Colorectal Cancer & IBD | Dr. Ran Zhihua (Gastroenterology) | CMCS Shanghai

About Dr. Ran Zhihua

Dr. Ran Zhihua is Director of Gastroenterology at Renji Hospital, Shanghai Jiao Tong University School of Medicine — one of China's foremost academic centres for inflammatory bowel disease, colorectal cancer screening, and advanced therapeutic endoscopy. He is a nationally recognised leader in the diagnosis and management of IBD-associated dysplasia and colorectal neoplasia, with particular expertise in chromoendoscopy, magnifying endoscopy, and endoscopic submucosal dissection (ESD) in the technically demanding setting of chronic colitis. Dr. Ran's practice is defined by the philosophy that precision endoscopic diagnosis — not empirical surveillance — is the foundation of IBD cancer prevention, and that organ-preserving endoscopic resection should be the first-line treatment for localised dysplasia whenever oncological safety can be guaranteed. He has published extensively in Gut, Gastroenterology, and Journal of Crohn's and Colitis, and serves on the expert committees of the Chinese Society of Gastroenterology and the Chinese IBD Quality Care Evaluation Centre.

Case Overview

Mr. James Whitfield, a 38-year-old British software engineer based in Shanghai, presented with an eight-year history of pan-colonic ulcerative colitis and a one-month history of worsening mucous bloody stool with tenesmus. He had been maintained on mesalazine but had not undergone surveillance colonoscopy for three years. Family history was significant for colorectal cancer in his father at age 55. Mayo score was 6 (moderate activity); faecal calprotectin exceeded 1,000 μg/g. High-definition colonoscopy with narrow-band imaging (NBI) and magnifying endoscopy performed by Dr. Ran Zhihua identified a 2.0 cm × 1.5 cm Paris 0-IIa lesion at the sigmoid-descending colon junction, with brownish background colouration and irregular microvessels on NBI, and Type V-I pit pattern on magnifying endoscopy — highly predictive of high-grade dysplasia (HGD). Targeted biopsy confirmed HGD with focal intramucosal carcinoma (Vienna Classification 4.2). Dr. Ran elected organ-preserving endoscopic submucosal dissection (ESD) over total colectomy, achieving en bloc R0 resection in 90 minutes with no perforation. Final pathology confirmed HGD with focal Tis, horizontal and vertical margins clear. The patient was transitioned to vedolizumab for mucosal healing maintenance and discharged on day five.

Patient Background

• Name / Nationality: Mr. James Whitfield (pseudonym) — British; software engineer based in Shanghai
• Age / Sex: 38-year-old male
• Chief Complaint: Recurrent mucous bloody stool for 8 years; worsening with tenesmus for 1 month
• IBD History: Pan-colonic ulcerative colitis diagnosed 8 years prior; maintained on mesalazine; no regular surveillance colonoscopy for 3 years
• Family History: Father diagnosed with colorectal cancer at age 55 — first-degree relative with CRC (high-risk factor)
• Disease Activity: Mayo score 6 (moderate); faecal calprotectin >1,000 μg/g; CRP 45 mg/L; ESR 30 mm/h
• Haematology: Haemoglobin 105 g/L (mild anaemia)
• Tumour Markers: CEA 5.2 ng/mL (mildly elevated); CA19-9 normal

Endoscopic Assessment

Equipment and Technique

• Platform: Olympus HQ290 high-definition colonoscope with NBI and optical magnification capability
• Extent of colitis: Pan-colonic involvement from rectum to caecum — diffuse mucosal hyperaemia, granularity, and multiple pseudopolyps

Target Lesion Characterisation

• Location: Sigmoid-descending colon junction
• Morphology: 2.0 cm × 1.5 cm slightly elevated lesion — Paris classification 0-IIa
• White-light endoscopy: Nodular surface; irregular contour; distinct from surrounding inflammatory mucosa
• NBI findings: Brownish background colouration (abnormal mucosal vascularity); irregular microvessels — both features highly predictive of HGD or early carcinoma
• Magnifying endoscopy (Kudo Pit Pattern): Type V-I (non-structural/irregular) — indicating loss of normal glandular architecture; high predictive value for HGD or intramucosal carcinoma

Targeted Biopsy

• Technique: Four-quadrant targeted biopsy of the lesion and surrounding mucosa
• Result: High-grade dysplasia (HGD) of colonic glands; focal area suspicious for intramucosal carcinoma — Vienna Classification Category 4.2

Dr. Ran's diagnostic note: White-light endoscopy alone will miss the majority of flat dysplastic lesions in an inflamed colon. The brownish background on NBI is not a subtle finding — it is a red flag that tells you the mucosal vascularity is abnormal. The Type V-I pit pattern under magnification tells you the glandular architecture has broken down. Together, these two findings mean HGD until proven otherwise. We do not wait for the biopsy to tell us this lesion is dangerous. The endoscopic appearance already has.

Clinical Decision Making

Three compounding factors defined the management decision: a 38-year-old patient with eight years of pan-colonic UC — placing him in the highest-risk category for IBD-associated colorectal cancer; a first-degree family history of colorectal cancer, amplifying the baseline risk; and a histologically confirmed HGD lesion with focal intramucosal carcinoma — the direct precursor to invasive cancer.

The conventional approach — total proctocolectomy with ileal pouch-anal anastomosis (IPAA) — would eliminate the cancer risk entirely but at the cost of permanent alteration of bowel function, risk of pouch failure, and profound impact on quality of life in a young professional.

Dr. Ran Zhihua's organ-preservation strategy: Total colectomy is the right answer when the disease cannot be controlled endoscopically — when the lesion is multifocal, when the margins cannot be defined, or when there is evidence of submucosal invasion. This lesion does not meet those criteria. It is localised, morphologically defined, and the NBI and pit pattern tell us it has not invaded beyond the mucosa. ESD gives us the same oncological outcome as colectomy for a Tis lesion — complete resection with clear margins — without removing the colon. For a 38-year-old patient, that difference in quality of life is not a minor consideration. It is the entire point of precision endoscopy.

Endoscopic Submucosal Dissection (ESD)

Phase 1 — Marking and Submucosal Injection

Anaesthesia: Intravenous propofol sedation with continuous vital sign monitoring.

Lesion marking: Dual knife electrocautery marking at 3 mm circumferential margin around the lesion — establishing the resection boundary before injection distorts the anatomy.

Submucosal injection: Glycerol fructose with indigo carmine and adrenaline — the indigo carmine stains the submucosal layer blue, providing a visual plane for dissection; the adrenaline reduces intraoperative bleeding. In UC patients, submucosal fibrosis from chronic inflammation frequently impairs the lifting sign — the injected fluid does not elevate the mucosa as expected in normal tissue. This is the primary technical challenge of ESD in the IBD setting.

Dr. Ran's technical note: When the lifting sign is poor, the inexperienced endoscopist stops. The experienced endoscopist adjusts. Poor lifting in UC means fibrosis — the submucosal plane is adherent to the muscularis propria. We use the transparent cap to create traction, we inject incrementally rather than in bolus, and we dissect under direct vision of the submucosal fibres rather than relying on the fluid cushion. The technique is different. The oncological goal is the same.

Phase 2 — Circumferential Incision and Submucosal Dissection

Instrument: IT knife-2 (insulation-tipped electrosurgical knife) — the insulated tip prevents inadvertent full-thickness perforation during dissection of adherent submucosal tissue.

Dissection: Circumferential mucosal incision completed along the marking dots, followed by systematic submucosal dissection from the proximal to distal margin. Dense fibrotic adhesions between the submucosal layer and muscularis propria were encountered throughout — requiring transparent cap-assisted countertraction to expose the dissection plane and precise knife angulation to maintain the correct depth.

Haemostasis: Small vessel bleeding controlled with Coagrasper hot biopsy forceps — preventing obscuration of the dissection field and reducing the risk of delayed post-procedural bleeding.

Phase 3 — En Bloc Resection and Specimen Handling

Result: Complete en bloc resection achieved — the lesion removed as a single unFragmented specimen, preserving the ability to assess lateral and deep margins histologically. Procedure duration 90 minutes. Intraoperative blood loss approximately 10 mL. No perforation.

Specimen processing: Resected specimen immediately pinned flat on a cork board and fixed in formalin — preventing contraction and ensuring accurate margin assessment by the pathologist.

Pathology and Post-operative Course

Final ESD Pathology

• Specimen size: 2.0 cm × 1.8 cm
• Diagnosis: Tubulovillous adenoma with high-grade dysplasia (HGD); focal intramucosal carcinoma (Tis)
• Resection margins: Horizontal margin clear; vertical (deep) margin clear — R0 resection confirmed
• Lymphovascular invasion: Absent
• Submucosal invasion: Absent — confirming endoscopic resection as oncologically curative

Post-operative Management

• Day 0–1: Nil by mouth; intravenous fluids; vital sign monitoring for bleeding or perforation
• Day 1–2: Clear liquid diet commenced; no haemorrhage or peritoneal signs
• IBD therapy: Intravenous corticosteroid induction for active colitis; transition to vedolizumab (gut-selective anti-integrin biologic) for maintenance — targeting endoscopic mucosal healing to reduce the substrate for future dysplasia
• Discharge: Day 5 post-procedure; no complications

Follow-up Protocol

• 3 months: Colonoscopy to assess ESD scar healing and exclude local recurrence; four-quadrant random biopsies of the remaining colon
• 6–12 months: High-definition chromoendoscopy surveillance with NBI and magnification; vedolizumab trough level monitoring
• Annual: Full surveillance colonoscopy with targeted and random biopsies; CEA monitoring

Expert Commentary — Dr. Ran Zhihua

1. IBD Surveillance: The Gap Between Guidelines and Practice

This patient had every major risk factor for IBD-associated colorectal cancer: disease duration exceeding eight years, pan-colonic extent, suboptimal inflammatory control, and a first-degree family history of colorectal cancer. Current international guidelines — British Society of Gastroenterology, European Crohn's and Colitis Organisation — recommend annual surveillance colonoscopy for patients in this risk category. He had not undergone colonoscopy for three years. The lesion we found was 2 cm with focal intramucosal carcinoma. Had he presented two years later, the same lesion may have been an invasive T1 or T2 cancer requiring colectomy and potentially lymph node dissection. The most important intervention in IBD cancer prevention is not the endoscopy technique — it is ensuring the patient attends surveillance. Compliance and systematic follow-up infrastructure are the foundation on which all technical expertise rests.

2. Advanced Endoscopic Imaging: Seeing What White Light Cannot

The detection of dysplasia in an inflamed colon is one of the most technically demanding tasks in diagnostic endoscopy. Chronic inflammation creates a background of mucosal irregularity — granularity, pseudopolyps, vascular distortion — that can camouflage flat dysplastic lesions on white-light examination. Chromoendoscopy with indigo carmine dye spray or electronic chromoendoscopy (NBI, BLI, FICE) enhances the contrast between dysplastic and non-dysplastic mucosa by highlighting surface microarchitecture and vascular patterns. The two key NBI findings in this case — brownish background colouration and irregular microvessels — reflect the abnormal angiogenesis and glandular disruption of dysplastic tissue. The Type V-I pit pattern under magnification confirms loss of normal crypt architecture. Together, these findings provide a pre-biopsy diagnosis of HGD with sensitivity and specificity exceeding 90% in experienced hands. We do not perform random biopsies of the entire colon and wait for pathology to find dysplasia. We use advanced imaging to find it first, then biopsy to confirm.

3. ESD in IBD: Technical Demands and Oncological Justification

ESD in the IBD colon is categorically more difficult than ESD in the non-IBD colon. Chronic transmural inflammation creates submucosal fibrosis that obliterates the normal tissue planes used for dissection. The lifting sign — the endoscopist's primary safety indicator that the submucosal injection has separated the mucosa from the muscularis propria — is frequently absent or attenuated. The risk of perforation is higher, the procedure is longer, and the technical demands on the operator are substantially greater. These challenges are real. They are also surmountable with appropriate expertise and technique. The oncological justification for ESD over colectomy in localised IBD-associated HGD is straightforward: for a Tis lesion with clear margins and no lymphovascular invasion, the risk of lymph node metastasis is effectively zero. Colectomy adds no oncological benefit. It adds only morbidity. ESD is not a compromise — it is the correct operation for the correct indication.

4. Vedolizumab and Mucosal Healing: Reducing the Future Cancer Substrate

Resecting the dysplastic lesion addresses the immediate oncological threat. It does not address the underlying inflammatory disease that created the dysplastic substrate. Post-ESD management in IBD must therefore pursue two simultaneous goals: surveillance for local recurrence at the resection site, and optimisation of disease control to reduce the risk of metachronous dysplasia elsewhere in the colon. Vedolizumab — a gut-selective anti-integrin monoclonal antibody — was selected for this patient because of its favourable safety profile for long-term use and its demonstrated efficacy in achieving endoscopic mucosal healing in UC. Mucosal healing is not a cosmetic endpoint. It is the most powerful predictor of reduced dysplasia risk in long-standing UC. A healed mucosa is a protected mucosa. That is the biological rationale for aggressive medical optimisation after endoscopic resection.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mr. Whitfield from initial inquiry through post-ESD surveillance scheduling, including: pre-consultation review of external colonoscopy reports, pathology slides, and mesalazine treatment records; specialist referral to Dr. Ran Zhihua at Renji Hospital's IBD and Advanced Endoscopy Centre; bilingual interpretation throughout all consultations and informed consent discussions; coordination of high-definition colonoscopy with NBI and magnifying endoscopy scheduling; real-time procedure updates to the patient's family; post-procedure monitoring communication with daily bilingual updates during the five-day admission; discharge planning including vedolizumab infusion scheduling, dietary guidance, and follow-up colonoscopy booking in English; three-month surveillance colonoscopy coordination with results translation and direct communication to the patient's gastroenterologist in the United Kingdom; and long-term annual surveillance protocol establishment with direct liaison between Dr. Ran's team and the patient's overseas physicians.

For international patients with inflammatory bowel disease requiring advanced endoscopic surveillance and intervention in Shanghai, Dr. Ran Zhihua's team at Renji Hospital represents IBD and endoscopic oncology expertise at the international frontier. CMCS ensures that expertise is accessible to every international patient — in their language, with their overseas physicians informed at every step, from the first surveillance colonoscopy through long-term remission maintenance.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.