1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 List of all recommendations

People with inflammatory bowel disease

1.1.1 Offer colonoscopic surveillance to people with inflammatory bowel disease (IBD) whose symptoms started 10 years ago and who have:

  • ulcerative colitis (but not proctitis alone) or

  • Crohn's colitis involving more than one segment of colon.

1.1.2 Offer a baseline colonoscopy with chromoscopy and targeted biopsy of any abnormal areas to people with IBD who are being considered for colonoscopic surveillance to determine their risk of developing colorectal cancer (see table 1).

Table 1 Risk of developing colorectal cancer in people with IBD

Low risk:

  • extensive but quiescent ulcerative colitis or

  • extensive but quiescent Crohn's colitis or

  • left-sided ulcerative colitis (but not proctitis alone) or Crohn's colitis of a similar extent.

Intermediate risk:

  • extensive ulcerative or Crohn's colitis with mild active inflammation that has been confirmed endoscopically or histologically or

  • post-inflammatory polyps or

  • family history of colorectal cancer in a first-degree relative aged 50 years or over.

High risk:

  • extensive ulcerative or Crohn's colitis with moderate or severe active inflammation that has been confirmed endoscopically or histologically or

  • primary sclerosing cholangitis (including after liver transplant) or

  • colonic stricture in the past 5 years or

  • any grade of dysplasia in the past 5 years or

  • family history of colorectal cancer in a first-degree relative aged under 50 years.

1.1.3 Offer colonoscopic surveillance to people with IBD as defined in 1.1.1 based on their risk of developing colorectal cancer (see table 1), determined at the last complete colonoscopy:

  • Low risk: offer colonoscopy at 5 years.

  • Intermediate risk: offer colonoscopy at 3 years.

  • High risk: offer colonoscopy at 1 year.

1.1.4 For people with IBD who have been offered colonoscopic surveillance, continue to use colonoscopy with chromoscopy as the method of surveillance.

1.1.5 Offer a repeat colonoscopy with chromoscopy if any colonoscopy is incomplete. Consider whether a more experienced colonoscopist is needed.

People with adenomas

1.1.6 Consider colonoscopic surveillance for people who have had adenomas removed and are at low risk of developing colorectal cancer (see table 2).

1.1.7 Offer colonoscopic surveillance to people who have had adenomas removed and are at intermediate or high risk of developing colorectal cancer (see table 2).

1.1.8 Use the findings at adenoma removal to determine people's risk of developing colorectal cancer (see table 2).

Table 2 Risk of developing colorectal cancer in people with adenomas

Low risk:

  • one or two adenomas smaller than 10 mm.

Intermediate risk:

  • three or four adenomas smaller than 10 mm or

  • one or two adenomas if one is 10 mm or larger.

High risk:

  • five or more adenomas smaller than 10 mm or

  • three or more adenomas if one is 10 mm or larger.

1.1.9 Offer the appropriate colonoscopic surveillance strategy to people with adenomas based on their risk of developing colorectal cancer as determined at initial adenoma removal (see table 2).

  • Low risk: consider colonoscopy at 5 years:

    • if the colonoscopy is negative (that is, no adenomas are found) stop surveillance

    • if low risk, consider the next colonoscopy at 5 years (with follow-up surveillance as for low risk)

    • if intermediate risk, offer the next colonoscopy at 3 years (with follow-up surveillance as for intermediate risk)

    • if high risk, offer the next colonoscopy at 1 year (with follow-up surveillance as for high risk).

  • Intermediate risk: offer colonoscopy at 3 years:

    • if the colonoscopy is negative, offer the next colonoscopy at 3 years. Stop surveillance if there is a further negative result

    • if low or intermediate risk, offer the next colonoscopy at 3 years (with follow-up surveillance as for intermediate risk)

    • if high risk, offer the next colonoscopy at 1 year (with follow-up surveillance as for high risk).

  • High risk: offer colonoscopy at 1 year.

    • if the colonoscopy is negative, or low or intermediate risk, offer the next colonoscopy at 3 years (with follow-up surveillance as for intermediate risk)

    • if high risk, offer the next colonoscopy at 1 year (with follow-up surveillance as for high risk).

1.1.10 Offer a repeat colonoscopy if any colonoscopy is incomplete. Consider whether a more experienced colonoscopist is needed.

1.1.11 Consider computed tomographic colonography[1] (CTC) as a single examination if colonoscopy is not clinically appropriate (for example, because of comorbidity or because colonoscopy cannot be tolerated).

1.1.12 Consider double contrast barium enema as a single examination if CTC is not available or not appropriate.

1.1.13 Consider CTC or double contrast barium enema for ongoing surveillance if colonoscopy remains clinically inappropriate, but discuss the risks and benefits with the person and their family or carers.

Providing information and support

1.1.14 Discuss the potential benefits, limitations and risks with people who are considering colonoscopic surveillance including:

  • early detection and prevention of colorectal cancer and

  • quality of life and psychological outcomes.

1.1.15 Inform people who have been offered colonoscopy, CTC, or barium enema about the procedure, including:

  • bowel preparation

  • impact on everyday activities

  • sedation

  • potential discomfort

  • risk of perforation and bleeding.

1.1.16 After receiving the results of each surveillance test, discuss the potential benefits, limitations and risks of ongoing surveillance. Base a decision to stop surveillance on potential benefits for the person, their preferences and any comorbidities. Make the decision jointly with the person, and if appropriate, their family or carers.

1.1.17 If there are any findings at surveillance that need treatment or referral, discuss the options with the person, and if appropriate, their family or carers.

1.1.18 Throughout the surveillance programme, give the person and their family or carers the opportunity to discuss any issues with a healthcare professional. Information should be provided in a variety of formats tailored to the person's needs and should include illustrations.



[1] Computed tomographic colonography (virtual colonoscopy). NICE interventional procedure guidance 129 (2005).

  • National Institute for Health and Care Excellence (NICE)