Post-inflammatory polyps and risk of dysplasia in inflammatory bowel disease: Wolves in sheep's clothing?

Patients with longstanding and extensive inflammatory bowel disease (IBD) have an enhanced risk of colorectal cancer (CRC), which accounts for up to 10% of all IBD-related deaths. Chronicity of bowel inflammation, co-existence of primary sclerosing cholangitis, and a family history of sporadic colorectal cancer represent further risk factors for development of CRC. Colon post-inflammatory polyps are believed to be another risk factor for IBD-associated CRC, even though it remains unclear how presence of such lesions could influence CRC development. Although earlier observational studies suggested an association between post-inflammatory polyps and colorectal neoplasia, more recent studies have indicated that these lesions do not independently increase neoplasia risk. However, they may, nonetheless, complicate surveillance by obscuring dysplastic lesions, particularly when numerous, and they are best regarded as markers of chronic and recurrent mucosal inflammation. Moreover, emerging evidence suggests that a minority of post-inflammatory-like lesions may conceal or coexist with dysplasia, underscoring the diagnostic challenge posed by polypoid lesions in chronically inflamed mucosa. In this article, we review the available data about the association between post-inflammatory polyps and development of CRC in IBD and discuss how advances in technology, particularly development of artificial intelligence models integrated with endoscopy, may contribute to their appropriate management.