Alexander Gerald Chen1 Kheng-Jim Lim2 1Undergraduate, Columbia University, New York City, NY 2Division of Gastroenterology and Hepatology, Rutgers-Robert Wood Johnson Medical School, New Brunswick NJ
Based on the Greek word …t….. (kriterion), “criterion” is defined as the standard upon which a decision or judgment is based. The medical field abounds in criteria to aid in the diagnosis of diseases. Traditionally, classification schemes were named after individuals, giving rise to numerous medical eponyms (e.g. Ranson’s criteria), however, of late, eponyms have been abandoned and toponyms, names based on places, have come into vogue (e.g. the Atlanta criteria). No particular rule appears to guide this nomenclature other than the fact that a major meeting in which experts met to collaborate on the rules of the criteria. Most of the observations in modern medicine cannot be credited solely to an individual as the majority of today’s research is produced by joint effort, thus the simpler solution is use the name of the locale where the experts met and analyzed the research to formulate the guidelines.
Some of these criteria are a useful set of rules to follow in the diagnosis (e.g. the Rome Criteria) or treatment (e.g. the Toronto Consensus) of specific conditions. Similar to the utility of the instruction manual for a new piece of complex equipment, the average clinician may find the guidelines useful, as the various criteria offer a substantial road map in the diagnosis and treatment of diseases without significant deviation from the standard of good care.
The use of criteria by the practitioners of medicine is variable and depends on the popularity of the criteria and the incidence or prevalence of the disease. A criterion for diverticular disease diagnosis is thus more often used than one for endoscopic grading of esophagitis. The authors, realizing these limitations, aim to summarize the criteria in gastroenterology and assess their impact by using the citation indexing database “Web of Science” managed by Thomson Reuters.
All accompanying images are in the public domain and a world map is provided for reference.
Amsterdam Criteria for Lynch Syndrome
The authors of the Amsterdam criteria1 for hereditary non-polyposis colorectal cancer (ICG-HNPCC) or Lynch Syndrome came together with the goal of creating a simple system to help clinicians identify Lynch Syndrome for which there was little data about at the time.
A patient is said to have Lynch Syndrome if he or she
meets all the following criteria:
3 relatives with colorectal cancer (one of which is a first-degree relative of the other two)
= 2 successive generations affected
= 1 of the three diagnosed before age 50
Citations for “Vasen HFA, Mecklin J-P, Meera Khan P, Lynch HT. The international collaborative group on hereditary non-polyposis colorectal cancer (ICG- HNPCC). Dis Colon Rectum 1991; 34: 424-425”
The Amsterdam Criteria was the result of the effort of 30 authorities in their respective fields from eight different countries who met in Amsterdam in 1990.
Atlanta Classification for Pancreatitis
Considering the many forms and complications of acute
pancreatitis, it is no surprise that many classification
systems for acute pancreatitis existed before the creation
of what is now known as the Atlanta Criteria.2 This
system set itself apart by being intended for clinical
practicality and it defines many of the terms associated
with acute pancreatitis.
Acute Pancreatitis The inflammation of the pancreas with possible involvement of other tissue or distant organ systems.
Severe Acute Pancreatitis Acute pancreatitis associated with organ failure and possibly local complications such as necrosis, abscess, or pseudocyst.
Mild Acute Pancreatitis Acute pancreatitis with minimal organ dysfunction and uneventful recovery. No indicators for severe acute pancreatitis present.
Acute Fluid Collections Occur early in acute pancreatitis, located within or close to the pancreas and always lack a wall of granulation or fibrous tissue.
Pancreatic Necrosis The diffuse or focal areas of nonviable pancreatic parenchyma, typically associated with peripancreatic fat necrosis.
Acute Pseudocysts A collection of pancreatic fluid enclosed by a wall of fibrous or granulation tissue, the result of acute pancreatitis, pancreatic trauma or chronic pancreatitis.
Pancreatic Abscess A circumscribed intra-abdominal collection of pus, usually near the pancreas, containing little or no pancreatic necrosis, the result of acute pancreatitis or pancreatic trauma.
Citations for “Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the international symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993; 128: 586-90.”
This consensus was the result of the effort of 40 experts in their respective medical fields from around the world coming together in Atlanta, Georgia to decide upon these definitions.
Chicago Criteria for Achalasia
With the development of high resolution manometry
(HRM), clinicians are able to more accurately measure
the pressurization of the esophagus during peristalsis.
However, there was no agreed upon usage of HRM to
diagnosis motility disorders until the study published
that is now referred to as the Chicago Criteria,3 which
is summarized as follows:
Type I Minimal esophageal pressurization
Type II Absent peristalsis with esophageal pressurization
Type III Lumen destroying spasm on HRM
Citations for “Pandolfino JE, Ghosh SK, Rice J, Clarke JO, Kwiatek MA, Kahrilas PJ. Classifying esophageal motility by pressure topography characteristics: a study of 400 patients and 75 controls. Am J Gastroenterol 2008; 108: 27-37”
The data for the study leading to the Chicago Criteria came from the Northwestern Memorial Hospital manometry laboratory located in Chicago, Illinois.
Glasgow Criteria for Pancreatitis
The Glasgow scoring system4 is intended to determine the severity of pancreatitis within 48 hours of a patient’s admission. It is actually a modification of a scoring system by Imrie et al.5 meant to increase accuracy and simplicity.
The scoring system is a set of possible factors that
the patient may exhibit. Three or more factors defines
Age > 55
White Blood Count > 15,000/µl
Blood Glucose > 180 mg/dl
PaO2 < 60 mmhg
Serum Calcium < 8 mg/dl
Serum Albumin < 3.3 g/dl
Blood Urea Nitrogen > 45 mg/dl
Lactate Dehydrogenase > 600 U/L
Citations for “Blamey SL, Imrie CW, O’Neill J, Gilmour WH, Carter DC. Prognostic factors in acute pancreatitis. Gut 1984; 25”
This criterion was put forth by Glasgow University and the Royal infirmary of Glasgow.
Glasgow Classification of Alcoholic Hepatitis
Although grading systems for alcoholic pancreatitis have existed before the Glasgow alcoholic hepatitis score6, the authors of this classification system wanted to create a clinically useful system that more accurately identified patients with higher mortality risks in order to better inform treatment decisions.
Each factor is given a score of 1, 2 or 3. Then, all the factor scores are combined for a total score. A total score greater than or equal to 9 is associated with a poor prognosis and increased risk of mortality.
Citations for “Forrest EH, Evans CDJ, Stewart S et al. Analysis of factors predictive of mortality in alcoholic hepatitis and derivation and validation of the Glasgow alcoholic hepatitis score. Gut 2005; 54: 1174-9”
The data for this study was obtained from patients presenting with alcoholic liver disease to the Glasgow Royal Infirmary and the Victoria Infirmary which is also in Glasgow.
Los Angeles Criteria for Esophagitis
The creation of the Los Angeles criteria7 for esophagitis was intended to implement a universally accepted standard for grading the severity of gastroesophageal reflux disease (GERD). This system was intended to be easier to use and more clinically practical than the many existing classification systems for GERD.
This system allows clinicians to interpret endoscopically
observed peptic lesions and grade the severity of the
GERD into one of the following categories:
Grade A 1 ≤ mucosal breaks, ≤ 5 mm long that does not extend between tops of two mucosal folds
Grade B 1 ≤ mucosal breaks, >5 mm long that does not extend between tops of two mucosal folds
Grade C 1 ≤ mucosal breaks, continuous between tops of = 2 mucosal folds but involves < 75% of esophageal circumference
Grade D 1 ≤ mucosal breaks that but involves = 75% of esophageal circumference
Citations for “Armstrong D, Bennett JR, Blum AL., et al. The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology 1996; 111: 85-92”
The study leading to this criterion was performed at the symposium of the World Congress of Gastroenterology in Los Angeles, earning its name.
Marseille Classification of Pancreatitis
The main goal of the Marseille Symposium was to clarify the ambiguity in the literature concerning terms such as “Acute pancreatitis” which writers defined differently. The Marseille classification sought to solve these problems with a single well defined set of criteria for classifying pancreatitis. It has been noted in at least one study8 on pancreatitis how difficult it is to obtain the official Marseille publication, which was also apparent when trying to obtain an originating document for the purposes of the citation history. As a result, what seemed to be the most widely used document9 based on the Marseille classification was used for the purposes of the citation history.
The Marseille classification of pancreatitis subdivided
pancreatitis into “acute” and “chronic”
Acute Pancreatitis Defined as restitution of the pancreas when the cause of the disease is removed, such as a gallstone.
Chronic Pancreatitis Defined as the progression and or worsening of general lesions despite removing the source of the disease, such as alcoholism.
Citations for “Sarles H, Sarles JC, Camatte R et al. Observations on 205 confirmed cases of acute pancreatitis, recurring pancreatitis, and chronic pancreatitis. Gut 1965. 6; 545”
The Marseille symposium on pancreatitis took place in Marseille, Italy.
Milan Criteria for Liver Transplantation
The Milan criteria10 was developed to analyze the effectiveness of liver transplantation as a treatment for unresectable hepatocellular carcinomas in patients with cirrhosis. The need for such a criteria was recognized because of the limited supply of livers for transplantation and the uncertainty of transplantation as a viable treatment.
The Milan criteria considers someone with
unresectable hepatocellular carcinomas eligible for
liver transplantation if they fall into one of these two
Number of Tumors
Each < 3 cm
Only 1 < 5 cm
Citations for “Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver transplantation for the treatment of small hepatocellular carinomas in patients with cirrhosis. N Engl J Med 1996; 334: 693-699.”
This classification system is known as the Milan criteria because multiple institutions that contributed to this study were all located in Milan, Italy. For example, the patients whose medical information was used to complete this study were all seen at the Division of Gastrointestinal Surgery of the National Cancer institute in Milan, Italy.
for Sphincter of Oddi Dysfunction
The Milwaukee criteria11 deals with overlaps in the etiology of the motor dysfunction of the sphincter of Oddi by trying to develop patient group classifications that describe the severity of their sphincter of Oddi dysfunction.
The Milwaukee system uses a scoring method,
determining the severity of a patient’s SOD.
A Biliary-like pain
B Elevated liver function tests documented = 2 times
C Delayed drainage of contrast medium at endoscopic retrograde cholangiopancreatopgraphy (ERCP)
D Dilated common bile duct with corrected diameter = 12mm at ERCP
Type I All four factors present
Type II Factor A in addition to = 1 other factors
Type III Only factor A present
Citations for “Hogan WJ, Greenen JE. Biliary dyskinesia. Endoscopy. 1988; 20: 179-183”
This criteria was formulated after an extensive study and a meeting of experts in Milwaukee, United States.
The Oslo Definitions for Celiac Disease
The incidence of celiac disease (CD) has been increasing in the United States over the past few decades, very often going undiagnosed.12 With greater recognition and literature concerning CD arising, the Oslo definitions13 seek to create a consensus concerning the definitions for the various types of this multifaceted disorder and its related terms. The Oslo definitions came about as the result of a literature review concerning CD related terms from the database PubMed.
The Oslo definitions cover a vast array of CD related terms, for simplicity only the definitions of different types
of CD are listed here.
Celiac Disease A Chronic small intestinal immune-mediated enteropathy caused by dietary gluten in genetically pre-disposed individuals.
Typical CD Gluten-induced enteropathy with signs of malabsorption. The use of this term is discouraged because “typical” implies this form of CD is the most common when in fact the presentation of CD has changed over time to include symptoms such as anemia, fatigue and abdominal pain.
Atypical CD Used only in reference to typical CD and its use is discouraged. Traditionally, this term has been used to describe patients with gluten-induced enteropathy who do not have weight loss but may have irritable bowel syndrome symptoms, liver dysfunction or gastrointestinal symptoms.
Symptomatic CD Characterized by clinically evident gastro-intestinal and/or extraintestinal symptoms resulting from gluten consumption.
Asymptomatic CD Used to describe patients who do not present common symptoms of CD
Classical CD CD defined as showing signs and symptoms of malabsorption such as diarrhea, steatorrhea, weight loss or growth failure must be present.
Non-classical CD CD presenting without signs and symptoms of malabsorption
Silent CD Equivalent to asymptomatic CD. The use of this term is discouraged.
Subclinical CD CD below the threshold of clinical detection. Often used in reference to silent CD.
Overt CD Most often used to describe clinically evident gastrointestinal or extra-intestinal symptoms. The use of symptomatic CD is encouraged as a replacement of Overt CD.
Refractory CD Describes persistent or recurrent symptoms of malabsorption and signs of villous atrophy despite a gluten free diet for man than 12 months.
Latent CD Because the authors of the Oslo definitions found 5 different definitions for Latent CD, its use is discouraged to minimize confusion.
Potential CD Refers to people with normal small intestinal mucosa but who are at a higher risk for developing CD as indicated by positive CD serology. This term is used, however, with different definitions.
Citations for Ludvigsson JF, Leffler DA, Bai JC, et al. The Oslo definitions for celiac disease and related terms. Gut 2013; 62: 43-52”
The team of 16 physicians from seven countries responsible for the Oslo definitions collaborated over the phone and internet but also had a meeting in Oslo, Norway.
Prague Criteria for Barrett’s Esophagus
The Prague classification system for Barrett’s Esophagus14 was developed in order to create one easily understood and effective method of describing Barrett’s Esophagus. Before this system, there was not only an absence of effective criteria but an abundance of ineffective methods for classifying Barrett’s Esophagus.
The Prague system consists of two components, a “C”
number and an “M” number.
Circumference (C) Describes the height above the gastroesophageal junction for which there is Barrett’s mucosa completely encircling the circumference of the esophagus.
Maximum (M) Describes the maximum height any “tongue” or continuation of the Barrett’s mucosa reaches in the esophagus.
Using this system, a description of a Barrett’s esophagus with a maximum circumferential height of 3cm and an absolute maximum height of 4cm can be abbreviated as “C3M4”.
Citations for “Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: The Prague c & m criteria. Gastroenterology 2006; 131: 1392-1399”
This criterion was first put forth at the United European Gastroenterology Week in Prague, September 2004.
Rome Criteria For Irritable Bowel Syndrome
What is referred to today as the Rome Criteria has a long history15 which makes it difficult to single out one particular paper as the “originating” paper. Because of this, both the first diagnostic criteria for irritable bowel syndrome that the Rome Criteria has been based off of and the most recent Rome Criteria are presented. The evolution of the Rome criteria is conveniently laid out by W. Grant Thompson in his article Road to Rome.15
The Manning criteria16 for IBS presents six factors
of IBS, the more of which a patient presents with the
more likely it is that he or she actually has IBS. The
six symptoms are:
1. Abdominal distention
2. Alleviation of pain by bowel action
3. More frequent stools with onset of pain
4. Looser stools with onset of pain
5. Rectal passage of mucus
6. A sensation of incomplete evacuation
The Rome III criteria17 for Irritable Bowel Syndrome
follows in the long tradition of the Rome criteria,
building upon the Rome II criteria to update diagnosis
and treatment recommendations. Concerning IBS, the
diagnostic criteria is as follows:
Recurrent abdominal pain or discomfort at least 3 days a month in the last 3 months associated with at least 2 of the following:
1. Improvement with defecation
2. Onset associated with a change in frequency of stool
3. Onset associated with a change in form (Appearance) of stool
Citations for “Manning AP, Thompson WG, Heaton
KW, Morris AF. Towards positive diagnosis of the
irritable bowel. Br Med J 1978;2:653-654”
Citations for “Longstreth G, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology 2006; 130: 1480-1491”
Sendai Consensus Guidelines for Management
of Intraductal Papillary Mucinous Neoplams
and Mucinous Cystic Neoplams of the Pancreas
The increased recognition of two types of non- inflammatory cystic lesions of the pancreas, intraductal papillary mucionous neoplams (IPMN) and mucinous cystic neoplasms (MCN), prompted the working group of the International Association of Pancreatology to put out what is now known as the Sendai consenss guidelines18 for the management of IPMN and MCN.
The Sendai consensus guidelines seek to answer 6
clinical questions with 18 subdivisions. Like the Sydney
system, there is no practical method to summarize the
Sendai consensus guidelines. Instead, the 6 areas of
IPMN and MCN management it is concerned with are
1. Definition and Classification
2. Preoperative evaluation
3. Indication for resection
4. Method of resection
5. Histological questions
6. Method of follow-up
Citations for “Tanaka M, Chari S, Adsay V, et al. International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology. 2006; 6: 17-32”
The Sendai consensus guidelines were formulated during the 11th Congress of the International Association of Pancreatology which was held in Sendai, Japan.
Sydney System for the
Classification of Gastritis
The Sydney Working Party developed the Sydney System19 in order to create a universal system that took into account the widespread use of endoscopic targeted biopsy and recognition of the H. pylori infection’s role in gastritis. It combines the etiology, topography and morphology of gastritis to create a working formula for its classification. It should be noted that The Sydney System was actually put fourth as six papers in the Journal Of Gastroenterology and Hepatology however for the purposes of this review, only the histological division was used for the citation history and criteria because it was the most frequently cited of the Sydney System papers.
The Sydney System is not easily reproducible; to do
so would be tantamount to including the entirety of
the original paper so simply the main components of
the histological division, as outlined in the paper, are
Etiology Pathogenic associations
Topography Pangastritis, gastritis of antrum, gastritis of corpus
Morphology Graded variables: Inflammation, activity, atrophy, intestinal metaplasia, H. Pylori Non-Graded variable: Non- specific, specific
Citations for “Price AB. The Sydney system: histological division. Gastroenterol. Hepatol. 1991;6: 209-22”
This criteria was the result of the efforts of the Sydney Working Party.
Toronto Consensus Guidelines
for Medical Management of
Nonhospitalized Ulcerative Colitis
Acknowledging the advancement of medical care for patients with Ulcerative Colitis (UC), the working group responsible for the Toronto consensus guidelines20 conducted a thorough and systematic literature review in order to reevaluate the management of UC.
The Toronto consensus guidelines include 34 statements on 5 classes of drugs, in addition to other conclusions.
Like the Sendai consensus guidelines, it would not be
practical to include all the statements of the Toronto
consensus here. The paper nicely summarizes its finding
in a single table, whose main categories are listed here.
1. Statements regarding 5-ASA
2. Statements regarding corticosteroids
3. Statements regarding immunosuppressants
4. Statements regarding anti-TNF therapy
5. Statements regarding other agents
Because the Toronto consensus guidelines came out last year, reporting its citation history is not practical or an accurate measure of its acceptance.
The working group met for 2 days in Toronto, Canada.