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90 A. Ederle, P. Inturri, P. Brosolo, A. Fantin, M. Preto
most frequent site of the disease, accounting for
about 70% of cases. Of these, 20–30% involved the
colon only, and 40–55% had ileocolic disease [12].
Although considered peculiar of Crohn’s colitis, rec-
tal sparing is found in less than half of patients.
When the rectum is involved, the disease begins at
the rectosigmoid junction or appears with anorectal
inflammation. The entire rectum is affected by the
disease from 5% to 10%. Lesion progression, from
aphthous to serpiginous ulcers, has a discontinuous
and asymmetric course, with the inflamed mucosa
typically presenting normal “skip areas” [13]. Seg-
mental localisation of the disease has a high predic-
tive value [14].
Other endoscopic features found during a
colonoscopy include pseudopolyps, erosions and
stenosis. A prospective study evaluated the incidence
of different lesions found during a colonoscopy. All
the patients were affected by Crohn’s disease and
underwent the procedure before beginning therapy.
Endoscopy showed the following findings: 93%
superficial erosions, 74% deep erosions, 48% mucos-
al oedema, 44% erythema, 41% pseudopolyps, 10%
aphthous ulcers, 8% ulcerated stenosis and 2%
nonulcerated stenosis [15].
Pseudopolyps represent regenerative epithelium
and may include granulation tissue without prema-
lignant potential. They are often multiple and bright,
with a fragile surface that bleeds very easily when
biopsies are taken. Endoscopic differential diagnosis
with adenomas can be difficult, and only biopsy will
provide definitive diagnosis [16]. They need to be
resected if bleeding or causing obstruction, and
polypectomy is performed in the same way as in the
general population [17].
Colonoscopy allows direct investigation of stric-
tures. Biopsies are mandatory to rule out stenoses
caused by carcinoma. Malignant lesions are usually
eccentric, rigid and may present nodules within the
stricture or at its margins [18]. The colonoscope
should go beyond the stenosis in order to carry out a
thorough inspection, using a pediatric instrument if
needed, avoiding the standard colonoscope to act as
a dilator [19]. Endoscopic features may also have
prognostic value, as reported by Allez and collabora-
tors [20]. They found that patients with deep and
extensive ulcerations of the colon are at higher risk of
penetrating complications and undergoing surgery.
Distribution of severe endoscopic lesions was the fol-
lowing: rectum 13%, sigmoid colon 77%, left colon
62%, transverse colon 51%, right colon 28%.
When disease involves the colon only, the main
differential diagnosis is between Crohn’s disease and
ulcerative colitis (UC) (Table 1). Usually, the two
entities can be differentiated endoscopically, and
inflammation distribution can aid diagnosis. Crohn’s
colitis is more likely in the presence of skip areas or
when the rectum is spared. In UC, the rectum may be
spared by local treatment or when the proximal
colon is more involved than the rectum during an
acute severe attack [21]. Moreover, peculiar to
Crohn’s disease is the presence of deep linear ulcera-
tions separated by areas of normal mucosa as well as
terminal ileum involvement. Inflamed mucosa
extends for more than a few centimeters, and ulcera-
tions are present in this portion of the small intes-
tine. Although the small bowel is not involved by UC,
a few centimeters of inflamed mucosa without ulcer-
ation may be present in the terminal ileum (back-
wash ileitis) in 15–20 % of patients with pancolitis.
When extensive inflammation of the colon is pres-
ent, differential diagnosis between Crohn’s disease
and UC may be very difficult. Patients presenting fea-
tures of both diseases are considered to have indeter-
Table 1. Crohn’s disease and ulcerative colitis: endoscopic differential diagnosis
Crohn’s disease Features Ulcerative colitis
Any portion of gastrointestinal tract Distribution Contiguous involvement of the colon
starting from rectum
Often stenotic or ulcerated Ileocecal valve Without ulcerations
Frequent Lesions to terminal ileum Backwash ileitis (15–20%)
Sometimes Lesions proximally to terminal ileum Not present
25–50% Rectal involvement 95–100%
Rare Continuous colitis Yes
Asymmetric inflammation Mucosal involvement Circumferential inflammation
Yes Segmental inflammation No
Yes Skip areas No
Frequent Cobblestones-like areas Rare
Aphthoid/deep Ulcerations Shallow
Frequent Fistulas Rare
Frequent Stenosis Rare
Endoscopy in Crohn’s Disease 91
minate colitis, and at least 10% of patients who pres-
ent with an IBD is regarded as having indeterminate
colitis [22]. Usually, they are treated and monitored
as are patients with UC unless signs of Crohn’s dis-
ease develop. Other diseases that may resemble
Crohn’s disease are functional disorders (e.g. irrita-
ble bowel syndrome), immunomediated (e.g. con-
nective tissue diseases), drug induced [(e.g. nons-
teroidal anti-inflammatory drugs (NSAID)], vascular
(e.g. intestinal ischaemia), neoplastic (e.g. carcino-
ma, lymphoma), infective or diverticular disease.
Upper- and Small-Bowel Endoscopy
Esophagus, stomach and duodenum may be involved
by Crohn’s disease [23]. Even in the upper gastroin-
testinal tract, aphthous ulcer is the most common
lesion, but mucosal nodularity and stenosis may be
seen [24]. The presence of inflamed mucosa in this
portion of the digestive tract is important for differ-
ential diagnosis between Crohn’s disease and UC.
Radiologic procedures with barium as small-bowel
follow-through or enteroclysis are important for
diagnosis of Crohn’s disease localised in the small
bowel and for demonstration of strictures and fistu-
lae [25]. However, a study comparing small-bowel
barium examination with enteroclysis and ileoscopy
showed that the radiology missed 27% of severe
inflammatory changes and 50% of mild inflammato-
ry changes [26]. Push enteroscopy allows evaluation
of the proximal small bowel whereas intraoperative
enteroscopy is used to explore the distal small intes-
tine [27]. The former procedure is useful especially in
patients without known Crohn’s disease but who are
suspected to have small-bowel involvement. Howev-
er, a recent study reported that in patients with
known Crohn’s disease, capsule endoscopy has a
higher yield in detecting mucosal involvement of the
small bowel than does push enteroscopy and entero-
clysis [28]. Intraoperative enteroscopy compared
with preoperative radiography is able to find more
intestinal lesions, especially small ulcers and inflam-
matory polyps [29].
A new method of carrying out enteroscopy consists
of using a double-balloon technique in which a first
balloon is placed on the tip of the enteroscope and the
second balloon on the tip of the overtube. This tech-
nique allows far better insertability and maneuver-
ability compared with conventional methods. Prelim-
inary experience reported the performance of this
procedure on eight patients with abdominal symp-
toms, three of whom were diagnosed with Crohn’s dis-
ease [30]. Enteroscopy with the double-balloon tech-
nique was carried out using the oral approach in all
patients and additionally with the anal approach in
four patients. In two patients, it was possible to exam-
ine the whole small bowel, with a visualised total
length of between 180 cm and 500 cm. Recently,
Yamamoto reviewed the publications on double-bal-
loon endoscopy, concluding that this method has the
potential to be the standard of enteroscopy by replac-
ing conventional push and intraoperative enteroscopy
for diagnosis by means of bioptic specimens and ther-
apeutic endoscopy of the small bowel [31].
Endoscopic Retrograde Cholangiopancreatography
Primary sclerosing cholangitis is a complication of
IBD, present especially in patients affected by UC
with an incidence between 1% and 4% and with lower
frequency in Crohn’s disease [32]. Patients with IBD
and abnormal liver function test need to be evaluat-
ed for hepatobiliary complications. Depending on
local availability, MR cholangiography or endoscop-
ic retrograde cholangiopancreatography should be
performed as the initial diagnostic test in the suspi-
cion of sclerosing cholangitis. The latter procedure is
indicated as the procedure of choice when biliary
stenosis is suspected or evident.
Endoscopic Ultrasound
EUS is a procedure for imaging the intestinal wall at
high resolution. The use of EUS shows findings that
distinguish normal colon from IBD as increased wall
thickness, lymphadenopathy or enlarged perirectal
vessels [33]. In particular, vessel enlargement is more
likely associated with patients with acute Crohn’s
disease whereas adenopathy is associated with acute
UC. Therefore, this procedure could be helpful in dif-
ferentiating the two diseases. An alternative to EUS is
the high-frequency ultrasound catheter probe. In one
study, a 20-MHz radial catheter was used to evaluate
the colorectal wall in patients with IBD [34]. Crohn’s
disease was associated with thickening of the fourth
hypoechoic layer (muscularis propria) or loss of
layer structure, and mucosal and submucosal thick-
ening was more likely in ulcerative disease.
Moreover, EUS plays a major role in diagnosis and
assessment of Crohn’s anorectal and perineal com-
plications, such as abscesses or fistulae. Barium fistu-
lography and computed tomography (CT) of the
pelvis have been less sensitive for perianal disease
[35] than EUS of the rectum [36]. One study demon-
strated that rectal EUS had a diagnostic accuracy of
at least 85%, as with examination under anesthesia
and pelvic MRI, when evaluating the anatomy of
perianal fistulae [37]. When any two tests were com-
bined, the accuracy was 100%.
92 A. Ederle, P. Inturri, P. Brosolo, A. Fantin, M. Preto
Finally, endoscopic-ultrasound-guided fine-nee-
dle aspiration may help confirm the diagnosis for
suspected abscesses and provide therapeutic proce-
dures [38].
Intestinal Strictures are a Commonly Encountered
Problem in Patients with Crohn’s Disease
Management of Strictures
Intestinal strictures are a commonly encountered
problem in patients with Crohn’s disease, resulting in
bowel obstruction and eventually in repeated bowel
resection and short bowel disease. Over one third of
patients with Crohn’s disease have a clear stenosing
disease phenotype, often in the absence of luminal
inflammatory symptoms [39]. At the foundation, as
in other organs and tissues, there is transformation
and activation of fibroblasts and smooth muscle cells
that underlie fibrogenesis in the gut. Endoscopic bal-
loon dilation is the preferred initial therapeutic
modality in anastomotic strictures. In fact, endo-
scopic management with hydrostatic balloon dilation
is an effective alternative to surgery in patients with
endoscopically accessible lesions shorter than 7–8 cm
[40], but careful patient selection is of great impor-
tance to ensure favourable long-term results. The
presence of inflammation near the stricture should
not be considered a contraindication to dilation, and
intralesional steroid injection should be considered
in these patients.
Among the three clinical patterns of Crohn’s dis-
ease (inflammatory, penetrating/fistulising and
obstructive/fibrostenotic), the latter is a frequent
cause of symptoms and is an indication for surgery in
over half of operations for Crohn’s disease. Small-
intestinal strictures are found in 21% of patients,
duodenale strictures in 5% [41], colonic strictures
range from 4% to 9% [42, 43] and anorectal strictures
in 7.5% [44]. Strictures may also arise from surgical
treatment for Crohn’s disease, with reported rates of
17–81%.
To avoid surgery in patients with symptomatic
Crohn’s strictures, various endoscopic techniques
have been successfully utilised: balloon dilation with
or without corticosteroid injection, Savary dilation,
endoscopic needle knife incisions and self-expand-
able metal stents, but no randomised clinical trials
compare these methods for dilation. However, clini-
cal situations in which to consider endoscopic man-
agement of Crohn’s strictures are: endoscopic acces-
sibility, multiple previous intestinal resections and
short strictures (<8 cm). It is important to consider
intralesional steroid injection if significant inflam-
mation is present.
Intestinal balloon dilation is attractive due to the
ability to directly apply the radial force achieved dur-
ing balloon insufflation, in contrast to the shearing
force applied during bougienage [45]. Balloon dila-
tion is the most widely reported method for nonsur-
gically dilating intestinal strictures in Crohn’s disease
[46, 47] resistant to medical therapy, with endoscop-
ic incisions of the stricture or electroincision with or
without intralesional steroid injection [48]. The bal-
loon, with a diameter from 18 mm to 25 mm, was
inflated for 1–4 min and repeated two to four times
per session [49]. Successful dilation was generally
defined as allowing the passage of a standard adult
colonoscope. One author [50] made four radial inci-
sions into the stricture with a standard papillotome if
the colonoscope could not pass the stricture. In this
way, dilation sufficient to allow passage of the adult
colonoscope was achieved in every patient, with 3%
of complications (minor bleeding and perforation) in
a total of 137 dilations, with complete symptom relief
achieved in 66% of patients over a mean follow-up of
19 months. It was suggested that the nonresponse
group had more aggressive disease. Other authors
performed hydrostatic balloon dilation with inflation
diameters from 12 mm to 18 mm [51]. Immediate
symptomatic relief was noted in 77% of patients, with
persistent long-term relief in 44% after a mean fol-
low-up of
25 months. Longer strictures and active
inflammation were characteristics that portended
poor response. The same authors, in a follow-up
study of a larger number of patients undergoing
hydrostatic balloon dilation for symptomatic ileo-
colonic stricture in Crohn’s disease resistant to med-
ical treatment and followed up over a 5-year period,
suggested that dilation can be successful in the set-
ting of inflammation [52]. Technical success was
achieved in 90% of procedures, with best results in
ileocolic anastomoses. Overall relief of symptoms
was achieved in 62% of patients after mean follow-up
of 33.6 months, with 8% of complications and no
deaths for a total of 76 dilations. Lack of success was
noted in strictures with tight angulation and longer
lenght.
Based on the success of using intralesional corti-
costeroids in caustic lesions, dilation followed by
intralesional steroid injection was performed in
Crohn’s strictures [53]. Following hydrostatic dila-
tion, approximately 5 mg betamethasone dipropi-
onate diluted into 5–10 ml of normal saline as 0.5- to
1-ml aliquots was injected into the most narrowed
area using a standard sclerotherapy needle. Immedi-
ate symptom relief was always achieved without
complications, and 84% of patients achieved a pro-
longed symptom-free period during a follow-up of 6
years after combination dilation/injection without
need for surgery. Use and control of a precut papillo-
Endoscopy in Crohn’s Disease 93
tome for luminal incision, followed by injection of
triamcinolone, is more difficult than hydrostatic bal-
loon dilation and limited to short strictures although
success rate is high [54]. Another study evaluated
efficacy and safety of endoscopic balloon dilation
with or without intralesional steroid injection for
symptomatic upper and lower gastrointestinal
Crohn’s disease strictures [55]. Using a mean follow-
up of 18.8 months, technical success was achieved in
96.5% of 17 patients. Recurrence rate in the steroid
group was 10% and that in the nonsteroid group
31%. Overall, long-term success was achieved in
76.5% of patients, with a complication rate of 10%
with no mortality.
Experience with self-expanding metal stents in
Crohn’s disease has been very limited [56], with com-
plete relief of obstructive symptoms after placement
despite stent migration some months after insertion.
Similarly, minimal data exist on endoscopic treat-
ment of gastroduodenal strictures in Crohn’s disease.
In one study, a 20-mm balloon was utilised, and
symptomatic relief was achieved in every patient,
with all responding to repeat dilation [57].
Fistulae Management
Currently, there are no data supporting the role of
endoscopy as primary treatment of fistulising
Crohn’s disease. Nevertheless, aside from guiding
medical and surgical therapy of a fistula, endoscopy
may indirectly and directly impact the treatment of
fistulising Crohn’s disease [58]. Indirectly, endoscopy
may allow for dilation of obstructing strictures that
prevent the closure of the fistula. Directly, may
treat the fistula via an injection of fibrin-based
sealants or anticytokine therapy. A fistula located
proximal to an obstructive stricture does not heal
due to an increase in luminal pressure. Endoscopic
balloon dilation of the stricture would reduce intra-
luminal pressure and the amount of bowel contents
passing through the fistula, and allow for a better
chance of closure. For endoscopic dilation to be suc-
cessful, the stricture must be accessible, short
(<8 cm) and not significantly inflamed, conditions
that are often not the present in fistulising Crohn’s
disease. Nevertheless, in a patient with a sympto-
matic fistula that is proximal to a short, noninflam-
matory stricture, endoscopic balloon dilation offers
an alternative to surgery.
There are case reports of injecting fibrin tissue
sealant into a perineal fistula of patients with IBD
[59]. Results of an external fistula closure with fibrin
sealants are disappointing. Recently, there have been
several reports on the endoscopic treatment of a gas-
trointestinal fistula with various tissue sealants as
fibrin-based, collagen or amino-acid solutions [60, 61].
However, these reports were not related to IBD but to
fistulas secondary to other diseases, and endoscopi-
cally administered tissue sealants are unlikely to play
a role in the treatment of Crohn’s disease fistulas
[62]. To date there are no studies that have evaluated
the role of endoscopically administered biologic
therapy for treatment of Crohn’s fistula, and there is
only one published abstract that has evaluated local
injection of infliximab into a perianal fistula. As new
therapies becomes available, there will be a greater
need for therapy administered directly to the
mucosa, and therapeutic endoscopy may play a role
in the treatment of fistulising Crohn’s disease. One
study was performed using EUS to assess and guide
combination medical and surgical therapy for
patients with Crohn’s perianal fistulas [63]. The pres-
ence of fistula healing on EUS was used to guide
seton removal and discontinuation of infliximab or
antibiotics, demonstrating that EUS may identify a
subset of patients who can discontinue infliximab
without recurrence of fistula drainage.
Although there are no reports of stricture dilation
in Crohn’s disease patients with ileal or colonic
stomas, the same principles as with ileocolonic or
colonic strictures apply [51]. Endoscopic manage-
ment of these strictures may be more desirable in
many of these patients who have already undergone
multiple bowel resections. Radiologic contrast imag-
ing and endoscopy will provide information on
whether the stricture is amenable to hydrostatic bal-
loon dilation. The procedure may be repeated with
progressively larger-diameter balloons until a satis-
factory result is obtained, such as being able to pass a
standard colonoscope through the stricture. Con-
traindications to dilation include coagulopathy and
strictures associated with large and deep ulcerations.
Capsule Endoscopy in Crohn’s Disease
Video capsule endoscopy (VCE) is a new, noninva-
sive imaging technique for the complete small bowel.
The video capsule is a small device with a diameter of
11 mm and a length of 26 mm, which can be swal-
lowed. It contains six light-emitting diodes, a lens, a
colour camera chip and two batteries. The video cap-
sule obtains two images per second. Video images are
transmitted by means of radiotelemetry to the sensor
array attached to the body with a belt. Images from a
period of time as long as 8 h are stored in a portable
recorder.
There are no standard preparations before the
examination: certain operators prescribe only a liq-
uid diet after lunch on the day preceding the capsule
endoscopy and a fast for 8 h before the procedure.
94 A. Ederle, P. Inturri, P. Brosolo, A. Fantin, M. Preto
Others recommend more complex preparation with
various combinations of laxatives [sennoside, poly-
ethylene glycol (PEG) solution]. After swallowing the
capsule endoscope with 100–200 ml of water contain-
ing 100 mg of simethicone, the patient could drink
2 h later and eat 4 h later. In patients who have
undergone gastric surgery or those with gastropare-
sis, the video capsule could be inserted endoscopical-
ly in the small intestine. Stomach passage takes an
average of 34 min, and passes through the small
intestine in about 4 h. Complete visualisation of the
small bowel up to the caecum is achieved in 80% of
patients. Most operators recommend a plain abdom-
inal X-ray be performed 7–14 days after the examina-
tion if the capsule examination does not show images
of the colon and the patient does not see the capsule
passage in the stool. The capsule is designed to be
used once, and after it is passed with the stool, it is
not reusable [64]. On completion of the examination,
the recorded images are downloaded and converted
into a movie by connecting the recorder to a work-
station. Data are reviewed by an operator in about 1 h
with dedicated software.
The main contraindication is the presence of
small-bowel stenosis that may lead to capsule reten-
tion and obstruction (see below). Other contraindi-
cations are a patient with difficulty swallowing, preg-
nancy or the presence of implanted medical devices
such pacemakers. Capsule endoscopy is very useful
in the management of patients with suspected small-
bowel disease.
The diagnosis of Crohn’s disease is difficult. Cur-
rent radiologic and endoscopic studies are limited in
the diagnosis of early small-bowel mucosal disease in
patients with this disease. VCE detects early lesions
in the small bowel of patients with Crohn’s disease
and is effective in diagnosing patients with suspected
Crohn’s disease undetected by small-bowel series
and enteroclysis [65, 66] and in some cases of
Crohn’s disease with intestinal strictures missed by
enteroclysis. Enteroclysis in patients with Crohn’s
disease has a diagnostic yield of 37% while capsule
endoscopy has a yield of 70%. This is not surprising
since enteroclysis will not easily detect flat or mucos-
al abnormalities [67]. VCE is also superior to CT
enteroclysis [5] in patients with known or suspected
Crohn’s disease, especially in the detection of signifi-
cantly more inflammatory lesions in the proximal
and middle part of the small bowel. VCE probably is
less effective than radiology at detecting fistulae, and
this might be a reason for sometimes choosing radi-
ological investigations in preference to VCE [68].
There is concern that a capsule might become
stuck or impacted against a stricture. In fact, capsule
impaction does occur approximately in the 2–5 % of
cases. Most capsule impactions are asymptomatic
and rarely produce obstructive symptoms. A “paten-
cy” capsule has been developed to detect possible
strictures noninvasively and more accurately than
enteroclysis. This device has the same dimensions as
the VCE but has a dissolving body. Use of the paten-
cy capsule may be of value to rule out the possibility
of intestinal strictures in patients with Crohn’s dis-
ease and suspected small-bowel obstruction although
the patency capsule can also cause transient obstruc-
tion.
The major difficulty of VCE is the definition of a
gold standard for diagnosis. Crohn’s disease pro-
duces mucosal inflammation and ulceration of vari-
ous intensities in different bowel areas. The earliest
lesion in Crohn’s disease displays tiny mucosal foci
of chronic inflammation and, more recently, a focal
loss of villi [69]. Another early lesion is aphthoid
ulceration. The finding of one or two aphthous ulcers
or erosion in patients during capsule endoscopy is
common, and it is likely that many of these do not
have Crohn’s disease [70].
It must be remembered that all ulceration is not
indicative of Crohn’s disease. Clinically relevant
points to keep in mind are the difficulty in differenti-
ating ulcers of Crohn’s disease from those of NSAID
use and the high prevalence of NSAID-induced ulcers
in 71% of NSAID users [71]. Hence, it is critical to
evaluate the history of NSAID use in every patient
undergoing VCE. In the absence of NSAID use, diag-
nosis of Crohn’s disease was purposed by certain
authors on the presence of multiple aphthous or ero-
sive lesions (>10) that were either continuous or seg-
mentally distributed [72]. Infections must be exclud-
ed by duodenal biopsy, stool microbiology or serolo-
gy.
It is known from older studies that the small bowel
is affected in Crohn’s disease in about one third of
cases [73, 74]. Newer studies based on VCE show that
the small bowel could be involved in approximately
60% of patients with Crohn’s disease. This might be
kept in mind in case of lack of response in patients
treated with drugs released into the terminal ileum or
colon [66, 68].
Diagnostic costs for Crohn’s disease can be very
high. This is probably due to the low diagnostic yield
of certain diagnostic procedures. VCE has a higher
average diagnostic yield than comparative proce-
dures due to imaging clarity and the ability to visu-
alise the entire small bowel [75–77]. Literature review
found the average diagnostic yield of small-bowel
follow-through (SBFT) and colonoscopy of Crohn’s
disease to be 53% whereas VCE had a diagnostic yield
of 69%. Recent economic analysis comparing VCE
with traditional diagnostic procedures demonstrates
that employing VCE as a first-line diagnostic proce-
dure appears to be less costly than current common
Endoscopy in Crohn’s Disease 95
procedures for diagnosing suspected Crohn’s disease
in the small bowel [77].
Risk of Cancer and Endoscopic Surveillance
The first description of a cancer of the colon compli-
cating “regional enteritis” was described in 1948[79].
After this, published works abounded with reports of
colorectal cancer in series of patients with Crohn’s
disease [80]. In a recent population-based study [81],
Bernstein et al. determined the incidence of cancer by
linking records from the IBD and non-IBD cohort
with the Comprehensive Cancer Care Manitoba Reg-
istry. IBD patients were matched 1:10 to randomly
selected members of the population without IBD
based on year, age gender and postal area of resi-
dence. There was an increased risk of colon carcino-
ma for both Crohn’s disease patients [2.64: 95% con-
fidence interval (95% CI), 1.69–4.12) and UC patients
(2.75; 95% CI, 1.91–3.97]. There was an increased IRR
of rectal carcinoma only among patients with UC
(1.90; 95% CI, 1.05–3.43) and an increased IRR of car-
cinoma of the small intestine only in Crohn’s disease
patients (17.4; 95% CI, 4.16–72.9). An increased IRR
of extraintestinal tumours was observed only for the
liver and biliary tract in both Crohn’s disease
patients (5.22; 95% CI, 1.05–14.9) and UC patients
(3,96; 95% CI,
1.05–14.9). Gillen et al. [82] concluded
that when cases of ulcerative and Crohn’s colitis of
similar anatomic extent are followed for similar
durations, the two diseases may ultimately prove to
have similar increases in risk for colorectal cancer
[83]. In fact, they compared the cancer risk in two
hospital-referred but identically selected cohorts of
patients with extensive UC and equally extensive
Crohn’s disease of the colon. As in the classic 1973
paper by Weedon et al. [84], the overall risk of col-
orectal cancer was increased nearly 20-fold over the
general population. Moreover, both relative risks and
absolute 20-year cumulative incidences of cancer
were virtually identical in the ulcerative and Crohn’s
colitis cohorts. This study, therefore, conclusively
establishes the previously reported [85–87] but still
underappreciated similarity between cancer risks in
these two diseases.
Friedman et al. [88] in 2001 concluded that
colonoscopy surveillance should be strongly consid-
ered in chronic extensive Crohn’s colitis. In fact, they
reported on 259 patients with chronic Crohn’s colitis
who underwent screening and subsequent surveil-
lance colonoscopy and biopsy since 1980. Biopsies
were performed at 10-cm intervals and from stric-
tures and polypoid masses. A total of 663 examina-
tions were performed on 259 patients. Median inter-
val between examinations was 24 months. The
screening and surveillance programme detected dys-
plasia or cancer in 16%. A finding of definite dyspla-
sia or cancer was associated with age >45 years and
increased symptoms. By life table analysis, the prob-
ability of detecting dysplasia or cancer after a nega-
tive screening colonoscopy was 22% by the fourth
surveillance examination. It is interesting from a
clinical point of view that the pediatric colonoscope
helped increase the yield of neoplasia by 19%.
Despite this report, Mpofu et al. [89] concluded a
review indicating that there is no clear evidence that
surveillance colonoscopy prolongs survival in
patients with IBD with extensive colitis.
There is evidence that cancers tend to be detected
at an earlier stage in patients who are undergoing sur-
veillance, and these patients have a correspondingly
better prognosis but lead-time bias could contribute
substantially to this apparent benefit. There is indirect
evidence that surveillance is likely to be effective at
reducing the risk of death from IBD-associated col-
orectal cancer and indirect evidence that it is accept-
ably cost effective. Therefore, the follow-up of colonic
Crohn’s disease must be similar to the follow-up of
ulcerative colitis. Itzkowitz et al. suggested [90], await-
ing more data about Crohn’s and colorectal cancer,
that it seems prudent to follow a UC-based surveil-
lance strategy for patients with at least 8 years of
Crohn’s colitis involving at least one third of the
colon. The suggested surveillance strategy is reported
in Fig. 1 with the performance reported in Table 2
indicated by these authors. Information on family his-
tory of colorectal cancer may be a simple way to iden-
tify individuals with extensive colonic Crohn’s disease
at more and more elevated risk of developing colorec-
tal cancer [91], especially with a first-degree diag-
nosed with colorectal cancer before 50 years of age.
Cases of colorectal cancer in Crohn’s disease are in
reality few, less than in UC, because many patients
with extensive Crohn’s colitis have early surgical
resection, eliminating the risk of cancer [82]. An
increased number of small intestinal carcinoma in
patients affected by Crohn’s disease has been report-
ed although the strength of this association (age,
length of disease, characteristics and distribution)
still has to be elucidated. Relative risk is estimated
between six and 50 times by different authors, but
small intestinal cancer is very rare, and this relative
risk does not justify endoscopic surveillance. Long-
standing disease, previous intestinal exclusion sur-
gery and enterocutaneous or other types of fistulae
should probably be considered for the development
of cancer [92] for eventual clinical suspicion but not
for scheduled endoscopic surveillance. Small intes-
tinal cancer in Crohn’s disease usually arises in distal
ileum [93], and therefore it seems reasonable to
attempt to extend surveillance colonoscopy to this
96 A. Ederle, P. Inturri, P. Brosolo, A. Fantin, M. Preto
bowel tract, dilating and biopsying stenosis, if possi-
ble.
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