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Endoscopy 2009; 41(3): 227-233
DOI: 10.1055/s-0028-1119644
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Appropriateness of colonoscopy in Europe (EPAGE II) – Iron-deficiency anemia and hematochezia

I.  Peytremann-Bridevaux1 , C.  Arditi1 , F.  Froehlich2,  3 , J.  O’Malley4 , P.  Fairclough5 , O.  Le Moine6 , R.  W.  Dubois7 , J.-J.  Gonvers2 , S.  Schusselé Filliettaz1 , J.-P.  Vader1 , P.  Juillerat2 , V.  Pittet1 , B.  Burnand1 , 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 Gastroenterology, University of Basle, Basle, Switzerland
  • 4General Practitioner, Moreton, United Kingdom
  • 5Endoscopy Unit, Barts and The London NHS Trust, London, United Kingdom
  • 6Gastroenterology Department, Hôpital Erasme-ULB, Brussels, Belgium
  • 7Cerner LifeSciences, Beverly Hills, USA
  • 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 iron-deficiency anemia (IDA) and hematochezia, 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 IDA and hematochezia was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions.

Results:IDA occurs in 2 % – 5 % of adult men and postmenopausal women. Examination of both the upper and lower gastrointestinal tract is recommended in patients with iron deficiency. Colonoscopy for IDA yields one colorectal cancer (CRC) in every 9 – 13 colonoscopies. Hematochezia is a well-recognized alarm symptom and such patients are likely to be referred for colonoscopy. Colonoscopy is unanimously recommended in patients aged ≥ 50. Diverticulosis, vascular ectasias, and ischemic colitis are common causes of acute lower gastrointestinal bleeding (LGIB); CRC is found in 0.2 % – 11 % of the colonoscopies performed for LGIB. Most patients with scant hematochezia have an anorectal or a distal source of bleeding. The expert panel considered most clinical indications for colonoscopy as appropriate in the presence of IDA (58 %) or hematochezia (83 %).

Conclusion:Despite the limitations of the published studies, guidelines unanimously recommend colonoscopy for the investigation of IDA and hematochezia in patients aged ≥ 50 years. These indications were also considered appropriate by EPAGE II, as were indications in patients at low risk for CRC with no obvious cause of bleeding found during adequate previous investigations.

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1 See Appendix: The EPAGE II Study Group

B. BurnandMD MPH 

Healthcare 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: Bernard.Burnand@chuv.ch

    The following figures and tables are available online:
    Fig. e1b Appropriateness ratings of clinical indications for performing colonoscopy in patients with iron-deficiency anemia (IDA), with malabsorption syndrome excluded (full decision tree). GI, gastrointestinal.
    Fig. e2b Appropriateness ratings of clinical indications for performing colonoscopy in patients with hematochezia (without inflammatory bowel disease [IBD]), and who are hemodynamically stable (full decision tree). GI, gastrointestinal.
    Table e1 Studies assessing the use of endoscopy for the diagnostic work-up of iron deficiency anemia (IDA), in men and postmenopausal women.
    Table e2 Studies assessing the use of endoscopy for the diagnostic work-up of iron-deficiency anemia (IDA), in premenopausal women.
    Table e3 Studies assessing the use of colonoscopy for the diagnostic work-up of hematochezia.