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Endoscopy 2009; 41(3): 234-239
DOI: 10.1055/s-0028-1119625
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Appropriateness of colonoscopy in Europe (EPAGE II) – Functional bowel disorders: pain, constipation and bloating

S.  Schusselé Filliettaz1 , J.-J.  Gonvers2 , I.  Peytremann-Bridevaux1 , C.  Arditi1 , M.  Delvaux3 , M.  E.  Numans4 , V.  Lorenzo-Zúñiga5 , R.  W. Dubois6 , P.  Juillerat2 , B.  Burnand1 , V.  Pittet1 , J.-P.  Vader1 , F.  Froehlich2,  7 , and the EPAGE II Study Group8
  • 1Healthcare Evaluation Unit, Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
  • 2Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
  • 3Department of Internal Medicine and Digestive Pathology, CHU de Nancy, Vandoeuvre-les-Nancy, France
  • 4Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
  • 5Gastroenterology/Endoscopy, Hospital Universitari Germans Trias I Pujol, Badalona (Barcelona), Spain
  • 6Cerner LifeSciences, Beverly Hills, USA
  • 7Department of Gastroenterology, University of Basle, Basle, Switzerland
  • 8The EPAGE II Study Group[*]
Further Information

Publication History

submitted17 June 2008

accepted after revision5 December 2008

Publication Date:
11 March 2009 (online)

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Commentaire de “Retour vers le futur: EPAGE II” (6 articles), pp. 200Endoscopy 2009; 41(03): 388-390
DOI: 10.1055/s-0032-1306673

Background and study aims: To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of functional bowel symptoms, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II.

Methods: A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of functional bowel symptoms was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions.

Results: Much of the evidence for use of colonoscopy in evaluation of chronic abdominal pain, and/or constipation and/or abdominal bloating is modest. Major limitations include small numbers of patients and lack of adequate characterization of these patients. Large community-based follow-up studies are needed to enable better definition of the natural history of patients with functional bowel disorders. Guidelines stress that alarm features (”red flags”), such as rectal bleeding, anemia, weight loss, nocturnal symptoms, family history of colon cancer, age of onset > 50 years, and recent onset of symptoms should all lead to careful evaluation before a diagnosis of functional bowel disorder is made. EPAGE II assessed these symptoms by means of 12 clinical scenarios, rating colonoscopy as appropriate, uncertain and inappropriate in 42 % (5/12), 25 % (3/12), and 33 % (4/12) of these, respectively.

Conclusions: Evidence to support the use of colonoscopy in the evaluation of patients with functional bowel disorders and no alarm features is lacking. These patients have no increased risk of colon cancer and thus advice on screening for this is not different from that for the general population. EPAGE II criteria, available online (http://www.epage.ch), consider colonoscopy appropriate in patients of > 50 years with chronic or new-onset bowel disturbances, but not in patients with isolated chronic abdominal pain.

References

  • 1 Drossman D A. The functional gastrointestinal disorders and the Rome II process.  Gut. 1999;  45 Suppl 2 II1-II5
    PubMedGoogle Scholar
  • 2 Drossman D A. The functional gastrointestinal disorders and the Rome III process.  Gastroenterology. 2006;  130 1377-1390
    Google Scholar
  • 3 Lewis S J, Heaton K W. Stool form scale as a useful guide to intestinal transit time.  Scand J Gastroenterol. 1997;  32 920-924
    CrossrefPubMedGoogle Scholar
  • 4 Manning A P, Thompson W G, Heaton K W, Morris A F. Towards positive diagnosis of the irritable bowel.  Br Med J. 1978;  2 653-654
    CrossrefPubMedGoogle Scholar
  • 5 Tougas G. The nature of pain in irritable bowel syndrome.  J Clin Gastroenterol. 2002;  35 S26-S30
    PubMedGoogle Scholar
  • 6 Garrigues V, Galvez C, Ortiz V. et al . Prevalence of constipation: agreement among several criteria and evaluation of the diagnostic accuracy of qualifying symptoms and self-reported definition in a population-based survey in Spain.  Am J Epidemiol. 2004;  159 520-526
    CrossrefPubMedGoogle Scholar
  • 7 Higgins P D, Johanson J F. Epidemiology of constipation in North America: a systematic review.  Am J Gastroenterol. 2004;  99 750-759
    CrossrefPubMedGoogle Scholar
  • 8 Pare P, Ferrazzi S, Thompson W G. et al . An epidemiological survey of constipation in Canada: definitions, rates, demographics, and predictors of health care seeking.  Am J Gastroenterol. 2001;  96 3130-3137
    CrossrefPubMedGoogle Scholar
  • 9 Sandler R S, Stewart W F, Liberman J N. et al . Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact.  Dig Dis Sci. 2000;  45 1166-1171
    CrossrefPubMedGoogle Scholar
  • 10 Hungin A P, Whorwell P J, Tack J, Mearin F. The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40 000 subjects.  Aliment Pharmacol Ther. 2003;  17 643-650
    CrossrefPubMedGoogle Scholar
  • 11 Mueller-Lissner S A, Bollani S, Brummer R J. et al . Epidemiological aspects of irritable bowel syndrome in Europe and North America.  Digestion. 2001;  64 200-204
    CrossrefPubMedGoogle Scholar
  • 12 Saito Y A, Schoenfeld P, Locke G R. The epidemiology of irritable bowel syndrome in North America: a systematic review.  Am J Gastroenterol. 2002;  97 1910-1915
    PubMedGoogle Scholar
  • 13 Thompson W G, Heaton K W, Smyth G T, Smyth C. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral.  Gut. 2000;  46 78-82
    CrossrefPubMedGoogle Scholar
  • 14 Agrawal A, Whorwell P J. Review article: abdominal bloating and distension in functional gastrointestinal disorders – epidemiology and exploration of possible mechanisms.  Aliment Pharmacol Ther. 2008;  27 2-10
    PubMedGoogle Scholar
  • 15 Kalloo A N. Overview of differential diagnoses of abdominal pain.  Gastrointest Endosc. 2002;  56 S255-S257
    CrossrefPubMedGoogle Scholar
  • 16 Leung F W. Etiologic factors of chronic constipation: review of the scientific evidence.  Dig Dis Sci. 2007;  52 313-316
    CrossrefPubMedGoogle Scholar
  • 17 Locke III G R, Pemberton J H, Phillips S F. American Gastroenterological Association technical review on constipation.  Gastroenterology. 2000;  119 1766-1778
    CrossrefPubMedGoogle Scholar
  • 18 Bond J H. Is referral for colonoscopy underutilized by primary care physicians?.  Gastrointest Endosc. 2000;  52 693-696
    CrossrefPubMedGoogle Scholar
  • 19 Vader J P, Pache I, Froehlich F. et al . Overuse and underuse of colonoscopy in a European primary care setting.  Gastrointest Endosc. 2000;  52 593-599
    PubMedGoogle Scholar
  • 20 Juillerat P, Peytremann-Bridevaux I, Vader J P. et al . Appropriateness of colonoscopy in Europe (EPAGE II). Presentation of methodology, general results, and analysis of complications.  Endoscopy. 2008;  41
    PubMedGoogle Scholar
  • 21 DeBosset V, Gonvers J J, Vader J P. et al . Appropriateness of colonoscopy: lower abdominal pain or constipation.  Endoscopy. 1999;  31 637 640
    PubMedGoogle Scholar
  • 22 Brandt L J, Prather C M, Quigley E M. et al . Systematic review on the management of chronic constipation in North America.  Am J Gastroenterol. 2005;  100 Suppl 1 S5-S21
    CrossrefPubMedGoogle Scholar
  • 23 Longstreth G F, Thompson W G, Chey W D. et al . Functional bowel disorders.  Gastroenterology. 2006;  130 1480-1491
    Google Scholar
  • 24 Piche T, Dapoigny M, Bouteloup C. et al . Recommandations pour la pratique clinique dans la prise en charge et le traitement de la constipation chronique de l’adulte.  Gastroenterol Clin Biol. 2007;  31 125-135
    PubMedGoogle Scholar
  • 25 Sowerby Centre for Health Informatics .Constipation in adults. Newcastle, UK; SCHIN 2005
    Google Scholar
  • 26 Adler A, Roll S, Marowski B. et al . Appropriateness of colonoscopy in the era of colorectal cancer screening: a prospective, multicenter study in a private-practice setting (Berlin Colonoscopy Project 1, BECOP 1).  Dis Colon Rectum. 2007;  50 1628-1638
    CrossrefPubMedGoogle Scholar
  • 27 DeBosset V, Froehlich F, Rey J P. et al . Do explicit appropriateness criteria enhance the diagnostic yield of colonoscopy?.  Endoscopy. 2002;  34 360-368
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Duncan J E, Sweeney W B, Trudel J L. et al . Colonoscopy in the elderly: low risk, low yield in asymptomatic patients.  Dis Colon Rectum. 2006;  49 646-651
    CrossrefPubMedGoogle Scholar
  • 29 Gonvers J J, Harris J K, Wietlisbach V. et al . A European view of diagnostic yield and appropriateness of colonoscopy.  Hepatogastroenterology. 2007;  54 729-735
    PubMedGoogle Scholar
  • 30 Lasson A, Kilander A, Stotzer P O. Diagnostic yield of colonoscopy based on symptoms.  Scand J Gastroenterol. 2007;  1-7
    PubMedGoogle Scholar
  • 31 Lieberman D A, de Garmo P L, Fleischer D E. et al . Colonic neoplasia in patients with nonspecific GI symptoms.  Gastrointest Endosc. 2000;  51 647-651
    CrossrefPubMedGoogle Scholar
  • 32 Morini S, Hassan C, Meucci G. et al . Diagnostic yield of open access colonoscopy according to appropriateness.  Gastrointest Endosc. 2001;  54 175-179
    CrossrefPubMedGoogle Scholar
  • 33 Pepin C, Ladabaum U. The yield of lower endoscopy in patients with constipation: survey of a university hospital, a public county hospital, and a Veterans Administration medical center.  Gastrointest Endosc. 2002;  56 325-332
    CrossrefPubMedGoogle Scholar
  • 34 Froehlich F, Gonvers J J. Diagnostic yield of colonoscopy by indication. In: Waye JD, Rex DK, Williams CB, eds Colonoscopy: principles and practice. Malden, Massachusetts, USA; Blackwell Publishing 2003: 111-130
    Google Scholar
  • 35 Agence Nationale d’Accréditation et d’Evaluation en Santé .Endoscopie digestive basse: indications en dehors du dépistage en population – Argumentaire. Saint-Denis La Plaine; Haute Autorité de Santé 2004
    Google Scholar
  • 36 Australian Cancer Network Colorectal Cancer Guidelines Revision Committee .Guidelines for the prevention, early detection and management of colorectal cancer. Sydney; The Cancer Council Australia and Australian Cancer Network 2005
    Google Scholar
  • 37 Bleser S D. Practical symptom-based evaluation of chronic constipation.  J Fam Pract. 2006;  55 580-584
    PubMedGoogle Scholar
  • 38 Brandt L J, Bjorkman D, Fennerty M B. et al . Systematic review on the management of irritable bowel syndrome in North America.  Am J Gastroenterol. 2002;  97 S7-S26
    PubMedGoogle Scholar
  • 39 Camilleri M, Heading R C, Thompson W G. Clinical perspectives, mechanisms, diagnosis and management of irritable bowel syndrome.  Aliment Pharmacol Ther. 2002;  16 1407-1430
    CrossrefPubMedGoogle Scholar
  • 40 Drossman D A, Camilleri M, Mayer E A, Whitehead W E. American Gastroenterological Association technical review on irritable bowel syndrome.  Gastroenterology. 2002;  123 2108-2131
    CrossrefPubMedGoogle Scholar
  • 41 Fass R, Longstreth G F, Pimentel M. et al . Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome.  Arch Intern Med. 2001;  161 2081-2088
    PubMedGoogle Scholar
  • 42 Horwitz B J, Fisher R S. The irritable bowel syndrome.  N Engl J Med. 2001;  344 1846-1850
    CrossrefPubMedGoogle Scholar
  • 43 Houghton L A, Whorwell P J. Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders.  Neurogastroenterol Motil. 2005;  17 500-511
    PubMedGoogle Scholar
  • 44 Jones J, Boorman J, Cann P. et al . British Society of Gastroenterology guidelines for the management of the irritable bowel syndrome.  Gut. 2000;  47 Suppl 2 ii1-19
    CrossrefPubMedGoogle Scholar
  • 45 Qureshi W, Adler D G, Davila R E. et al . ASGE guideline: guideline on the use of endoscopy in the management of constipation.  Gastrointest Endosc. 2005;  62 199-201
    CrossrefPubMedGoogle Scholar
  • 46 Rao S S, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review.  Am J Gastroenterol. 2005;  100 1605-1615
    CrossrefPubMedGoogle Scholar
  • 47 Singapore Ministry of Health .Colorectal cancer. Singapore 2004: 98p
    Google Scholar
  • 48 Spiller R, Aziz Q, Creed F. et al . Guidelines for the management of irritable bowel syndrome.  Gut. 2007;  56 1770-1798
    Google Scholar
  • 49 Talley N J. Irritable bowel syndrome.  Intern Med J. 2006;  36 724-728
    CrossrefPubMedGoogle Scholar
  • 50 World Gastroenterology Organization .Constipation. 2007
    Google Scholar
  • 51 Chan A O, Hui W M, Leung G. et al . Patients with functional constipation do not have increased prevalence of colorectal cancer precursors.  Gut. 2007;  56 451-452
    CrossrefPubMedGoogle Scholar
  • 52 Dorval E, Jankowski J M, Barbieux J P. et al . Polyethylene glycol and prevalence of colorectal adenomas.  Gastroenterol Clin Biol. 2006;  30 1196-1199
    PubMedGoogle Scholar
  • 53 Dukas L, Willett W C, Colditz G A. et al . Prospective study of bowel movement, laxative use, and risk of colorectal cancer among women.  Am J Epidemiol. 2000;  151 958-964
    PubMedGoogle Scholar
  • 54 Ghadirian P, Maisonneuve P, Perret C. et al . Epidemiology of sociodemographic characteristics, lifestyle, medical history, and colon cancer: a case–control study among French Canadians in Montreal.  Cancer Detect Prev. 1998;  22 396-404
    CrossrefPubMedGoogle Scholar
  • 55 Jacobs E J, White E. Constipation, laxative use, and colon cancer among middle-aged adults.  Epidemiology. 1998;  9 385-391
    CrossrefPubMedGoogle Scholar
  • 56 Kojima M, Wakai K, Tokudome S. et al . Bowel movement frequency and risk of colorectal cancer in a large cohort study of Japanese men and women.  Br J Cancer. 2004;  90 1397-1401
    CrossrefPubMedGoogle Scholar
  • 57 LeMarchand L, Wilkens L R, Kolonel L N. et al . Associations of sedentary lifestyle, obesity, smoking, alcohol use, and diabetes with the risk of colorectal cancer.  Cancer Res. 1997;  57 4787-4794
    PubMedGoogle Scholar
  • 58 Otani T, Iwasaki M, Inoue M. et al . Bowel movement, state of stool, and subsequent risk for colorectal cancer: the Japan public health center-based prospective study.  Ann Epidemiol. 2006;  16 888-894
    CrossrefPubMedGoogle Scholar
  • 59 Roberts M C, Millikan R C, Galanko J A. et al . Constipation, laxative use, and colon cancer in a North Carolina population.  Am J Gastroenterol. 2003;  98 857-864
    CrossrefPubMedGoogle Scholar
  • 60 Sonnenberg A, Muller A D. Constipation and cathartics as risk factors of colorectal cancer: a meta-analysis.  Pharmacology. 1993;  47 Suppl 1 224-233
    CrossrefPubMedGoogle Scholar
  • 61 Watanabe T, Nakaya N, Kurashima K. et al . Constipation, laxative use and risk of colorectal cancer: The Miyagi Cohort Study.  Eur J Cancer. 2004;  40 2109-2115
    CrossrefPubMedGoogle Scholar
  • 62 American Cancer Society .Cancer facts and figures 2007. 56p. http://www.cancer.org
    Google Scholar
  • 63 Davila R E, Rajan E, Adler D. et al . ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer.  Gastrointest Endosc. 2005;  61 1-7
    CrossrefPubMedGoogle Scholar
  • 64 Davila R E, Rajan E, Baron T H. et al . ASGE guideline: colorectal cancer screening and surveillance.  Gastrointest Endosc. 2006;  63 546-557
    CrossrefPubMedGoogle Scholar
  • 65 Institute for Clinical Systems Improvement .Colorectal cancer screening. Bloomington, Minnesota 2006: 51p
    Google Scholar
  • 66 Levin B, Barthel J S, Burt R W. et al .Practice guidelines in Oncology: Colorectal cancer screening. National Comprehensive Cancer Network 2007
    Google Scholar
  • 67 McLeod R. and the CTFPHC .Screening strategies for colorectal cancer: systematic review and recommendations. Technical review. London, Ontario; Canadian Task Force on Preventive Health Care (CTFPHC) 2001
    Google Scholar
  • 68 National Guideline Clearinghouse .Colorectal cancer screening clinical practice guideline – NGC summary. Oakland (USA); Kaiser Permanente Care Management Institute 2006
    Google Scholar
  • 69 Pignone M P, Rich M, Teutsch S. et al .Screening for colorectal cancer in adults. Rockville; Agency for Healthcare Research and Quality (AHRQ) 2002
    Google Scholar
  • 70 Rex D K, Johnson D A, Lieberman D A. et al . Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. American College of Gastroenterology.  Am J Gastroenterol. 2000;  95 868-877
    PubMedGoogle Scholar
  • 71 Winawer S, Fletcher R, Rex D. et al . Colorectal cancer screening and surveillance: clinical guidelines and rationale – Update based on new evidence.  Gastroenterology. 2003;  124 544-560
    CrossrefPubMedGoogle Scholar
  • 72 Ternent C A, Bastawrous A L, Morin N A. et al . Practice parameters for the evaluation and management of constipation.  Dis Colon Rectum. 2007;  50 2013-2022
    CrossrefPubMedGoogle Scholar
  • 73 American College of Gastroenterology . An evidence-based approach to the management of chronic constipation in North America.  Am J Gastroenterol. 2005;  100 Suppl 1 S1-S4
    CrossrefPubMedGoogle Scholar
  • 74 Thompson W G, Longstreth G F, Drossman D A. et al . Functional bowel disorders and functional abdominal pain.  Gut. 1999;  45 Suppl 2 II43-II47
    CrossrefPubMedGoogle Scholar

1 See Appendix: The EPAGE II Study Group

F. FroehlichMD 

Rue Achille-Merguin 44
CH-2900 Porrentruy
Switzerland

Fax: +41 32 466 29 55

Email: florian.froehlich@bluewin.ch

    The following figure and tables are available online:
    Fig. e1b Appropriateness ratings of clinical indications for performing colonoscopy in patients with lower abdominal symptoms (full decision tree).
    Table e1 Functional bowel disorders: Rome III definitions (adapted from [2]).
    Table e2 Comparison between the Rome II and Rome III definitions of functional bowel disorders.
    Table e3 Studies investigating the diagnostic yield of colonoscopy in patients presenting with chronic constipation and/or abdominal pain and/or bloating (1997 – February 2008).
    Table e4 Guidelines/reviews issuing recommendations on the appropriateness of colonoscopy for diagnostic purposes in chronic constipation and/or abdominal pain and/or bloating.
    Table e5 Guidelines/reviews issuing recommendations on the appropriateness of colonoscopy for diagnostic purposes in chronic constipation and/or abdominal pain and/or bloating.
    Table e6 Studies investigating the association between chronic constipation and colorectal cancer (1997 – February 2008).