IBD Dysplasia Surveillance in 2026: Dye Spray, HD White Light, NBI, and Targeted Biopsies

Clinical Bottom Line

Decision	2026 practical answer
What exam is this?	A dysplasia hunt in longstanding colonic IBD. Do not score Mayo endoscopic subscore or UCEIS as if they were the surveillance method. Healing scores belong on the UC therapy post.
Who is in the program?	Colonic IBD beyond the rectum, starting 8 years after symptom onset. PSC: annual from diagnosis, including after liver transplant. Isolated proctitis or small-bowel-only Crohn: population CRC screening, not IBD surveillance.
Scope hardware	HD colonoscope is the floor. Standard-definition white light is obsolete for this indication.
Dye spray	HD dye-based chromoendoscopy (indigo carmine or methylene blue) is still suggested. The per-patient dysplasia gain versus HD white light is small. Extra time. Needs training and a clean prep.
HD white light without dye	Acceptable when HD, prep is excellent, and inspection is slow and complete. HELIOS [17]: HD-WLE with segmental re-inspection was non-inferior to HD dye (10.3% vs 13.1%). Single-pass HD-WLE was 6.1% and was not the equal arm.
NBI / virtual chromo	Not a proven upgrade. Later RCTs show NBI or i-scan roughly similar to HD dye or HD-WLE. BSG 2025 [8] did not GRADE-recommend virtual chromo. ESGE 2019 still allows dye or virtual with targeted biopsies.
Random vs targeted	Most dysplasia is visible on HD. Targeted biopsy or resection is the detection engine. Quadrantic randoms are not routine after high-quality HD dye or virtual chromo. Keep them for PSC, prior dysplasia, a tubular colon, or white light without dye.
If you find a lesion	Use SCENIC [1] language (visible vs invisible; polypoid vs nonpolypoid). Resect clearly delineated visible dysplasia, preferably en bloc. Invisible HGD, unresectable visible dysplasia, or invisible multifocal dysplasia: colectomy after an expert HD dye exam.

What do I do tonight?

1. If this is treat-to-target UC scoring, stop. Mayo endoscopic subscore and UCEIS are not the surveillance method.
2. If the patient has colonic IBD beyond the rectum, start surveillance 8 years after symptom onset. If there is PSC, start annual colonoscopy at diagnosis, including after transplant.
3. Use an HD colonoscope. Standard-definition white light is obsolete for this indication.
4. Spray indigo carmine or methylene blue and inspect slowly. Virtual chromoendoscopy is acceptable on HD when dye is not available and inspection is complete.
5. Resect or biopsy every visible lesion. Keep random quadrantic biopsies in PSC, prior dysplasia, a tubular colon, or when you did not use dye.
6. If dysplasia is visible and clearly delineated, resect it endoscopically. If HGD is invisible or visible dysplasia is unresectable after an expert HD dye exam, that is a surgical discussion.

What do the societies say?

Do not score Mayo endoscopic subscore as if it were the surveillance method. Do not skip random biopsies in PSC, prior dysplasia, or a tubular colon.

Who belongs on the surveillance list?

Start surveillance about 8 years after symptom onset in ulcerative colitis beyond the rectum and in Crohn colitis involving at least one third of the colon (ACG 2019, AGA 2021, ECCO 2023, BSG 2025). Some US sources say 8 to 10 years after diagnosis. Symptom onset is usually earlier. PSC: annual from diagnosis, including after transplant. Isolated proctitis and small-bowel-only Crohn stay on population CRC screening. Scope a quiet colon. Activity hides flat dysplasia and itself marks a high-risk interval.

Does dye spray still beat HD white light?

The SD-era trials are consistent. Kiesslich's 2003 methylene-blue RCT found intraepithelial neoplasia in 32 patients versus 10 with conventional colonoscopy. Rutter's 2004 tandem indigo-carmine study found 0 dysplasia in 2904 nontargeted biopsies, then 7 extra dysplastic lesions in 5 patients after dye. Marion's 2008 sequential exam found dye-targeted dysplasia in 17 patients versus 3 with randoms alone. SCENIC (2015) converted that into guidance: HD rather than SD (strong), dye rather than WLE on SD scopes (strong), and dye suggested rather than WLE on HD scopes (conditional, low-quality evidence). The panel was explicit that better detection has not been shown to cut CRC incidence or CRC death.

On HD scopes the RCTs split. Alexandersson (2020) found dysplasia in 11% with HD dye versus 5% with HD-WLE when both arms still took 32 randoms (P=0.032). Yang (2019) found no significant difference in colitis-associated dysplasia (fewer biopsies in the dye arm: 9 vs 34). Iacucci (2018) found HD-WLE non-inferior to dye in one expert's hands; do not treat that as community performance. Feuerstein's 2019 RCT meta: dye versus SD-WLE RR 2.12, versus HD-WLE RR 1.36 (0.84-2.18), not significant. Mohamed's 2024 AJG update (6 RCTs, n=978) swung back: patients with dysplasia 18.8% versus 9.4%, OR 1.94. HGD was not significantly different. BSG 2025 suggests HD dye, calls the gain small, and rates certainty low (network RR 1.42).

HELIOS (2025) is the time lesson. Per-protocol neoplasia: HD-WLE with segmental re-inspection 10.3% (24/234), HD dye 13.1% (28/214), single-pass HD-WLE 6.1% (7/115). Re-inspection was non-inferior to dye. Neoplasia per 10 minutes of withdrawal was almost identical. Dye cost about 8 extra minutes. HELIOS does not license a rushed single-pass HD withdrawal. A second look at each segment closed most of the gap.

NBI is not a SCENIC substitute for dye. Bisschops (2018) found methylene blue and NBI equivalent (21.2% vs 21.5%) with NBI about 7 minutes shorter and no dysplasia in surrounding-mucosa biopsies. VIRTUOSO (2021) compared HD i-scan with HD-WLE: neoplasia 14.9% versus 24.2% (P=0.14). El-Dallal's VCE meta did not show virtual chromo beating HD-WLE. ACG 2019 rec 49 is more permissive of NBI on HD than SCENIC was. ESGE 2019 rec 3 allows dye or virtual with targeted biopsies in quiescent disease. BSG 2025 made no GRADE recommendation for virtual chromo and none for generic CADe trained off IBD datasets.

When do I still take random biopsies?

Watanabe [12]'s Japanese RCT (n=246) compared target-only biopsies with randoms plus targeted: neoplasia in 11.4% versus 9.3% of patients, 3.1 versus 34.8 biopsies, 27 versus 42 minutes. Randoms from never-inflamed mucosa found no neoplasia. VIRTUOSO took 6751 nontargeted biopsies and found 1 intraepithelial neoplasm. That is why AGA 2021 and BSG 2025 do not require quadrantic mapping after a high-quality HD dye or virtual-chromo exam in a low-risk, well-healed colon.

Moussata (n=1000, pan-chromo then targeted then randoms) is why you do not drop randoms everywhere. Of 94 patients with neoplasia, randoms were the only site in 12.8%. Yield was 1.2% per colonoscopy and 0.2% per biopsy. The associated settings were prior neoplasia, a tubular colon, and PSC. Keep protocol randoms there, and when you are on white light without dye or virtual chromo (about 4 every 10 cm). Map histologic activity and extent at the same sitting when it will change the interval.

What do I do with visible dysplasia?

SCENIC retired DALM/ALM language. Describe visible versus invisible, polypoid versus nonpolypoid, and whether the borders are clear. Resect clearly delineated visible dysplasia, preferably en bloc. Adjacent randoms after complete resection are usually unnecessary. Confirm IBD-associated dysplasia with a GI pathologist. A lesion outside the colitis segment is a sporadic polyp.

Invisible dysplasia: repeat expert HD dye with extensive nontargeted biopsies in that segment. Invisible HGD, unresectable visible dysplasia, or invisible multifocal dysplasia: colectomy after that exam (AGA BPA 10, ECCO 2023). Invisible LGD is individualized after MDT. Completely resected visible LGD gets intensive early follow-up (AGA 6-12 months; ECCO often 3-6 months, then annual HD dye or VCE).

What interval after a negative screen?

Reassess after every exam. The classic box (ECCO 2023, BSG 2019) is 1 / 3 / 5 years:

Risk	Typical features	Next exam
High	Extensive colitis with moderate or severe endoscopic or histologic activity; stricture or dysplasia in the last 5 years; PSC (including post-transplant); first-degree relative with CRC under age 50	1 year
Intermediate	Extensive colitis with mild or moderate activity; post-inflammatory polyps; first-degree relative with CRC at age 50 or older	2-3 years (ECCO) or 3 years (BSG 2019)
Lower	Extensive colitis with no active inflammation, or left-sided / Crohn affecting less than half the colon, and none of the high-risk features	5 years

BSG 2025 moved toward annual versus 3-year versus population screening plus 10-year reassessment (Oxford calculator). Modern CRC relative risk in IBD is about 1.4 to 1.7 versus the population. Age 75 is a shared-decision stop. Two consecutive quiet, good-quality exams support de-escalation. The 2025 ACG UC update does not cover surveillance; keep ACG 2019 for those US statements. UC drugs and healing scores live on the UC therapy post. A shorter intervals companion is the IBD endoscopy guide.

Pitfalls

Pitfall	Better move
Treating this as mucosal healing	MES and UCEIS grade inflammation. They do not find flat dysplasia.
Equating single-pass HD-WLE with dye	HELIOS single-pass was 6.1% versus 13.1% dye. Re-inspection, not hardware alone, closed the gap.
Using 2015 SCENIC NBI statements as 2026 practice	SCENIC did not replace dye with NBI. Later HD RCTs made virtual chromo a reasonable alternative, not a proven upgrade.
Dropping all randoms in PSC or prior dysplasia	Moussata: randoms were the only neoplasia in 12.8% of patients who had it.
Scoping through moderate-severe activity	Inflammation mimics dysplasia. Best done in remission. Activity is itself a high-risk interval driver.
DALM language, or claiming dye prevents cancer	Use visible vs invisible. Detection is a surrogate. No mortality RCT.

Selected references

1. Laine L, et al. SCENIC international consensus on surveillance and management of dysplasia in IBD. Gastroenterology. 2015.
2. Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA Clinical Practice Update on endoscopic surveillance and management of colorectal dysplasia in IBD. Gastroenterology. 2021.
3. Rubin DT, et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019. Recs 47-49.
4. Lichtenstein GR, et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol. 2018.
5. Shergill AK, et al. The role of endoscopy in IBD. Gastrointest Endosc. 2015.
6. Bisschops R, et al. ESGE Guideline update: advanced imaging for colorectal neoplasia. Endoscopy. 2019. Rec 3.
7. Gordon H, et al. ECCO Guidelines on IBD and malignancies. J Crohns Colitis. 2023.
8. East JE, et al. BSG guidelines on colorectal surveillance in IBD. Gut. 2025.
9. Kiesslich R, et al. Methylene blue-aided chromoendoscopy in ulcerative colitis. Gastroenterology. 2003.
10. Rutter MD, et al. Pancolonic indigo carmine dye spraying in ulcerative colitis. Gut. 2004.
11. Marion JF, et al. Chromoendoscopy-targeted biopsies versus standard colonoscopic surveillance in IBD. Am J Gastroenterol. 2008.
12. Watanabe T, et al. Targeted vs random biopsies for UC-associated CRC surveillance. Gastroenterology. 2016.
13. Iacucci M, et al. HD colonoscopy vs HD dye spraying vs virtual chromoendoscopy in IBD surveillance. Am J Gastroenterol. 2018.
14. Bisschops R, et al. Chromoendoscopy versus NBI in ulcerative colitis. Gut. 2018.
15. Alexandersson B, et al. HD chromoendoscopy superior to HD-WLE in IBD surveillance. Clin Gastroenterol Hepatol. 2020.
16. Kandiah K, et al. VIRTUOSO: virtual chromoendoscopy in colitis surveillance. Gut. 2021.
17. te Groen M, et al. HELIOS: HD-WLE with segmental re-inspection versus dye-based chromoendoscopy. Gut. 2025.
18. Feuerstein JD, et al. Meta-analysis of dye-based chromoendoscopy vs SD- and HD-WLE in IBD. Gastrointest Endosc. 2019.
19. Mohamed MF, et al. Dye chromoendoscopy vs HD-WLE for dysplasia detection in IBD: updated RCT meta-analysis. Am J Gastroenterol. 2024.
20. Moussata D, et al. Are random biopsies still useful after chromoendoscopy in IBD? Gut. 2018.