Introduction
Introduction
Several definitions have been used to describe chronic constipation, using features
such as type and consistency of stools, frequency of bowel movements and duration
of symptoms (chronic/acute) [1 2 3 4 5
The definition of irritable bowel syndrome (IBS) is complex and has been subject to
considerable modification over the years. (For the Rome III criteria see Table e1 ; for a comparison of the Rome II and III criteria see Table e2 ). [Table A 2 2
Table A Definitions related to lower abdominal functional bowel disorders.
Term
Definition
Uncomplicated
None of following: melena, hematochezia, hemoccult-positive stools, unexplained iron-deficiency
anemia, weight loss.
Lower abdominal pain
Pain or discomfort below the umbilicus, with or without bloating.
Empirical inflammatory bowel syndrome (IBS) therapy
At least 2 weeks of daily treatment with fiber (psyllium- or methylcellulose-containing
preparations) or antispasmodics (dicyclomine, propantheline, hyscosamine, loperamide,
diphenoxylate). Empirical therapy does not allow prediction of endoscopic lesions;
therefore, it does not appear in the matrix though widely used in clinical practice.
Risk factors for colorectal cancer
Personal history of colorectal cancer (CRC) or colorectal adenomas, inflammatory bowel
disease (IBD)
Lower GI investigations
Sigmoidoscopy or barium enema since onset of lower abdominal pain or within past 5
years
Barium enema
Double-contrast technique.
Sigmoidoscopy
Flexible tube (60 cm)
Constipation therapy
At least 2 weeks of daily treatment with fibers (psyllium- or methycellulose-containing
preparations)
Constipation
Two or more of the following symptoms for at least 3 months: 2 or fewer bowel movements
per week, hard stools more than 25 % of the time, straining more than 25 % of the
time, or incomplete evacuation more than 25 % of the time
Chronic bowel disturbances
Change in bowel habits (mainly constipation) with/without bloating of at least 3 months’
duration.
New-onset bowel disturbances
Change in bowel habits of < 3 months duration (excluding isolated diarrhea which is
dealt with in the companion article about diarrhea)
The prevalence of constipation in the general population[6 7 8 9 10 11 12 13 14 15 16 17
Thus the main difficulty is to differentiate between organic and functional disorders.
Although diagnostic colonoscopy may be useful for such patients, its appropriateness
is questioned [18 19
In April 2008, a multidisciplinary European expert panel convened in Montreux, Switzerland,
to discuss and develop criteria for the appropriate use of colonoscopy. The RAND Appropriateness
Method was chosen for this purpose, because it allows the development of appropriateness
criteria based on published evidence and supplemented by explicit expert opinion.
A detailed description of the application of the RAND Appropriateness Method, including
the literature search process, is published separately in a companion article in this
issue [20
This article presents the literature review on the appropriateness of colonoscopy
in functional bowel disorders (chronic constipation and/or pain and/or bloating) that
was provided to the panelists before the panel meeting, to support their ratings of
appropriateness of use of colonoscopy in such circumstances; their ratings are also
reported here. This updates a previous literature review published in 1999 [21
The present chapter refers to diagnostic colonoscopy only. Patients considered here
for colonoscopic evaluation would have no risk factor for colorectal cancer (CRC),
except for age, and none of the following so-called alarm or “red flag” symptoms:
hematochezia; positive fecal occult blood test (FOBT); anemia; personal/family history
of colon cancer; personal/family history of inflammatory bowel disease; weight loss
of ≥ 5 kg; severe, persistent constipation that is unresponsive to treatment; recent-onset
constipation in an elderly patient without any evidence of a possible primary cause;
abdominal pain/discomfort associated with exercise, movement, urination, or menstruation;
fever; presence of an abdominal mass; or HIV/AIDS [22 23 24 25
Methods
Methods
The literature review process included a systematic search of websites issuing guidelines
and of Medline (1997 – February 2008) to select published guidelines, systematic reviews,
and primary studies assessing the use of colonoscopy in patients with functional bowel
disorders. With the exception of certain relevant articles, the literature published
before 1997 is presented in the previous literature review [21
As mentioned above, the application of the RAND/UCLA Appropriateness Method is described
in detail in a companion article in this issue[20
To simplify the graphical presentation of the appropriateness results, these four
categories were consolidated into two clusters: “Appropriate” (including “appropriate,”
and “appropriate and necessary”) and “Not appropriate” (comprising “inappropriate”
and “uncertain”). In addition to simplification and enhanced clarity of presentation,
the rationale for this choice was that in many instances in the case of a nonappropriate
scenario, whether it be uncertain or inappropriate, the decision for not proposing
the colonoscopy should be specifically discussed and shared with the patient. All
clinical indications and their ratings are available on the EPAGE website (www.epage.ch).
Results
Results
Literature review
Eight primary studies investigating the diagnostic yield of colonoscopy in patients
presenting chronic constipation and/or abdominal pain and/or bloating and published
between 1997 and February 2008 were identified; 21 guidelines published over the same
period on the use of colonoscopy in such patients were retrieved.
Primary studies [26 27 28 29 30 31 32 33 34 Table e3 ). Guidelines [17 22 23 24 25 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Table e4 ) show no clear consensus on the role of colonoscopy in the diagnosis of patients
presenting chronic constipation and/or lower abdominal pain and/or bloating. Patient
groups presenting such nonspecific symptoms tend to be classified according to age
and whether or not they have associated alarm symptoms and/or “red flags” for organic
disease. Lower gastrointestinal endoscopic evaluation would then be justified for
patients ≥ 50 years with recent-onset complaints or for any patients with complaints
associated with alarm features. There is no clear consensus on whether the initial
procedure in patients presenting these nonspecific symptoms should be a sigmoidoscopy
or a colonoscopy.
In patients presenting with chronic constipation and/or lower abdominal pain and/or
bloating, practitioners might principally consider performing a colonoscopy to exclude
colorectal cancer (CRC). In primary studies [51 52 53 54 55 56 57 58 59 60 61 Table e5 ). The literature does not give a clear indication as to whether individuals presenting
with chronic constipation and/or abdominal pain and/or bloating should be considered
“asymptomatic” thus being eligible for “colorectal cancer screening,” or “symptomatic”
thus justifying the search for a potential colonic pathology [26 35 36 47 62 63 64 65 66 67 68 69 70 71 38 35
EPAGE II appropriateness criteria
EPAGE II appropriateness criteria
The panelists assessed lower abdominal symptoms (chronic constipation/abdominal pain/bloating)
in three categories: chronic abdominal pain only, chronic bowel disturbances, and
new-onset bowel disturbances (see [Table A
Out of 463 indication scenarios presented to the panel, 12 pertained to these symptoms;
in 5/12 scenarios colonoscopy was considered appropriate, in 3/12 uncertain, and in
4/12 it was considered inappropriate. [Fig. 1 a
Fig. 1 a Appropriateness ratings of clinical indications for performing colonoscopy in patients
with lower abdominal symptoms (simplified decision tree).
Fig. e1b presents appropriateness criteria in more detail. With isolated chronic abdominal
pain, colonoscopy is considered inappropriate in individuals younger than 50 years,
and of uncertain appropriateness in individuals 50 years or older. Patients with chronic
bowel disturbances (i. e. mainly constipation under 50 years) are not considered appropriate
candidates for colonoscopy under 50 years. In contrast to isolated abdominal pain,
change in bowel habits of at least 3 months’ duration is deemed appropriate for colonoscopy
in patients aged 50 years or more. In patients under 50 years with new-onset bowel
disturbances (new onset constipation with/without bloating, excluding diarrhea), panelists
strongly disagreed, resulting in an “uncertain” rating. In contrast, patients with
similar complaints but aged 50 years or more are all considered appropriate candidates
for colonoscopy. If the procedure had never been performed previously, or was done
5 years or more previously, then colonoscopy was even deemed necessary (mandatory)
in this clinical situation.
The panelists did not consider response to irritable bowel syndrome therapy as an
important factor when taking decisions about appropriateness of colonoscopy.
All the clinical indications and their ratings are available online (http://www.epage,ch),
where answering a few clinical questions allows the appropriateness score for each
indication to be obtained.
Conclusions
Conclusions
Primary studies evaluating the appropriateness of colonoscopy in patients presenting
nonspecific symptoms such as chronic constipation and/or lower abdominal pain and/or
bloating are of modest quality. Most of them are retrospective case series without
control groups. The variations among results can be explained by the heterogeneity
in measured outcomes, study design, samples, definitions, indications for colonoscopy
and/or inclusion criteria, which may also reflect the discrepancies in and the evolution
of the definitions, and the still unknown etiologies of these nonspecific symptoms.
Direct comparisons of results between studies, as well as generalization and recommendations
for all individuals with chronic constipation and/or abdominal pain and/or bloating
are therefore difficult. Guidelines on these topics must therefore be interpreted
with caution since they are mainly based on modest evidence and on expert opinion.
The complaints dealt with in this article are difficult to define clinically and often
overlap, but are extremely frequent: chronic constipation and/or lower abdominal pain
and/or bloating are mainly indicators of functional disease. This review of the published
literature highlights the fact that, despite the modest quality of the evidence, and
although the presence of these symptoms probably does not enhance the pick-up rate
of CRC per se, recommendations tend to consider screening purposes associated with
clinical symptoms as a reason for performing colonoscopy. The notion of alarm symptoms
(“red flags”) is used to differentiate between symptoms of functional disease in which
colonoscopy probably is of little help, and symptoms of organic disease in which colonoscopy
would be appropriate. Colonoscopic evaluation may thus be justified for patients aged
≥ 50 years with recent-onset complaints (chronic constipation and/or abdominal pain
and/or bloating) or for any patients with such complaints in association with alarm
symptoms.
The EPAGE II panel considered chronic as well as new-onset changes in bowel habits
in patients aged ≥ 50 years to be appropriate indications for performing colonoscopy.
In contrast, isolated pain is not deemed to be an appropriate indication whatever
the patients’ age. New-onset bowel disturbances at ≥ 50 years are necessary (i. e.
mandating) indications for colonoscopy. The EPAGE II panel results show the importance
of the cutoff age of 50 years for the decision as to whether colonoscopy should be
performed in patients with lower abdominal symptoms such as abdominal pain, constipation,
and bloating.
Acknowledgments
Acknowledgments
The authors gratefully acknowledge the selfless commitment and invaluable contribution
of the expert panel members, who made this project possible: Lars Agréus (SE), Christoph
Beglinger (CH), Peter Bytzer (DK), Michel Delvaux (FR), Volker F. Eckardt (DE), Peter
D. Fairclough (UK), François Lacaine (FR), Olivier Le Moine (BE), Vicente Lorenzo
Zúñiga Garcia (ES), Giorgio Minoli (IT), Mattijs E. Numans (NL), Daniel Oertli (CH),
John O"Malley (UK), Alastair Windsor (UK). The authors warmly thank Susan Giddons
for her invaluable assistance in the administration of the expert panel process, as
well as in the meticulous preparation of the manuscripts.
Appendix: The EPAGE II Study Group
Appendix: The EPAGE II Study Group
See page 205.
Competing interests: None
