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In the years 1966-80, 303 patients with radiologically extensive ulcerative colitis were followed up regularly, both by clinical assessment and by mucosal biopsies, to detect dysplastic (precancerous) change. Moderate or severe dysplasia (but no carcinoma) was found in the specimen in 8 patients treated surgically. Despite regular surveillance, carcinoma developed in 13 of the 186 patients with a history of disease for ten years or more. Of the total sixteen carcinomas in these 13 patients, eleven were Dukes stage A, three stage B, one stage C, and one was inoperable. There has been 1 death from carcinoma in this series over the fifteen year observation period. The method of follow-up has probably prevented the development of carcinoma in 8 patients and permitted diagnosis of carcinoma at a stage when cure is likely in 11. The incidence of moderate or severe dysplasia and carcinoma in these patients with mild or symptomless extensive colitis shows that either proctocolectomy or careful follow-up should be advised once the duration of symptoms reaches ten years.

171 patients with extensive colitis have been followed up as outpatients for periods up to seven years between 1966 and 1973. The mean length of follow-up was 3.3 years. 7 patients have died compared with the expected mortality of 4.83, giving an excess mortality of 0.003 per patient-year. 3 patients have developed carcinoma of the large bowel; they remain well seven, six, and two years after operation. In all 3, epithelial dysplasia was observed on rectal mucosal biopsy, and no patient in this series has developed carcinoma without this abnormality being present. 11 other patients had epithelial dysplasia on rectal biopsy; 4 of these underwent colectomy without evidence of carcinoma in the operative specimen. 29 patients underwent colectomy without mortality, 7 during a severe attack of colitis, the remainder electively. These results suggest that patients with quiescent extensive colitis can be managed conservatively with relative safety provided that close supervision is maintained.

A prospective study was undertaken between 1974 and 1985 of 102 patients with extensive ulcerative colitis (UC) of more than 10 years' duration. Faeces were collected for measurement of faecal bile acid concentrations (FBA), and the clinical outcome was recorded. The average faecal bile acid value among the 14 patients who showed carcinoma or definite dysplasia in the excised large bowel (9.86 [SE 0.81] mg/g FBA) was higher than in the 88 patients without dysplasia or carcinoma (7.51 [0.24] mg/g). These results lend support to the theory that bile acids are causally related to colorectal cancer.