
![Page 8: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/8.jpg)
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
![Page 9: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/9.jpg)
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
![Page 10: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/10.jpg)
Two IssuesBarrett’s Esophagus
![Page 11: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/11.jpg)
Two IssuesBarrett’s Esophagus
![Page 12: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/12.jpg)
• 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
![Page 13: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/13.jpg)
2009Barrett’s Esophagus
![Page 14: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/14.jpg)
2010Barrett’s Esophagus
![Page 15: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/15.jpg)
2011 [Mar]Barrett’s Esophagus
![Page 16: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/16.jpg)
2011 [Mar]Barrett’s Esophagus
![Page 17: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/17.jpg)
2011 [Jul]Barrett’s Esophagus
![Page 18: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/18.jpg)
2011 [Jul]Barrett’s Esophagus
![Page 19: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/19.jpg)
• Esophagectomy• R0 resection• T1, N0 lesion
2011 [Aug]Barrett’s Esophagus
![Page 20: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/20.jpg)
Two IssuesBarrett’s Esophagus
![Page 21: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/21.jpg)
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
![Page 22: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/22.jpg)
Two IssuesAtrophic Gastritis
![Page 23: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/23.jpg)
Two IssuesAtrophic Gastritis
![Page 24: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/24.jpg)
Two IssuesAtrophic Gastritis
![Page 25: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/25.jpg)
Two IssuesColon Cancer : Screening
![Page 26: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/26.jpg)
Two IssuesColon Cancer : Screening
High Risk Group• Male• > 70 years• Family history of CRC• Smoking• High BMI• NAFLD
![Page 27: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/27.jpg)
Two IssuesColonic Polyps
![Page 28: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/28.jpg)
Two Issues• Size• Number• Histology type• Serrated polyp
Colonic Polyps
![Page 29: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/29.jpg)
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
![Page 30: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/30.jpg)
Two Issues• Disease duration and extent• Activity and severity of inflammation• Strictures • Primary sclerosing cholangitis• Family history of CRC• Dysplasia
Inflammatory Bowel Disease
![Page 31: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/31.jpg)
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
![Page 32: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/32.jpg)
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
![Page 33: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/33.jpg)
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
![Page 34: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/34.jpg)
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
![Page 35: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/35.jpg)
Two Issues
Type Is
Inflammatory Bowel Disease
![Page 36: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/36.jpg)
Two IssuesInflammatory Bowel Disease
Type IIa
![Page 37: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/37.jpg)
Two IssuesInflammatory Bowel Disease
Type IIa
![Page 38: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/38.jpg)
Two IssuesInflammatory Bowel Disease
Type IIb
![Page 39: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/39.jpg)
Two IssuesInflammatory Bowel Disease
Type IIc
![Page 40: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/40.jpg)
Two IssuesLIMITATIONS
• Active inflammation• Multiple pseudopolyps
Inflammatory Bowel Disease
![Page 41: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/41.jpg)
Two IssuesPancreatic Cysts
![Page 42: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/42.jpg)
Two IssuesPancreatic Cysts
![Page 43: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/43.jpg)
Two IssuesPancreatic Cysts
![Page 44: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/44.jpg)
Two Issues• Size < 3 cm• Non dilated main pancreatic duct• No intramural nodule / solid component
Pancreatic Cysts
![Page 45: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/45.jpg)
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
![Page 46: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/46.jpg)
Two IssuesChronic Pancreatitis
• Hereditary pancreatitis• “Tropical” pancreatitis• Alcohol related pancreatitis ?• Increasing pain• Weight loss• Jaundice• Head mass• Rising CA 19-9
![Page 47: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/47.jpg)
Two IssuesChronic Pancreatitis
![Page 48: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/48.jpg)
Two Issues• Gallbladder polyps (>13 mm)
Gallbladder Polyps
![Page 49: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/49.jpg)
Two Issues• Thickened gallbladder wall on T-USG / CT scan• Obesity• Women
Gallstones
![Page 50: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/50.jpg)
Two Issues• Thickened gallbladder wall on T-USG / CT scan• Obesity• Women
Gallstones
![Page 51: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/51.jpg)
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
![Page 54: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/54.jpg)
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.
![Page 55: Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases](https://reader035.fdocuments.net/reader035/viewer/2022062822/587eb35c1a28abbb688b5759/html5/thumbnails/55.jpg)
Two IssuesSurveillance