Colonoscopy appropriateness: Really needed or a waste of time?

Technical and quality improvements in colonoscopy along with the widespread implementation of population screening programs and the development of open-access units have resulted in an exponential increase in colonoscopy demands, forcing endoscopy units to bear an excessive burden of work. The American Society for Gastrointestinal Endoscopy appropriateness guideline and the European panel appropriateness of gastrointestinal endoscopy guideline have appeared as potential solutions to tackle this problem and to increase detection rates of relevant lesions. Inappropriate indications based on either guideline are as high as 30%. Strategies based on these clinical criteria or other systems may be used to reduce inappropriate indications, thus decreasing waiting lists for outpatient colonoscopy, saving costs, prioritizing colonoscopy referrals and subsequently decreasing interval times from diagnosis to treatment. Despite the potential role of appropriateness guidelines, they have not been widely adopted partly due to fear of missing significant lesions detected in inappropriate indications. We review the main appropriateness and prioritising systems, their usefulness for detecting relevant lesions, as well as interventions based on those systems and cost-effectiveness.