Definitions for EPAGE II chapters

Iron-deficiency anemia
Hematochezia.
Non specific abdominal symptoms (chronic constipation / abdominal pain / bloating) of at least 2 months duration, without known inflammatory bowel disease, without anemia and without FOBT positive stools, with or without empirical IBS therapy. No risk factors for colorectal cancer.
Uncomplicated chronic diarrhea (infectious or malabsorption origin excluded and without known IBD). No anemia. No bleeding. No laxatif or sorbitol abuse. No risk factors for colorectal cancer. No HIV / AIDS. With or without empirical treatment.
Evaluation of known ulcerative colitis (UC), excluding surveillance for colorectal cancer.
Evaluation of known Crohn's disease (CD), excluding surveillance for colorectal cancer.
Surveillance for colorectal cancer in patients with known inflammatory bowel disease.
Surveillance after colonic polypectomy; follow-up colonoscopy (complete colonoscopy, bowel preparation adequate, patient asymptomatic, life expectancy >10 years). Familial polyposis, HNPCC and hyperplastic polyposis syndrome excluded.
Surveillance after curative intent resection of colorectal cancer.
Screening for colorectal cancer.
Miscellaneous indications.

Definitions for chapter "Iron-deficiency anemia (malabsorption syndrome excluded)"

Iron-deficiency anemia (IDA) (malabsorption symptoms excluded)
Hb <120 g/l in females or Hb <140 g/l in males with no obvious cause of blood loss, decreased serum iron, decreased ferritine.

Risk factors for colorectal cancer

• Personal history of colorectal cancer or colorectal adenomas, inflammatory bowel disease,
  OR
  
• Family history of a first-degree relative with colorectal cancer or colorectal adenomas, familial polyposis syndrome, hereditary non-polyposis colorectal cancer syndrome.

Lower abdominal symptoms
One or more of the following: abdominal pain or discomfort below the umbilicus, alteration in bowel habits, bloating.

Upper abdominal symptoms
One or more of the following: upper abdominal discomfort, dyspepsia, heartburn, early satiety, anorexia, nausea or vomiting.

Source of IDA:

• Potential lower GI bleeding source:
  Bleeding diverticula, vascular malformation (AVM), polyp, tumor, colitis diagnosed by barium enema, sigmoidoscopy or colonoscopy within the last 3 months.
• Potential upper GI bleeding source:
  Duodenal, gastric or esophageal ulcer, esophageal varices, esophagitis, hemorrhagic gastritis, erosive gastritis, Mallory-Weiss tear, Dieulafoy lesion within the last 3 months.

Lower GI investigations (for this episode of IDA)
Sigmoidoscopy or barium enema since onset of lower abdominal pain or within past 5 years.

Barium enema (for this episode of IDA)
Double contrast technique.

Sigmoidoscopy (for this episode of IDA)
Flexible tube (60 cm).

Gynecological cause excluded
No excessive menstrual bloodness.
Gynecological examination normal or status after hysterectomy

Definitions for chapter "Hematochezia (without IBD). Patient hemodynamically stable"

Hematochezia (without IBD). Patient hemodynamically stable
Passage of bright red or maroon blood from the rectum.

Hemodynamically stable patient
No postural hypotension, no fall in blood pressure by more than 15-20 mmHg when patient sits up.

Risk factors for colorectal cancer

• Personal history of colorectal cancer or colorectal adenomas, inflammatory bowel disease,
  OR
  
• Family history of a first-degree relative with colorectal cancer or colorectal adenomas, familial polyposis syndrome, hereditary non-polyposis colorectal cancer syndrome.

Lower GI investigations FOR THIS EPISODE
Sigmoidoscopy or barium enema

Barium enema
Double contrast technique

Sigmoidoscopy
Flexible tube (60 cm)

Potential lower GI bleeding source
Hemorrhoids, fissure, bleeding diverticula, vascular malformation (AVM), polyp, tumor, colitis diagnosed by barium enema, sigmoidoscopy or colonoscopy within the last 3 months.

Definition for chapter "Lower abdominal symptoms"

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 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 or colorectal adenomas, inflammatory bowel disease,
  OR
  
• Family history of a first-degree relative with colorectal cancer or colorectal adenomas, familial polyposis syndrome, hereditary non-polyposis colorectal cancer syndrome.

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: two or less 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.

Definition for chapter "Uncomplicated chronic diarrhea"

Diarrhea with one or more of the following: > 3 loose stools/day. Infectious or malabsorption origin excluded. Without known IBD. No anemia. No bleeding. No RF for CRC. No HIV / AIDS. Chronic diarrhea >= 4 weeks duration.

Infectious work-up
Stool culture for enteric pathogens and examination for ova and parasites, immunoassay for Clostridium difficile toxin if patient was taking antibiotics within 2 weeks prior to onset of diarrhea.

Lower GI investigations
Sigmoidoscopy or barium enema since onset of lower abdominal pain or within past 5 years

Barium enema
Double contrast technique (in some countries BE may still be need widely in particular in patients with non specific abdominal symptoms)

Sigmoidoscopy
Flexible tube (60 cm)

Definitions for chapter "Evaluation of known ulcerative colitis (UC), excluding surveillance for colorectal cancer."

Documented by one or more of the following: endoscopic appearance, mucosal biopsy, operative report with pathology AND infectious cause excluded.

Extension of UC
Evaluation of the extension of the disease (proctitis, pancolitis, left-sided colitis) with no previous colonoscopy done.

Previous investigation
Sigmoidoscopy performed within the last 3 months and since symptoms began, recurred or worsened.

Sigmoidoscopy
Flexible tube (60 cm)

Current therapy
Daily treatment for at least 14 days with one or more of the following: 5-ASA (enema, suppositories or oral), sulfasalazine, topical steroids
OR
Daily prednisone for at least 2 weeks
OR
Daily treatment with one of the following for at least 60 days: azathioprine, cyclosporine, 6-MP.

Definitions for chapter "Evaluation of known Crohn's disease (CD), excluding surveillance for colorectal cancer."

Crohn's disease (CD)
Documented with compatible symptoms, confirmed by barium radiography or CT, without Documented by one or more of the following: endoscopic appearance, mucosal biopsy, radiography, operative report with pathology AND infectious cause excluded.

Extension of CD
Evaluation of the extension of the disease with no previous colonoscopy done.

Previous investigation
SBFT (small bowel follow-through) or entero-CT / IRM performed within the last 3 months and since symptoms began, recurred or worsened.

Current therapy
Daily treatment for at least 14 days with one or more of the following: 5-ASA (enema, suppositories or oral), sulfasalazine, or topical steroids
OR
Daily prednisone for at least 2 weeks
OR
Daily treatment with one of the following for at least 60 days: azathioprine, cyclosporine, 6-MP.

Definitions for chapter "Surveillance for colorectal cancer in patients with known inflammatory bowel disease."

Ulcerative colitis
Documented by one or more of the following: endoscopic appearance, mucosal biopsy, operative report with pathology AND infectious cause excluded.

Crohn's disease
Documented by one or more of the following: endoscopic appearance, mucosal biopsy, radiography, operative report with pathology AND infectious cause excluded.

Low-grade dysplasia
Low degree of a combination of architectural and cytological alterations such as gross distortion, hyperchromasia, enlarged nuclei, large nucleoli, loss of cellular polarity confined within the basement membrane of the glands in which it arose

High-grade dysplasia
High degree of architectural and cytological alterations

Definitions for chapter "Surveillance after colonic polypectomy; follow-up colonoscopy (complete colonoscopy, bowel preparation adequate, patient asymptomatic, life expectancy >10 years). Familial polyposis, HNPCC and hyperplastic polyposis syndrome excluded."

Low risk adenomas