Endoscopy 2009; 41(3): 240-246
DOI: 10.1055/s-0028-1119643
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Appropriateness of colonoscopy in Europe (EPAGE II) – Presentation of methodology, general results, and analysis of complications

P.  Juillerat1 , I.  Peytremann-Bridevaux2 , J.-P.  Vader2 , C.  Arditi2 , S.  Schusselé Filliettaz2 , R.  W.  Dubois3 , J.-J.  Gonvers1 , F.  Froehlich1,  4 , B.  Burnand2 , V.  Pittet2
  • 1Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
  • 2Healthcare Evaluation Unit, Institute of Social and Preventive Medicine (IUMSP), Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
  • 3Cerner LifeSciences, Beverly Hills, USA
  • 4Department of Gastroenterology, University of Basle, Basle, Switzerland
Further Information

Publication History

submitted17 June

accepted after revision15 December 2008

Publication Date:
11 March 2009 (online)

Background and study aims: Appropriate use of colonoscopy is a key component of quality management in gastrointestinal endoscopy. In an update of a 1998 publication, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE II) defined appropriateness criteria for various colonoscopy indications. This introductory paper therefore deals with methodology, general appropriateness, and a review of colonoscopy complications.

Methods:The RAND/UCLA Appropriateness Method was used to evaluate the appropriateness of various diagnostic colonoscopy indications, with 14 multidisciplinary experts using a scale from 1 (extremely inappropriate) to 9 (extremely appropriate). Evidence reported in a comprehensive updated literature review was used for these decisions. Consolidation of the ratings into three appropriateness categories (appropriate, uncertain, inappropriate) was based on the median and the heterogeneity of the votes. The experts then met to discuss areas of disagreement in the light of existing evidence, followed by a second rating round, with a subsequent third voting round on necessity criteria, using much more stringent criteria (i. e. colonoscopy is deemed mandatory).

Results: Overall, 463 indications were rated, with 55 %, 16 % and 29 % of them being judged appropriate, uncertain and inappropriate, respectively. Perforation and hemorrhage rates, as reported in 39 studies, were in general < 0.1 % and < 0.3 %, respectively

Conclusions: The updated EPAGE II criteria constitute an aid to clinical decision-making but should in no way replace individual judgment. Detailed panel results are freely available on the internet (www.epage.ch) and will thus constitute a reference source of information for clinicians.

References

  • 1 Misra T, Lalor E, Fedorak R N. Endoscopic perforation rates at a Canadian university teaching hospital.  Can J Gastroenterol. 2004;  18 221-226
  • 2 Viiala C H, Zimmerman M, Cullen D J, Hoffman N E. Complication rates of colonoscopy in an Australian teaching hospital environment.  Intern Med J. 2003;  33 355-359
  • 3 Froehlich F, Harris J K, Wietlisbach V. et al . Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE).  Endoscopy. 2006;  38 461-469
  • 4 Heuss L T, Froehlich F, Beglinger C. Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 2005;  37 161-166
  • 5 Rex D K, Overley C, Kinser K. et al . Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases.  Am J Gastroenterol. 2002;  97 1159-1163
  • 6 Cohen L B, Wecsler J S, Gaetano J N. et al . Endoscopic sedation in the United States: results from a nationwide survey.  Am J Gastroenterol. 2006;  101 967-974
  • 7 Sonnenberg A, Amorosi S L, Lacey M J, Lieberman D A. Patterns of endoscopy in the United States: analysis of data from the Centers for Medicare and Medicaid Services and the National Endoscopic Database.  Gastrointest Endosc. 2008;  67 489-496
  • 8 Harewood G C, Lieberman D A. Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening.  Clin Gastroenterol Hepatol. 2004;  2 72-77
  • 9 Froehlich F, Gonvers J J, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 1994;  26 231-234
  • 10 May A, Manner H, Schneider M. et al . Prospective multicenter trial of capsule endoscopy in patients with chronic abdominal pain, diarrhea and other signs and symptoms (CEDAP-Plus Study).  Endoscopy. 2007;  39 606-612
  • 11 Mergener K, Ponchon T, Gralnek I. et al . Literature review and recommendations for clinical application of small-bowel capsule endoscopy, based on a panel discussion by international experts. Consensus statements for small-bowel capsule endoscopy, 2006/2007.  Endoscopy. 2007;  39 895-909
  • 12 Cotton P B, Durkalski V L, Pineau B C. et al . Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia.  JAMA. 2004;  291 1713-1719
  • 13 Johnson C D, Toledano A Y, Herman B A. et al . Computerized tomographic colonography: performance evaluation in a retrospective multicenter setting.  Gastroenterology. 2003;  125 688-695
  • 14 Kim D H, Pickhardt P J, Taylor A J. et al . CT colonography versus colonoscopy for the detection of advanced neoplasia.  N Engl J Med. 2007;  357 1403-1412
  • 15 Pickhardt P J, Choi J R, Hwang I. et al . Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults.  N Engl J Med. 2003;  349 2191-2200
  • 16 Rex D K, Lieberman D. ACG colorectal cancer prevention action plan: update on CT-colonography.  Am J Gastroenterol. 2006;  101 1410-1413
  • 17 Rockey D C, Paulson E, Niedzwiecki D. et al . Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison.  Lancet. 2005;  365 305-311
  • 18 Brook R H, Chassin M R, Fink A. et al . A method for the detailed assessment of the appropriateness of medical technologies.  Int J Technol Assess Health Care. 1986;  2 53-63
  • 19 Naylor C D. What is appropriate care?.  N Engl J Med. 1998;  338 1918-1920
  • 20 Bernstein S J, Hilborne L H, Leape L L. et al . The appropriateness of use of coronary angiography in New York State.  JAMA. 1993;  269 766-769
  • 21 Vader J P, Froehlich F, Juillerat P. et al . Appropriate treatment for Crohn’s disease: methodology and summary results of a multidisciplinary international expert panel approach – EPACT.  Digestion. 2006;  73 237-248
  • 22 Park R E, Fink A, Brook R H. et al . Physician ratings of appropriate indications for six medical and surgical procedures.  Am J Public Health. 1986;  76 766-772
  • 23 Vader J P, Porchet F, Larequi-Lauber T. et al . Appropriateness of surgery for sciatica: reliability of guidelines from expert panels.  Spine. 2000;  25 1831-1836
  • 24 Bochud M, Burnand B, Froehlich F. et al . 12. Appropriateness of colonoscopy: surveillance after polypectomy.  Endoscopy. 1999;  31 654-663
  • 25 Bochud M, Burnand B, Froehlich F. et al . 13. Appropriateness of colonoscopy: surveillance after curative resection of colorectal cancer.  Endoscopy. 1999;  31 664-672
  • 26 Bochud M, Gonvers J J, Vader J P. et al . 2. Appropriateness of gastroscopy: gastro-esophageal reflux disease.  Endoscopy. 1999;  31 596-603
  • 27 Bochud M, Gonvers J J, Vader J P. et al . 3. Appropriateness of gastroscopy: Barrett’s esophagus.  Endoscopy. 1999;  31 604-610
  • 28 Burnand B, Bochud M, Froehlich F. et al . 14. Appropriateness of colonoscopy: screening for colorectal cancer in asymptomatic individuals.  Endoscopy. 1999;  31 673-683
  • 29 De Bosset V, Gonvers J J, Burnand B. et al . 7. Appropriateness of colonoscopy: iron-deficiency anemia.  Endoscopy. 1999;  31 627-630
  • 30 De Bosset V, Gonvers J J, Froehlich F. et al . 5. Appropriateness of gastroscopy: bleeding and dysphagia.  Endoscopy. 1999;  31 615-622
  • 31 De Bosset V, Gonvers J J, Vader J P. et al . 9. Appropriateness of colonoscopy: lower abdominal pain or constipation.  Endoscopy. 1999;  31 637-640
  • 32 Froehlich F, Bochud M, Gonvers J J. et al . 1. Appropriateness of gastroscopy: dyspepsia.  Endoscopy. 1999;  31 579-595
  • 33 Froehlich F, Gonvers J J, Vader J P. et al . Appropriateness of gastrointestinal endoscopy: risk of complications.  Endoscopy. 1999;  31 684-686
  • 34 Froehlich F, Larequi-Lauber T, Gonvers J J. et al . 11. Appropriateness of colonoscopy: inflammatory bowel disease.  Endoscopy. 1999;  31 647-653
  • 35 Gonvers J J, De Bosset V, Froehlich F. et al . 8. Appropriateness of colonoscopy: hematochezia.  Endoscopy. 1999;  31 631-636
  • 36 Gonvers J J, de Bosset V, Vader J P. et al . 6. Appropriateness of gastroscopy: risk factors for gastric cancer.  Endoscopy. 1999;  31 623-626
  • 37 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
  • 38 Vader J P, Burnand B, Froehlich F. et al . The European Panel on Appropriateness of Gastrointestinal Endoscopy (EPAGE): project and methods.  Endoscopy. 1999;  31 572-578
  • 39 Vader J P, Froehlich F, Dubois R W. et al . European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE): conclusion and WWW site.  Endoscopy. 1999;  31 687-694
  • 40 Vader J P, Larequi-Lauber T, Froehlich F. et al . 4. Appropriateness of gastroscopy: atypical chest pain.  Endoscopy. 1999;  31 611-614
  • 41 Burnand B, Harris J K, Wietlisbach V. et al . Use, appropriateness, and diagnostic yield of screening colonoscopy: an international observational study (EPAGE).  Gastrointest Endosc. 2006;  63 1018-1026
  • 42 Harris J K, Froehlich F, Gonvers J J. et al . The appropriateness of colonoscopy: a multi-center, international, observational study.  Int J Qual Health Care. 2007;  19 150-157
  • 43 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
  • 44 Vader J P, Wietlisbach V, Harris J K. et al . Gastroenterologists overestimate the appropriateness of colonoscopies they perform: an international observational study.  Endoscopy. 2005;  37 840-846
  • 45 Terraz O, Wietlisbach V, Jeannot J G. et al . The EPAGE internet guideline as a decision support tool for determining the appropriateness of colonoscopy.  Digestion. 2005;  71 72-77
  • 46 Arditi C, Gonvers J J, Burnand B. et al . Appropriateness of colonoscopy in Europe (EPAGE II) Surveillance after polypectomy and after resection of colorectal cancer.  Endoscopy. 2009;  41 209-217
  • 47 Arditi C, Peytremann-Bridevaux I, Burnand B. et al . Appropriateness of colonoscopy in Europe (EPAGE II) Screening for colorectal cancer.  Endoscopy. 2009;  41 200-208
  • 48 Peytremann-Bridevaux I, Arditi C, Froehlich F. et al . Appropriateness of colonoscopy in Europe (EPAGE II) Iron-deficiency anemia (IDA) and hematochezia.  Endoscopy. 2009;  41 227-233
  • 49 Schusselé Filliettaz S, Gonvers J J, Peytremann-Bridevaux I. et al . Appropriateness of colonoscopy in Europe (EPAGE II) Functional bowel disorders: pain, constipation and bloating.  Endoscopy. 2009;  41 234-239
  • 50 Schusselé Filliettaz S, Juillerat P, Burnand B. et al . Appropriateness of colonoscopy in Europe (EPAGE II) Chronic diarrhea and known inflammatory bowel disease.  Endoscopy. 2009;  41 218-226
  • 51 Kahan J P, Bernstein S J, Leape L L. et al . Measuring the necessity of medical procedures.  Med Care. 1994;  32 357-365
  • 52 Anderson M L, Pasha T M, Leighton J A. Endoscopic perforation of the colon: lessons from a 10-year study.  Am J Gastroenterol. 2000;  95 3418-3422
  • 53 Araghizadeh F Y, Timmcke A E, Opelka F G. et al . Colonoscopic perforations.  Dis Colon Rectum. 2001;  44 713-716
  • 54 Arora A, Singh P. Colonoscopy in patients 80 years of age and older is safe, with high success rate and diagnostic yield.  Gastrointest Endosc. 2004;  60 408-413
  • 55 Bini E J, Firoozi B, Choung R J. et al . Systematic evaluation of complications related to endoscopy in a training setting: a prospective 30-day outcomes study.  Gastrointest Endosc. 2003;  57 8-16
  • 56 Bowles C J, Leicester R, Romaya C. et al . A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?.  Gut. 2004;  53 277-283
  • 57 Canard J M, Debette-Gratien M, Dumas R. et al . A prospective national study on colonoscopy and sigmoidoscopy in 2000 in France.  Gastroenterol Clin Biol. 2005;  29 17-22
  • 58 Cobb W S, Heniford B T, Sigmon L B. et al . Colonoscopic perforations: incidence, management, and outcomes.  Am Surg. 2004;  70 750-757; discussion 757–758
  • 59 Cotton P B, Connor P, McGee D. et al . Colonoscopy: practice variation among 69 hospital-based endoscopists.  Gastrointest Endosc. 2003;  57 352-357
  • 60 Dafnis G, Ekbom A, Pahlman L, Blomqvist P. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden.  Gastrointest Endosc. 2001;  54 302-309
  • 61 Denis B, Ben Abdelghani M, Peter A. et al . [Two years of mortality and morbidity conferences in a hospital gastrointestinal endoscopy unit].  Gastroenterol Clin Biol. 2003;  27 1100-1104
  • 62 Denis B, Weiss A M, Peter A. et al . Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures.  Gastroenterol Clin Biol. 2004;  28 1245-1255
  • 63 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
  • 64 Eckardt V F, Kanzler G, Schmitt T. et al . Complications and adverse effects of colonoscopy with selective sedation.  Gastrointest Endosc. 1999;  49 560-565
  • 65 Fasoli R, Repaci G, Comin U, Minoli G. A multi-centre North Italian prospective survey on some quality parameters in lower gastrointestinal endoscopy.  Dig Liver Dis. 2002;  34 833-841
  • 66 Gangi S, Saidi F, Patel K. et al . Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.  Gastrointest Endosc. 2004;  60 679-685
  • 67 Gatto N M, Frucht H, Sundararajan V. et al . Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study.  J Natl Cancer Inst. 2003;  95 230-236
  • 68 Heldwein W, Dollhopf M, Rosch T. et al . The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies.  Endoscopy. 2005;  37 1116-1122
  • 69 Karajeh M A, Sanders D S, Hurlstone D P. Colonoscopy in elderly people is a safe procedure with a high diagnostic yield: a prospective comparative study of 2000 patients.  Endoscopy. 2006;  38 226-230
  • 70 Ko C W, Riffle S, Shapiro J A. et al . Incidence of minor complications and time lost from normal activities after screening or surveillance colonoscopy.  Gastrointest Endosc. 2007;  65 648-656
  • 71 Korman L Y, Overholt B F, Box T, Winker C K. Perforation during colonoscopy in endoscopic ambulatory surgical centers.  Gastrointest Endosc. 2003;  58 554-557
  • 72 Levin T R, Zhao W, Conell C. et al . Complications of colonoscopy in an integrated health care delivery system.  Ann Intern Med. 2006;  145 880-886
  • 73 Luning T H, Keemers-Gels M E, Barendregt W B. et al . Colonoscopic perforations: a review of 30 366 patients.  Surg Endosc. 2007;  21 994-997
  • 74 Ma W T, Mahadeva S, Kunanayagam S. et al . Colonoscopy in elderly Asians: a prospective evaluation in routine clinical practice.  J Dig Dis. 2007;  8 77-81
  • 75 Nelson D B, McQuaid K R, Bond J H. et al . Procedural success and complications of large-scale screening colonoscopy.  Gastrointest Endosc. 2002;  55 307-314
  • 76 Newcomer M K, Shaw M J, Williams D M, Jowell P S. Unplanned work absence following outpatient colonoscopy.  J Clin Gastroenterol. 1999;  29 76-78
  • 77 Rathgaber S W, Wick T M. Colonoscopy completion and complication rates in a community gastroenterology practice.  Gastrointest Endosc. 2006;  64 556-562
  • 78 Sardinha T C, Nogueras J J, Ehrenpreis E D. et al . Colonoscopy in octogenarians: a review of 428 cases.  Int J Colorect Dis. 1999;  14 172-176
  • 79 Sharma V K, Nguyen C C, Crowell M D. et al . A national study of cardiopulmonary unplanned events after GI endoscopy.  Gastrointest Endosc. 2007;  66 27-34
  • 80 Sieg A, Hachmoeller-Eisenbach U, Eisenbach T. Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.  Gastrointest Endosc. 2001;  53 620-627
  • 81 Sieg A, Theilmeier A. [Results of coloscopy screening in 2005 – an Internet-based documentation].  Dtsch Med Wochenschr. 2006;  131 379-383
  • 82 Taku K, Sano Y, Fu K I. et al . Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan.  J Gastroenterol Hepatol. 2007;  22 1409-1414
  • 83 Tran D Q, Rosen L, Kim R. et al . Actual colonoscopy: what are the risks of perforation?.  Am Surg. 2001;  67 845-847; discussion 847–848
  • 84 Tulchinsky H, Madhala-Givon O, Wasserberg N. et al . Incidence and management of colonoscopic perforations: 8 years’ experience.  World J Gastroenterol. 2006;  12 4211-4213
  • 85 Wexner S D, Forde K A, Sellers G. et al . How well can surgeons perform colonoscopy?.  Surg Endosc. 1998;  12 1410-1414
  • 86 Wexner S D, Garbus J E, Singh J J. A prospective analysis of 13 580 colonoscopies. Reevaluation of credentialing guidelines.  Surg Endosc. 2001;  15 251-261
  • 87 Zerey M, Paton B L, Khan P D. et al . Colonoscopy in the very elderly: a review of 157 cases.  Surg Endosc. 2007;  21 1806-1809
  • 88 Zubarik R, Fleischer D E, Mastropietro C. et al . Prospective analysis of complications 30 days after outpatient colonoscopy.  Gastrointest Endosc. 1999;  50 322-328
  • 89 Imperiale T F, Wagner D R, Lin C Y. et al . Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings.  N Engl J Med. 2000;  343 169-174
  • 90 Lieberman D A, Weiss D G, Bond J H. et al . Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.  N Engl J Med. 2000;  343 162-168

V. PittetPhD 

Health Care Evaluation Unit
Institute of Social and Preventive Medicine (IUMSP)
Centre Hospitalier Universitaire Vaudois and University of Lausanne

Rue du Bugnon 17
CH-1005 Lausanne
Switzerland

Fax: +41-21-3144954

Email: valerie.pittet@chuv.ch