Indications and findings of oesophagogastroduodenoscopy in patients with symptoms of upper gastrointestinal disease in Eastern Regional Hospital, Koforidua, Ghana

¹University of Ghana Medical Centre Ltd, Department of Medicine, Legon, Ghana, ²University of Ghana Medical School and Korle-Bu Teaching Hospital, Accra, Ghana, ³Trust Hospital, Department of Medicine, Accra, Ghana, ⁴Eastern Regional Hospital, Department of Surgery, Koforidua, Ghana

^&Corresponding author
Amoako Duah, University of Ghana Medical Centre Ltd, Department of Medicine, Legon, Ghana

Introduction    

Prevalence of upper gastrointestinal symptoms in the general population is high [1,2]. Diseases associated with upper gastrointestinal tract (UGIT) causes morbidity and mortality globally. Peptic ulcer disease, gastroesophageal reflux disease and cancers affect millions of people worldwide [3]. Oesophagogastroduodenoscopy or upper gastrointestinal endoscopy (UGIE) provides valuable information in patients with gastrointestinal disorders and is one of the most commonly performed procedures. upper gastrointestinal endoscopy (UGIE) enables visual inspection of the mucosa of the UGIT (oesophagus, stomach, and duodenum). It also gives a better diagnostic yield over radiology particularly in the investigation of upper gastrointestinal bleeding, inflammatory conditions of the UGIT such as esophagitis, gastritis and duodenitis as well as the diagnosis of Mallory Weiss tears and vascular malformations [4]. Standard diagnostic indications for UGIE include the following: evaluation of persistent upper abdominal symptoms despite an appropriate trial of therapy; upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia, weight loss, dysphagia, anemia, persistent vomiting of unknown cause, melena stools, hematemesis); new onset dyspepsia in a patient older than 50 years of age. In addition to these, another indication is oesophageal reflux symptoms that persist or recur despite appropriate therapy.

Furthermore, is also indicated for diseases in which the presence of upper gastrointestinal pathology might modify other planned management (e.g., patients who have a history of ulcer or gastrointestinal bleeding who are scheduled for organ transplantation, long-term anticoagulant, or nonsteroidal anti-inflammatory drug (NSAIDS) therapy for arthritis and those with cancer of the head and neck). upper gastrointestinal endoscopy (UGIE) is also performed for surveillance of malignancy (familial adenomatous polyposis coli syndrome, adenomatous gastric polyps, Barrett´s oesophagus, gastric or oesophageal ulcers), screening for oesophageal varices in cirrhotic patients, occult gastrointestinal bleeding, caustic substance ingestion, and evaluation of chronic diarrhea [5]. upper gastrointestinal endoscopy (UGIE) has been found to be both effective and a relatively safe procedure that can be performed at large medical centres, small rural hospitals, outpatient clinics or even private offices [6]. Establishing causes of UGIT diseases leads to more efficient treatment and consequently decreases morbidity and mortality rates. upper gastrointestinal endoscopy (UGIE) service is offered in a few health facilities in Ghana. These include three of the teaching hospitals and a few other public or private centres, all located within major cities. There are many reports in the literature on the indications and findings of UGIE mainly from the teaching hospitals and few private hospitals [4,6,7-11]. However, limited data are available from the regional hospitals on the profile of patients attending endoscopy unit for examination in this country. This study aims to document the demographic characteristics, indications and endoscopic findings of patients undergoing UGIE at a regional hospital in Ghana.

Methods     

Study design and setting: this was a retrospective cross-sectional study of patients who had UGIE between January 2019 and February 2020 at the Eastern Regional Hospital, Koforidua in Ghana. The endoscopy unit of the Eastern Regional Hospital, Koforidua in Ghana was set up and started operating in January 2019. The unit operates on an open access policy. As such, primary care providers could directly refer without consultation with a gastroenterologist or endoscopist. They thus served patients referred from various hospitals in eastern region and its environs, including those from the regional hospital. An experienced gastroenterologist performed all the procedures.

Study population: all patients subjected to UGIE for various indications during the study period were included in the study, except those whose data were grossly incomplete, inconsistent or illegible.

Data collection: upper gastrointestinal endoscopy (UGIE) was performed using the Aohua VME-2800 videoscope. Study participants were given the option of sedation with intravenous midazolam 2 mg and 25 mg pethidine or 10% lidocaine (xylocaine) throat spray or both. H. pylori infection was determined by the rapid-urease campylobacter like-organism (CLO) test on gastric antral and body biopsies at UGIE (specificity 98%, sensitivity > 93%; Cambridge Life Sciences Ltd, Cambridge, UK). Data available from the records included the age and gender of the patients, principal indication for the procedure and primary UGIE findings. Although biopsies were taken in some instances, information on histological diagnosis was not available. Data on other investigations the patients had done prior to being sent to the endoscopic centre for UGIE were not available from the records.

Consideration: formal approval was obtained from the institutional Ethical Review Board at the Eastern Regional Hospital. An informed consent was obtained from each patient prior to the procedure.

Statistical analysis: data entry was done with Excel and analysis were done with Stata version 13 (StataCorp, College Station, TX). Descriptive statistics were expressed as frequencies and percentages.

Results     

There were 244 (42.73%) males out of the 571 patients. Their ages ranged from 7 to 94 years, with a mean age of 50.24±18.07 years (Table 1). The 50-59 years age group had the highest frequency of 131 (22.94%) patients, followed by the 60-69 year age group with 97 (16.99%) patients. Other details of the age distribution are shown in Table 1. The prevalence of H. pylori obtained by immediate CLO-testing of gastric antral and body biopsies for 548 patients out of 571 was 41.06% (Table 1). Dyspepsia was the commonest indication, occurring in 399 (69.88%) patients followed by upper gastrointestinal bleeding symptoms (hematemesis and melena stools) representing 139 (24.34%) patients (Table 2). The major endoscopic diagnoses were gastritis which occurred in 408 (71.45%) patients followed by duodenitis in 331 (57.97%) patients, duodenal ulcer in 52 (9.11%), normal findings in 43 (7.53%), oesophageal varices in 34 (5.95%), gastric ulcer in 30 (5.25%), and others as shown in (Table 3). Amongst the 399 dyspeptic patients, gastritis was the commonest finding of 315 (78.95) followed by duodenitis 264 (66.17) (Table 4). One hundred and thirty-nine (139) patients were endoscoped for upper gastrointestinal bleeding. The causes of upper gastrointestinal bleeding are given in Table 5. The commonest cause was found to be gastritis (29.50%) followed by peptic ulcer diseases (gastric and duodenal ulcer) (12.60%). No cause of bleeding was found in 7.91% of patients.

Discussion     

This study aimed to document the demographic characteristics, indications and endoscopic findings of patients undergoing UGIE at the Eastern Regional Hospital, koforidua in Ghana. Dyspepsia was the commonest indication, occurring in 399 (69.88%) patients, followed by upper gastrointestinal bleeding symptoms (24.34%). The major endoscopic diagnosis was gastritis, and gastro-duodenitis was the commonest caused of upper gastrointestinal bleeding among the patients. The prevalence of H. pylori in this study was 41.06%. For patients with dyspepsia alone as an indication for endoscopy, gastro-duodenitis was the major finding identified. Dyspepsia was the commonest indication for UGIE in the vast majority of our patients. This is similar to findings in other studies conducted in Ghana, Nigeria and other West and East African countries [9,12-16]. Other reasons for UGIE among our patients were symptoms of UGIB, screening for oesophageal varices in cirrhotic patients and recurrent vomiting. Only 2.28% of our patients underwent upper GI endoscopy for dysphagia, which is similar to 1.0% reported by study conducted in Kumasi, Ghana [9]. This differs from findings by a study conducted in Malawi by Wolf et al. [17] which reported dysphagia as the commonest indication for UGIE. Thirty-seven percent (37%) of their patients had dysphagia as an indication for UGIE. The high prevalence of oesophageal cancer in Malawi may account for this difference [18].

Moreover, endoscopy services are restricted in Malawi and as such only patients with alarm symptoms may be referred for endoscopy gastritis was the most frequent endoscopic finding in our patients, followed by duodenitis. This is comparable to previous Ghanaian studies [4,9], which reported gastritis and duodenitis as common endoscopic findings among their patients. Gastritis and duodenitis were also the commonest findings by Danbauchi et al. [12] in Zaria and Ismaila et al. [19] in Jos all in Nigeria. Duodenal ulcers were diagnosed more frequently than gastric ulcers among our patients and this is similar to study conducted by Aduful et al. [4] in Accra, Ghana. This contrasts with the findings of one study from Kumasi, Ghana, that reported more gastric ulcers than duodenal ulcers [9]. The high intake of NSAIDs and herbal medicine in the Kumasi area may account for this difference [20]. The percentage of oesophageal varices detected in this study was more than previous studies published in this country [4,9]. This is because as part of the indications for endoscopy, patients with liver cirrhosis without bleeding were referred for endoscopy to be screened for oesophageal varices in this study. Normal findings were far lower than earlier studies that have been published in this country [4,9]. The difference may probably be due to improved endoscopic techniques in identifying UGIT pathology or improved methods in clinical diagnosis over the decade. It may also be as a result of the scarce availability of endoscopy services in our catchment area, leading to people being referred appropriately for endoscopy. The use of Proton Pump Inhibitors (PPI) and stopping NSAIDs use before the procedure could also modify the findings of endoscopy, and information about this was not available in all the studies.

Gastro-duodenitis, mainly gastritis, was the commonest cause of UGIB in this study occurring in 37.41% followed by peptic ulcer disease in 21.60% of the patients. High prevalence of H. pylori and NSAIDs intake in our environment may have accounted for this. This compares well with reports from Nigerian and Ghanaian studies [21,22], where gastritis ranked first and peptic ulcer disease second. Other studies conducted in Ghana, north-eastern Nigeria and South America [4,23,24], reported peptic ulcer disease as the number one cause of UGIB. The third-commonest cause of bleeding was oesophageal varices, accounting for 12.2% of cases. This is similar to studies conducted in Nigeria and Ghana [21,22], where varices ranked third in their review, but contrasts sharply with reports from the northern part of Nigeria, Egypt, and Tanzania, where oesophageal varices were their commonest finding [25-27]. A previous study done at Korle-Bu Teaching Hospital in Ghana identified bleeding oesophageal varices as the second-commonest cause of UGIB. The prevalence of H. pylori in this study was 41.06%. This is similar to 45.2% reported by Darko et al. [10] but in contrast to 74.8% reported by Archampong et al. [28] in the country. Other previous studies in Ghana and other developing countries have also reported high prevalence of H. pylori [29,30]. Possible reasons for this difference may be the increasing use of effective eradication therapy and indiscriminate use of antibiotics, as well as PPI. This study did not exclude patients who were already on antibiotics and/or PPI, or those who had taken these drugs previously. This would have given false negative results for the H. pylori test. It may also be associated with improved sanitation among the populace [10]. Despite the decrease in prevalence of H. pylori among patients in this study, the current prevalence of 41.06% is still high compared to rates in developed countries [31]. The prevalence of H. pylori infection is associated with lower socioeconomic status, poor sanitation and basic hygiene, overcrowding and geographic location [32,33]. This may still explain the higher prevalence of H. pylori in developing countries, including Ghana.

For patients with dyspepsia alone as an indication for endoscopy, gastro-duodenitis was the major finding identified. This is comparable to similar studies conducted in Nigeria and this country [16,34]. This supports the fact that patients with dyspepsia without any alarm features should be managed by either the “test and treat” strategy for H. pylori or a trial of proton pump inhibitor (PPI) depending on the H. pylori prevalence. Because patients with dyspepsia alone without any alarm features have been found to have low prevalence of significant endoscopic findings [35]. There were limitations to this study. It was a retrospective design and had to depend on patients´ records from an endoscopy records book, which is subject to clinician and observer error. This data is from a single center and may not be representative of the general population, as this was a regional, hospital-based study in Ghana.

Conclusion     

Dyspepsia was the commonest indication for UGIE in the studied patients from a regional hospital in Ghana, and most of these patients had gastroduodenitis on endoscopy. Only few patients had normal findings. The prevalence of H. pylori in this population was low compared with most of the previous studies conducted in Ghana and other African countries. Gastritis was more common than peptic ulcer disease and oesophageal varices in patient presenting with UGIB. The outcomes of this study have implications for policy and planning. There is a need to identify the common causes of gastroduodenitis/peptic ulcer disease in the community. This will help formulate and put in place community-based interventions including education to avoid these precipitating factors.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Amoako Duah, the principal investigator of the project and Adwoa Agyei-Nkansah were involved in concept design, data analysis and drafting of the manuscript. Frempong Asafu-Adjaye, William Erzuah Arthur and Foster Amponsah-Manu assisted the principal investigator in the collection, analysis and interpretation of the data and critically revised the article. All the authors provided final approval of the article

Acknowledgments     

We are grateful to Mariam, Bernice, Ransford, Hilda, Helena and all the endoscopy nurses of Eastern Regional Hospital Endoscopy Unit, for their assistance during data collection. Special appreciation also goes to the management members, especially the medical director for their immense contribution in the setting up of the endoscopy unit and their continuous support in its operation.

Tables     

Table 1: demographic characteristics and CLO test

Table 2: indications of upper gastrointestinal endoscopy

Table 3: upper gastrointestinal endoscopy findings

Table 4: endoscopic findings of dyspeptic patients alone

Table 5: upper gastrointestinal endoscopic findings among patients presenting with UGIB (N=139)

References