Colonoscopy appropriateness: Really needed or a waste of time?

Table 1 Summary box

Appropriateness guidelines and prioritising criteria have been developed to lessen colonoscopy workload in endoscopy units

The sensitivity of EPAGE II criteria is higher than that of EPAGE I criteria for detecting significant colorectal lesions (especially CRC); however, specificity should be further improved. Since these criteria are not perfect, in clinical practice, they should be used to assist the clinician before requesting a colonoscopy but they should not be the sole criteria for the decision

Although EPAGE II criteria might be used to cancel inappropriate colonoscopy referrals, in clinical practice they should be used with caution, because some life-threatening lesions are missed, even in inappropriate requests

NICE criteria used for prioritising colonoscopy are not accurate enough for detecting advanced colorectal neoplasms, but may be improved in combination with other markers (i.e., immunochemical fecal occult blood tests)

Adherence to guidelines required to decrease inappropriate indications and colonoscopy waiting lists

EPAGE: European panel appropriateness of gastrointestinal endoscopy; CRC: Colorectal cancer; NICE: National Institute for Health and Clinical Excellence.

Table 2 Main indications for colonoscopy according to European panel appropriateness of gastrointestinal endoscopy II (http://www.epage.ch)

Iron deficiency anemia

Hematochezia

Discomfort or pain in the lower abdomen persisting ≥ 3 mo

Uncomplicated chronic diarrhea

Assessment of ulcerative colitis

Assessment of Crohn disease

Colorectal cancer screening

Colorectal cancer screening in patients with inflammatory bowel disease

Surveillance colonoscopy after polypectomy

Surveillance colonoscopy after colorectal cancer resection

Miscellaneous

Table 3 European panel appropriateness of gastrointestinal endoscopy II studies addressing appropriateness and diagnostic yield

Ref.	Design1 (referrals)	EPAGE II2(% appropriate)	S3 (95%CI)	Sp (95%CI)	PPV (95%CI)4	NPV (95%CI)
Carrión et al[33] (2010)	R 655	82.0	80.3 (74.0-84.3)	16.8 (14.9-18.5)	24.8 (23.1-26.4)	71.3 (63.1-78.6)
Arguello et al[9] (2012)	R 619	82.6	78.3 (73.8-82.4)	34.4 (31.3-37.3)	45.2 (42.6-47.6)	69.6 (63.4-75.4)
Gimeno García et al[10] (2012)	P 968	89.5	93.1 (90.0-96.3)	12.7 (10.0-15.0)	38.8 (36.0-42.0)	75.5 (67.0-84.0)
Eskeland et al[16] (2014)	R 295	91.0	92.6 (84.8-96.6)	22.9 (17.8-29.0)	31.3 (25.3-37.3)	89.1 (80.7-97.5)

¹Study design: R (retrospective); P (prospective); ²Appropriate and uncertain referrals jointly analysed;

³S (sensitivity); Sp (specificity);

⁴PPV (positive predictive value); NPV (negative predictive value).

Table 4 Clinical criteria for prompt colonoscopy referral (2 wk) according to the National Institute for Health and Clinical Excellence in the United Kingdom[44]

Patients ≥ 40 yr with rectal bleeding and change of bowel habit persisting ≥ 6 wk

Patients ≥ 60 yr with rectal bleeding persisting ≥ 6 wk without a change in bowel habit and without anal symptoms

Patients ≥ 60 yr with a change of bowel habit persisting ≥ 6 wk without rectal bleeding

Patients with right lower abdominal mass

Patients with palpable rectal mass

Patients with unexplained iron deficiency anemia ( ≤ 11 g/100 mL in men and ≤ 10 g/100 mL in women)

Table 5 Scottish Intercollegiate Guidelines network referral criteria[45]

1 Persistent rectal bleeding without anal symptoms

2 Persistent change in bowel habit (> 6 wk)

3 Significant family history

4 Right-side abdominal mass

5 Palpable rectal mass

6 Unexplained iron deficiency anemia

7 Persistent diarrhea