Background:Pediatric patients presenting with colitis, suggestive of inflammatory bowel disease, undergo evaluation with either flexible sigmoidoscopy or colonoscopy. Our objectives were to assess current practice behavior in the evaluation of pediatric patients with colitis and to determine whether flexible sigmoidoscopy or colonoscopy was more cost-effective as the initial evaluation.Methods:Practice behavior and procedure charges were assessed using a nationwide survey, and costs for diagnostic strategies were compared using a decision analysis program.Results:The vast majority of survey respondents would proceed with colonoscopy if colitis suggestive of Crohn's disease was noted in the rectosigmoid area (81%) or if ulcerative colitis extended proximal to the rectosigmoid area (70%). If colonoscopy would follow if flexible sigmoidoscopy suggested either ulcerative colitis or Crohn's disease (67%), then colonoscopy would result in a savings of 23%. If the evaluation was predetermined to be limited to flexible sigmoidoscopy (16%), then flexible sigmoidoscopy was the cost-effective strategy with savings of 29%. If colonoscopy would follow flexible sigmoidoscopy for Crohn's colitis only (13%), there was no clear cost advantage.Conclusions:The most cost-effective strategy depends on the physician's need to know the disease location. Our survey results indicate that most physicians chose to establish the extent of disease in both ulcerative colitis and in Crohn's disease; thus initial colonoscopy would be the more cost-effective strategy. When knowledge of disease distribution is not essential for patient care, flexible sigmoidoscopy can lead to substantial cost savings.