Inflammatory bowel disease-related colorectal cancer (IBD-CRC) is one of the most serious complications of IBD contributing to significant mortality in this cohort of patients. IBD is often associated with diet and lifestyle-related gut microbial dysbiosis, the interaction of genetic and environmental factors, leading to chronic gut inflammation. According to the “common ground hypothesis”, microbial dysbiosis and intestinal barrier impairment are at the core of the chronic inflammatory process associated with IBD-CRC. Among the many underlying factors known to increase the risk of IBD-CRC, perhaps the most important factor is chronic persistent inflammation. The persistent inflammation in the colon results in increased proliferation of cells necessary for repair but this also increases the risk of dysplastic changes due to chromosomal and microsatellite instability. Multiple pathways have been identified, regulated by many positive and negative factors involved in the development of cancer, which in this case follows the ‘inflammation-dysplasia-carcinoma’ sequence. Strategies to lower this risk are extremely important to reduce morbidity and mortality due to IBD-CRC, among which colonoscopic surveillance is the most widely accepted and implemented modality, forming part of many national and international guidelines. However, the effectiveness of surveillance in IBD has been a topic of much debate in recent years for multiple reasons — cost-benefit to health systems, resource requirements, and also because of studies showing conflicting long-term data. Our review provides a comprehensive overview of past, present, and future perspectives of IBD-CRC. We explore and analyse evidence from studies over decades and current best practices followed globally. In the future directions section, we cover emerging novel endoscopic techniques and artificial intelligence that could play an important role in managing the risk of IBD-CRC.
The white nipple sign is a term used to describe a fresh fi brin clot on a varix that has bled recently. The authors describe a case to highlight the importance of prompt endo-therapy when this sign is recognised as disturbing this clot can cause brisk bleeding A 63-year-old lady with acute alcoholic hepatitis was admitted with haematemesis. Emergency gastroscopy revealed the presence of 'white nipple sign': fresh platelet fibrin clot at the site of recent variceal haemorrhage. She underwent immediate endoscopic band ligation and haemostasis was achieved after transient bleeding. The white nipple sign is specific for recent variceal haemorrhage and is likely to be encountered when endoscopy is performed early and has no prognostic significance. Endoscopists must familiarise themselves with this sign and, on recognising this finding, the emphasis should be on immediate banding as clot destabilisation will cause brisk bleeding.
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