Evaluation Of Chronic Abdominal Pain Research Articles

S3631 March of the Eosinophils: A Case of Eosinophilic Gastroenteritis, Immune Thrombocytopenia, and Iron Deficiency Anemia

Introduction: Eosinophilic gastrointestinal disorders (EGIDs) refer to eosinophilic infiltration of the gastrointestinal tract in the absence of secondary causes. Here, we present a case of a young male with immune thrombocytopenia (ITP) and biopsy-proven eosinophilic gastroenteritis that developed iron-deficiency anemia. Case Description/Methods: A 16-year old male with a past medical history significant for autism, ITP, melanoma, allergic rhinitis, and eosinophilic esophagitis presented for evaluation of chronic abdominal pain. He had an EGD in April 2018 that revealed white exudates at the gastroesophageal junction, scattered erosions in the gastric body and fundus, severe antral gastritis, and scattered erosions noted throughout the duodenal bulb. Biopsies were taken and revealed distal eosinophilic esophagitis (greater than 50/HPF), eosinophilic gastritis, and chronic inflammation of the duodenal bulb with Brunner gland hyperplasia and villous blunting. Absolute eosinophil count was higher than 2,000/uL. Given findings of persistent inflammation despite a six-food elimination diet, the patient was started on oral Budesonide, a proton-pump inhibitor, and an H2 receptor blocker. In March 2020, a repeat surveillance EGD with biopsy revealed the duodenum was free of inflammation or other diagnostic abnormalities. Roughly 28 eosinophils/HPF were present in the gastric cardia near the GEJ, and numerous eosinophils remained in the other gastric tissues sampled. B udesonide was discontinued due to patient intolerance. In early 2021, the patient was found to have microcytic anemia. Further Hematologic evaluation revealed low folate and iron levels. He was started on supplemental iron and folic acid, leading to resolution of the anemia. Iron and folate deficiency was believed to be secondary to malabsorption caused by EGE. (Figure) Discussion: Eosinophilic gastrointestinal diseases remain a rare and underexplored clinical entity. While its pathophysiology is not fully understood at this time, TH2 mediated activation of B-cells and subsequent stimulation of eosinophils locally appears to be at play. Given ITP has a TH1 predominant cytokine profile, it is unclear if there is a causal association between the two. Diagnosis of EGID necessitates histological evidence of eosinophilic infiltration of the GI tract in the absence of secondary causes or infiltration elsewhere. Dietary modification to eliminate food allergens is a reasonable initial treatment, glucocorticoids remain the mainstay of pharmacotherapy at this time.Figure 1.: Cross-section of gastric tissue stained with hematoxylin and eosin demonstrating prominent eosinophils (greater than 100 per high-power field) within the lamina propria and gastric epithelium with associated epithelial injury.

S2334 Incidentally Diagnosed Triple Cancers Within 2 Years: A Novel Case of Rare Metachronous Cancers, Renal Cell Carcinoma, Cholangiocarcinoma, and Squamous Cell Carcinoma of the Gastroesophageal Junction

Introduction: The gastrointestinal (GI) tract is involved in many familial cancer syndromes usually involving the colon or stomach. We present a patient with 3 rare cancers that were detected within a span of 2 years in a single individual: clear cell renal cell carcinoma (ccRCC), cholangiocarcinoma (CCA), and esophageal squamous cell carcinoma (SCC); a combination not previously described in the literature Case Description/Methods: A 50-year-old male with a history of ccRCC, GERD, and CCA was admitted for evaluation of chronic abdominal pain during chemotherapy for CCA. Regarding his cancer history, ccRCC was incidentally diagnosed 18 months prior on a CT scan for diverticulitis. He underwent a left partial nephrectomy. Surveillance CT imaging 6 months after surgery revealed new incidental liver lesions. Biopsies confirmed metastatic CCA and he started chemotherapy. He noted a 15-year history of episodic abdominal pain and vomiting with no dysphagia or weight loss. Upper endoscopy 16 months prior was normal. He was a former smoker, drank alcohol a few times per month, used marijuana daily, and used cocaine rarely. His family history was significant for multiple cancers at a young age on his maternal side of unknown type. Physical exam showed diffuse abdominal tenderness, worse in the epigastrium without guarding. Labs showed mild anemia, normal BMP/LFTs, and negative H. pylori stool antigen. Upper endoscopy found nodularity adjacent to the esophagogastric junction (EGJ) with abnormal pit pattern under narrow band imaging (Figure). Biopsies confirmed invasive SCC. Staging endoscopic ultrasound showed T3N3 EGJ SCC. He was referred to oncology to discuss treatment options. Genetic testing was positive for BAP1 tumor predisposition syndrome (BAP1-TPDS) Discussion: A review of published literature did not yield a previous description of this combination of cancers in a single individual. BAP1-TPDS is an uncommon autosomal dominant syndrome caused by germline mutation in a tumor suppressor gene. Patients typically present with melanocytic tumors or malignant mesotheliomas but are at risk for RCC, hepatocellular carcinoma, meningioma and CCA. Literature has not revealed esophageal SCC to be associated. In addition to the incidental nature and timing of diagnosis of all 3 of these cancers within a short period of 2 years, the EGJ involvement is unusual. This case suggests atypical EGJ-SCC may be considered as part of the BAP1-TPDS tumor spectrum and warrant additional screening for at-risk individuals.Figure 1.: Left panel showing abnormal nodular mucosa adjacent to the gastro-esophageal junction under high-definition white light imaging. Right panel showing the same area under narrow band imaging.

Neoplasia mucinosa apendicular

Appendiceal mucinous neoplasms are rare and represent 0.2-0.7% of all appendectomies. They usual present as an incidental finding. The diagnosis can be made during the evaluation of chronic abdominal pain in the right lower quadrant or may emerge in the pathology report in the setting of an acute appendicitis.Appendectomy is the treatment of choice and care must be taken to avoid perforation of the appendix with dissemination of neoplastic cells or mucus into the peritoneum and thus prevent the development of pseudomyxoma peritonei.

English

BACKGROUND Mesenteric lymphadenitis (MLN) is found commonly associated with children having chronic abdominal pain, but its significance is rarely mentioned in literature. Mesenteric lymphadenitis is the inflammation of the mesenteric lymph nodes that drain the gastrointestinal tract. The present study was undertaken to assess the prevalence and significance of mesenteric lymphadenopathy among children with chronic abdominal pain (CAP). METHODS This is a single center retrospective case control study conducted in the department of paediatrics of a private medical college in Puducherry. Data was obtained from the records over a period of past 24 months. Cases were defined as 5 - 15 years aged children presenting with chronic abdominal pain. Controls were defined as 5 - 15 years aged children who were subjected to abdominal ultrasonography for reasons other than abdominal pain. Records over past 24 months were studied and for uniformity of analysis, a total of 100 children aged 5 - 15 years, were included in both the groups. Data from the case records was analysed retrospectively to calculate the prevalence of mesenteric lymphadenitis in both the groups. RESULTS Chronic abdominal pain was almost equal in both sexes with a male : female ratio of 0.9 : 1. In our study, the incidence of significant MLN among children with chronic abdominal pain was 89 % [n = 89, out of 100 cases] and was 26 % among controls [n = 26, out of 100 controls]. CONCLUSIONS This study showed that MLN is one of the most common findings in children with CAP with higher incidence among cases than controls and is statistically significant. Abdominal ultrasonography is a useful tool in the evaluation of CAP to rule out organic causes. KEYWORDS Chronic Abdominal Pain (CAP), American Academy of Paediatrics (AAP), Mesenteric Lymphadenopathy [MLN], Recurrent Abdominal Pain (RAP)

A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI: A Prospective Cohort Study

Chronic abdominal pain develops in 11-20% of patients undergoing abdominal surgery, partly owing to post-operative adhesions. In this study we evaluate results of a novel diagnostic and therapeutic approach for pain associated with adhesions. Prospective cohort study including patients with a history of abdominal surgery referred to the outpatient clinic of a tertiary referral center for the evaluation of chronic abdominal pain. Subgroups were made based on outcome of adhesion mapping with cine-MRI and shared decision making. In operatively managed cases, anti-adhesion barriers were applied after adhesiolysis. Long-term results for pain were evaluated by a questionnaire. A total of 106 patients were recruited. Seventy-nine patients had adhesions on cine-MRI, 45 of whom underwent an operation. Response rate to follow-up questionnaire was 86.8%. In the operative group (Group 1), the number of negative laparoscopies was 3 (6%). After a median of 19 (range 6-47) months follow-up, 80.0% of patients in group 1 reported improvement of pain, compared with 42.9% in patients with adhesions on cine-MRI who declined surgery (group 2), and 26.3% in patients with no adhesions on cine-MRI (group 3), P = 0.002. Consultation of medical specialists was significantly lower in group 1 compared with groups 2 and 3 (35.7 vs. 65.2 vs. 58.8%; P = 0.023). We demonstrate long-term pain relief in two-thirds of patients with chronic pain likely caused by adhesions, using cine-MRI and a shared decision-making process. Long-term improvement of pain was achieved in 80% of patients who underwent surgery with concurrent application of an anti-adhesion barrier.

Carnettʼs Sign: An Easy Tool That Saves Unnecessary Expenses in the Evaluation of Chronic Abdominal Pain

Carnettʼs Sign: An Easy Tool That Saves Unnecessary Expenses in the Evaluation of Chronic Abdominal Pain

Recurrent Abdominal Pain in 2 Years Old Girl due to Hereditary Angioedema

There is considerable variation among children in their perception and tolerance for abdominal pain. Thismake the evaluation of chronic abdominal pain is difficult (1). Hereditary angioedema is a raredifferential diagnosis to cause abdominal pain in 2 years old child. We report a 2 years old girl withrecurrent abdominal pain that require recurrent visit to ER without accompanying skin swelling whosediagnosis as hereditary angioedema and it is the first case reported at this age

Identifying potential pediatric chronic abdominal pain triggers using ecological momentary assessment.

The purpose of this study was to evaluate associations between pediatric chronic abdominal pain and a variety of presumed triggers for abdominal pain in real-time. Associations were explored at the level of patient self-perception and empirically across the group. Thirteen patients (8 to 17 years) presenting for initial subspecialty evaluation of chronic abdominal pain at a large Midwestern children’s hospital were asked to complete an electronic diary questionnaire on a handheld mobile device 3 times daily for 14 days. This questionnaire assessed for the presence/absence of pain and a wide variety of presumed triggers for abdominal pain. Participants also completed a survey at preand postmonitoring that asked them to check off whether they believed that any of the presumed triggers were actual triggers for them personally. Participants self-identified a few pain triggers consistently across the group. Group-based analyses of diary data revealed several predictive relationships, including some not consistently self-identified by participants. Several variables (e.g., acute illness, drinking soda, eating spicy or fried foods, consuming seafood, nuts, or chocolate, experiencing negative affect, getting fewer hours of sleep, and increased pollen count) appear reliably associated with onset of pain across individuals from among the array of presumed triggers investigated. Clinical treatment for pediatric chronic abdominal pain should include consideration and discussion of these triggering relationships. Future work in this line of research may help to support the development of personalized treatment approaches for this complex condition.

Su1772 Diagnostic Yield of Colonoscopy in Children With Chronic Abdominal Pain

Colonoscopy is often performed in the evaluation of chronic abdominal pain (CAP) in children. However, the diagnostic yield in this clinical scenario is unknown.

Metastatic Small Cell Lung Carcinoma Masquerading as Recurrent Acute Pancreatitis

Purpose: A 57-year-old Caucasian female was referred to the gastroenterology service at our institution for evaluation of chronic abdominal pain and multiple admissions for recurrent attacks of acute pancreatitis. Clinically, the patient suffered from severe mid-epigastric pain with nausea, emesis, lumbago, and stools consistent with steatorrhea. Her constellation of symptoms also included unintentional weight loss of 35 pounds in 6 months and anorexia. She denied any history of diabetes mellitus, hyperlipidemia, or alcohol use, or a family history of gastrointestinal or other malignancy. She was, however, an avid tobacco user and was status-post cholecystectomy. On physical exam, the patient was afebrile with a benign, non-surgical abdomen with mild epigastric tenderness to palpation without obvious masses, hepatosplenomegaly, ecchymosis, icterus, jaundice, or nodules. Labs were consistent with transaminasemia (elevated AST and ALT >3 times upper limit of normal), cholestasis (alkaline phosphatase over 400), mild hyperbilirubinemia, and hyperlipasemia (over 400). Previous computed tomography of the abdomen with intravenous contrast was negative for pancreatic parenchymal changes, biliary dilation, or mass; on this admission, a repeat study revealed mild pancreatic ductal dilation and a questionable 1.3-cm focal hypodensity within the pancreatic body. Subsequent magnetic resonance cholangiopancreatography showed multifocal hypodense lesions throughout the pancreas suspicious for neoplasm, and the patient underwent esophagogastroduodenoscopy with endoscopic ultrasound and fine needle aspiration to rule out lymphoma versus neuroendocrine tumor of the pancreas. Final pathology indicated the lesions to be small cell lung cancer with neuroendocrine features. Although previous chest radiography was negative, a subsequent computed tomography of the chest revealed a right hilar prominence/mass and mediastinal lymphadenopathy. Hematology-oncology facilitated the insertion of a port for chemotherapy, and the patient received and tolerated her first course without incident prior to discharge. Metastatic disease to the pancreas is seldom included in the differential diagnosis of the etiology of pancreatitis due to its rare occurrence. This case represents a rare occurrence of small cell lung neoplasm with metastasis to the pancreas, and illustrates the need for a higher index of suspicion for possible neoplastic process in patients with pancreatitis, especially in the instance of recurrent attacks, chronic pancreatitis, and attacks recalcitrant to standard therapy.

55-jähriger Patient mit abdominellen Schmerzen und Fieber

A 55-year-old man was admitted for evaluation of chronic abdominal pain and fever. Computed tomography demonstrated a retroperitoneal inflammatory process involving the mesenteric root. Adipose tissue biopsy showed panniculitis mesenterica with granulomas. Further examinations confirmed the diagnosis of plasmocytoma type IgG kappa. Treatment with steroids (prednisolone), resulted in immediate improvement of pain and fever. Mesenteric panniculitis represents a paraneoplastic syndrome associated with non-Hodgkin lymphoma.

Intra-abdominal insertion of sewing needles: a rare method of child abuse

The insertion of sewing needles into the abdominal cavity is an uncommon form of child abuse. We report a 2-and-a-half-year-old boy with 2 intra-abdominal sewing needles that were discovered during the evaluation of chronic abdominal pain and vomiting. This case report illustrates the wide range with which abusive injury can present in children. Pediatricians need to be alerted to this newly-recognized and the increasing form of child abuse so that they examine and diagnose their patients appropriately.

Laparoscopic transgastric removal of an eroded adjustable gastric band

A 48-year-old woman had undergone placement of a laparoscopic adjustable gastric band (LAGB) 5 years ago at another facility. Her preoperative weight was 138 kg, with a body mass index (BMI) of 52 kg/m. A year later, she developed a subcutaneous port site infection. The port was removed at that time, but the band was left in place. She subsequently presented with generalized peritonitis and underwent exploratory laparotomy without removal of the gastric band. She was referred to us after she was found to have an eroded band on esophagogastroduodenoscopy (EGD) done for evaluation of chronic abdominal pain. Her weight at the time of referral to us was 104 kg, with a BMI of 39 kg/m. We performed a preoperative EGD with confirmation of band erosion with a significant amount of band seen intragastrically, but we were unable to visualize the buckle of the band. With this finding, we chose to proceed with laparoscopic removal of the eroded band instead of attempting endoscopic removal. At surgery (Video 1), pneumoperitoneum was achieved using a spring-loaded needle, and access to the peritoneal cavity was gained with the optical trocar. Additional 5-mm trocars were placed, 2 in the left upper quadrant and 1 in the right upper quadrant for placement of the liver retractor. Because of her history of generalized peritonitis from an infected and eroded LAGB, we had to undertake an extensive adhesiolysis freeing the omentum and liver from the anterior abdominal wall. We dissected along the anterior portion of the stomach toward the area of the gastroesophageal junction where the eroded band should have been but could not clearly identify it. The posterior wall of the stomach was not involved with a significant

Sa1189 Use of Spiral Enteroscopy for Evaluation of Chronic Abdominal Pain in Patients After Gastric Bypass Surgery.

Sa1189 Use of Spiral Enteroscopy for Evaluation of Chronic Abdominal Pain in Patients After Gastric Bypass Surgery.

A RARE CAUSE OF INVOLUNTARY WEIGHT LOSS IN AN OLDER WOMAN: ENDOMETRIAL TUBERCULOSIS

To the Editor: Tuberculosis (TB) frequently presents with pulmonary involvement and is one of the oldest and the most fatal infectious disease.1 Genitourinary TB is a rare situation, although it is commonly seen secondary to pulmonary involvement, but the increasing rate of infection with the human immunodeficiency virus worldwide has led to greater clinical use of immunosuppressive therapies, and the development of multidrug resistance in people treated for TB is thought to be the possible reason. People with chronic kidney disease (CKD) also have a greater risk TB infection than the general population.2 A 68-year-old woman was referred to our clinic with complaints of fever, weight loss of 10 kg, and abdominal pain for 3 months. She had been diagnosed with CKD, caused by hypertensive nephropathy, 2 years earlier. She was an ex-smoker. Her physical examination did not reveal any pathological findings. Laboratory analyses indicated leukocytes, 9,000/μL; erythrocyte sedimentation rate, 80 mm/h; blood urea nitrogen, 53 mg/dL; and creatinine, 1.6 mg/dL. Creatinine clearance was 32 mL/min per 1.73m2. Abdominal ultrasonography indicated an increase in wall thickness of the uterus. Probe curettage material of the nulligravid patient demonstrated granulomatous inflammation (Figure 1). She had two scars of Bacillus Calmette-Gurin vaccine; tuberculin skin test was positive and measured 21mm. Her chest X-ray was within the normal range. She was diagnosed with genitourinary TB and initiated antituberculosis therapy of isoniazid (300 mg/d), rifampicin (600 mg/d), ethambutol (1,500 mg/d), and pyrazinamide (2,000 mg/d), which was modulated for renal failure. Her abdominal pain improved after the first 2 weeks of the treatment. Endometrial biopsy showing granulomatous inflammation. The risk of TB is high in individuals with CKD.3 Nutritional status, systemic diseases, and age are the basic features of TB susceptibility. Latent diseases such as TB should be considered in the evaluation of chronic abdominal pain and weight loss. In individuals with chronic renal diseases, endometrial TB is a rare cause of involuntary weight loss, which is associated with mortality.4 Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Alper Azak, Bülent Huddam, and Fatma Kılıç: acquisition of data, preparation of manuscript. Gülay Koçak: acquisition of data, preparation of manuscript, correction of the draft manuscript. Murat Duranay: correction of the draft manuscript and approval for submission. Sponsor's Role: No sponsorship.

Impact of Endoscopy on Management of Chronic Abdominal Pain in Children

Endoscopy is performed frequently in children with chronic abdominal pain (CAP), but its impact on clinical management is unclear. We aimed to examine the frequency of changes in immediate medical management resulting from endoscopy with biopsy evaluating CAP in children. We conducted a prospective cross-sectional study to assess the frequency and determinants of management change in children who underwent endoscopy for evaluation of chronic abdominal pain. Patients were screened prior to undergoing endoscopy according to inclusion criteria. Each endoscopist was contacted prior to performing endoscopy and recorded a management plan if endoscopy could not be performed. These responses were compared with management recommendations by the same physician after the endoscopy and review of histopathology. We analyzed 92 endoscopic procedures [63 esophagogastroduodenoscopies (EGDs) and 29 EGD/colonoscopy] performed in 92 children (mean age 11.6 years) with CAP. Overall, gastroenterologists changed management plans post endoscopy in 61 (66.3%) patients. In 46 (75%) of these cases, management was changed as a direct result of endoscopic or histologic findings. Overall, management changes included: reassurance in 17 cases, dietary changes in 6 cases, proton pump inhibitor (PPI) trial in 11 cases, antispasmodic/anticholinergic medication trials in 4 cases, and food allergy testing in 4 cases. No significant association was found between management changes and type of histologic findings or presence of alarm symptoms. The overall rate of management change after endoscopic evaluation in children with CAP was approximately 66% (61/92). Management outcome was not associated with type of histologic findings.

The role of endoscopy in the management of patients with diarrhea

The role of endoscopy in the management of patients with diarrhea

Endoscopic Ultrasound in the Evaluation of Patients with Chronic Abdominal Pain

Purpose: The diagnostic evaluation of chronic abdominal pain can be difficult. The role of endoscopic ultrasound (EUS) in the work-up of chronic abdominal pain has not been defined. The purpose of this study is to determine the diagnostic yield of EUS in unexplained, chronic abdominal pain. Methods: Retrospective study of veteran patients referred for EUS for evaluation of chronic abdominal pain over a two year period. Patients were included if they had pain or discomfort within the upper abdomen for at least 6 months, did not respond to a 4-week trial of a proton pump inhibitor, and had negative work-up including computer tomography (CT) within 1 year prior to EUS. All patients underwent esophagogastroduodenoscopy (EGD) immediately prior to EUS examination during the same procedure using the Olympus GIF-H180 upper endoscope. EUS was performed using the Olympus GF-UE160 radial echoendoscope at a frequency of 7.5 MHz. A diagnosis of chronic pancreatitis was made when ≥ 5 EUS features were present. Statistical analysis was performed using the student's t-test and univariate analysis. Results: Seventeen patients (15 men, mean age 53.7 yrs) were included. Mean duration of abdominal pain was 79.3 months. EGD performed immediately prior to EUS showed no evidence of peptic ulcer disease, esophagitis or cancer. Two patients had significant extrinsic compression of the stomach on EGD. EUS showed evidence of chronic pancreatitis in 5 patients (29.4%). Two patients had extrinsic compression of the stomach caused by a markedly enlarged spleen (n=1), and an enlarged left lobe of the liver (n=1). One patient had cholelithiasis not seen on prior CT scan. Three patients had EUS findings that did not meet criteria for chronic pancreatitis. Two patients had benign appearing mediastinal lymphadenopathy. Four patients had no abnormalities on EUS. The overall diagnostic yield of EUS was 47% (8/17). When comparing patients with EUS evidence of chronic pancreatitis (5/17) to those without chronic pancreatitis (12/17), patients with chronic pancreatitis were more likely to be African American (p=0.002), have epigastric abdominal pain (p=0.037), and have weight loss (p=0.027). Patients without chronic pancreatitis were more likely to have a psychiatric illness (p=0.029). There was no significant difference among the two groups in age, alcohol use, tobacco use, duration of pain, history of diabetes, amylase, lipase, and liver function tests. Conclusion: EUS is useful in the work-up of unexplained, chronic abdominal pain. The diagnostic yield of EUS was 47% in our veteran population. EUS should be considered early in the diagnostic evaluation of select patients with chronic abdominal pain.

Diagnostic yield of oesophagogastroduodenoscopy in children with abdominal pain.

Abdominal pain is the most common indication for oesophagogastroduodenoscopy (OGD) in children. However, existing studies examining the diagnostic outcomes of OGD in children with abdominal pain are limited. To examine the diagnostic yield of OGD with biopsy in the evaluation of abdominal pain and to describe the endoscopic and histological findings in patients undergoing OGD for abdominal pain of unclear aetiology. We performed a retrospective cross-sectional cohort study in children under 18 years of age who had OGD for the primary indication of abdominal pain, at Texas Children's Hospital and Children's Hospital of The King's Daughters from 1 January 2002 to 30 June 2005. Overall, OGD was diagnostic in 454 (38.1%) of the 1191 procedures, including reflux oesophagitis (23%, n = 271), Helicobacter pylori infections (5%, n = 55), peptic ulcers (3%, n = 32), eosinophilic oesophagitis (2%, n = 25), celiac disease (1%, n = 9) and Crohn's disease (0.5%, n = 7). Male gender, older age, elevated C-reactive protein and vomiting were associated with increased diagnostic yield. Our findings suggest that OGD is valuable for the evaluation of chronic abdominal pain in children, with a diagnostic yield of 38%. The majority of alarm symptoms and routine laboratory tests are not significantly associated with diagnostic yield.

Appropriateness of colonoscopy in Europe (EPAGE II) – Functional bowel disorders: pain, constipation and bloating

To summarize the published literature on assessment of appropriateness of colonoscopy for the investigation of functional bowel symptoms, and report appropriateness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. A systematic search of guidelines, systematic reviews and primary studies regarding the evaluation and management of functional bowel symptoms was performed. The RAND/UCLA Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Much of the evidence for use of colonoscopy in evaluation of chronic abdominal pain, and/or constipation and/or abdominal bloating is modest. Major limitations include small numbers of patients and lack of adequate characterization of these patients. Large community-based follow-up studies are needed to enable better definition of the natural history of patients with functional bowel disorders. Guidelines stress that alarm features ("red flags"), such as rectal bleeding, anemia, weight loss, nocturnal symptoms, family history of colon cancer, age of onset > 50 years, and recent onset of symptoms should all lead to careful evaluation before a diagnosis of functional bowel disorder is made. EPAGE II assessed these symptoms by means of 12 clinical scenarios, rating colonoscopy as appropriate, uncertain and inappropriate in 42 % (5/12), 25 % (3/12), and 33 % (4/12) of these, respectively. Evidence to support the use of colonoscopy in the evaluation of patients with functional bowel disorders and no alarm features is lacking. These patients have no increased risk of colon cancer and thus advice on screening for this is not different from that for the general population. EPAGE II criteria, available online (http://www.epage.ch), consider colonoscopy appropriate in patients of > 50 years with chronic or new-onset bowel disturbances, but not in patients with isolated chronic abdominal pain.