Indications and findings of lower gastrointestinal endoscopy: a retrospective study in Eastern Regional Hospital, Koforidua, Ghana

¹St Dominic Hospital, Department of Medicine, Akwatia, Ghana, ²Eastern Regional Hospital, Department of Surgery, Koforidua, Ghana, ³Trust Hospital, Department of Medicine, Accra, Ghana, ⁴Pantang Hospital, Department of Medicine, Accra, Ghana

^&Corresponding author
Amoako Duah, St Dominic Hospital, Department of Medicine, Akwatia, Ghana

Introduction    

Colonoscopy is a safe and effective means of visual inspection of the large bowel from the distal rectum to the caecum and terminal ileum. LGIE may be carried out for diagnostic and or therapeutic reasons [1,2]. Colonoscopy is important in the investigation of symptoms arising from the lower gastrointestinal tract and is the gold standard for diagnosis and screening of colorectal cancer [3]. This procedure is cost effective as it can be used to obtain tissue (biopsy) and perform interventional procedures like total resection of lesion, haemostasis, dilatation etc. Other indications for colonoscopy are to investigate the cause of gastrointestinal bleeding and unexplained anemia, abdominal pain, unexplained changes in bowel habit, suspicion of malignancy, or an abnormality found on abdominal ultrasound, colonic X-rays, barium enema or a computerised tomographic (CT) scan [2]. Even though the procedure is widely used in developed countries, it is not readily available in Ghana [4]. Scanty data are available on the indications and findings of colonoscopy in Ghana. The only data in literature are from Kumasi and Accra [5-7]. The aim of our study was to retrospectively evaluate the indications and findings in patients subjected to LGIE in Eastern Regional Hospital (ERH), Koforidua, Ghana.

Methods     

This is a retrospective study, performed by reviewing the records of all patients who underwent diagnostic LGIE in Eastern Regional Hospital in Koforidua from January 2019 to December 2019. Formal approval was obtained from the institutional Ethical Review Board at the Eastern Regional Hospital. The endoscopy unit was set up and started operating in January 2019. Before then, the patient in the catchment area have to travel to Accra for endoscopy services, especially those who could afford. The unit operated 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. Bowel preparation was by ingestion of 2 litres of polyethylene glycol-containing solution 12 hours before the procedure (typically overnight). Bowel preparation was deemed optimal when there were no solids in the stool and patients with suboptimal bowel preparation were rescheduled. Sedation with intravenous midazolam 2.5mg (Dormicum^®, Roche, Switzerland) and pethidine 25mg (Intravenous Infusions Ltd, Ghana) was routinely used for all colonoscopies. Experience gastroenterologist performed all the procedures. Data on other investigations the patients had done prior to being sent to the endoscopic center for LGIE were not available from the records. All patients subjected to colonoscopy for various indications during the aforementioned period were included in the study except those that were grossly incomplete, inconsistent or illegible. An informed consent was obtained from each patient prior to the procedure. Data available from the records included the age and gender of the patients, principal indication for the procedure and primary LGIE findings. Although biopsies were taken in some instances, information on histological diagnosis was not available. Data entry and analysis were done with Stata version 13 (StataCorp, College Station, TX). Descriptive statistics were expressed as frequencies and percentages.

Results     

One hundred and six LGIE (full colonoscopy and proctosigmoidoscopy) procedures were performed over the period. Caecal intubation rate was 86.2%. Poor bowel preparation or patient inability to comfortably tolerate and some technical difficulties of the procedure accounted for the failure to intubate the cecum in all cases. Sixty-nine (65.09%) were males giving a male to female ratio of 1.9:1. Their ages ranged from 21 to 97 years, with a mean age of 56.67 ± 16.48 years. (Table 1). The commonest indications for colonoscopy were rectal bleeding 75 (66.96%), abdominal pain 20 (17.86%), chronic diarrhea and chronic constipation representing 5 (4.46%) and 4 (3.57%) respectively. Only 2 (1.79%) patient undergone LGIE on account of colorectal cancer screening (Table 2). Endoscopic findings were haemorrhoids 65 (54.17%), diverticulosis 15 (12.50%), colorectal cancer 18 (15.0%), polyp 5 (4.17%), melanosis coli 2 (1.67%) and ulcerative colitis 1 (0.83 %) (Table 3). Among patients whose indication for LGIE was bleeding per rectum, more than half had hemorrhoids as their primary finding. It is worth noting that 12.22% of such patients had a colorectal tumor with 3.33% having a colorectal polyp. Thus, almost 15.55% of patients having LGIE because of bleeding from rectum were found to have either a colorectal tumor or a potential precursor of it (Table 4).

Discussion     

Colonoscopy has emerged as the procedure of choice for evaluation of patient with lower gastrointestinal symptoms, colorectal cancer (CRC) screening, and polyp surveillance with its ability to allow for therapeutic intervention. Ghana as a country has no national screening program for colorectal cancer [5] and patients undergo LGIE for specific indications. Therefore, LGIE is rarely performed for the purposes of colorectal cancer screening in Ghana. The main aim of our study was to determine the indications and findings of patient undergoing colonoscopy at Eastern Regional Hospital, Koforidua in Ghana. This study represents the first ever report on LGIE findings from regional hospital in Ghana and few of such report on Ghanaian patients after earlier ones by Dakubo et al. [5,6] in Accra and Gyedu et al. [7] in Kumasi.

From this study, the commonest indications for colonoscopy were bleeding per rectum (66.96%), abdominal pain (17.86%) and an unexplained change in bowel habit (constipation and diarrhea) (8.3%). This is not surprising since bleeding per rectum and abdominal pains are problems that prompts patients to seek urgent medical help. These were also the indications for colonoscopy in the works carried out by Kassa et al. [8] Sahuet al. [9] and Berkowitz et al. [1] in their Ethiopian, Indian and South African patients, respectively. Previous study by Gyedu et al. [7] from Kumasi in Ghana also reported bleeding per rectum, colorectal tumour, hemorrhoids and change in bowel habit as the commonest indications for colonoscopy. Similar studies from Egypt and Nigeria also reported bleeding per rectum as the most common indication for LGIE accounting for 50.0% and 43.3% of their patients, respectively [10,11]. In the Nigeria study, altered bowel habits accounted for as much as 36.2% of the indications for LGIE [10]. In the Egyptian study by El batea et al. [11] 48.0% and 30.0% of patients had LGIE for diarrhea and constipation, respectively.

The commonest colonoscopy finding in this study was haemorrhoids (54.17%) which was higher than 42.0% and 32.3% in previous studies conducted in this country by Gyedu et al. [7] and Dakubo et al. [6] respectively. This is also high compared to the 18.9% and 20.9% reported among Egyptian and Nigerian patients, respectively [10,11]. However, this is similar to study conducted by Ray-Offor et al. [12] in Port Harcourt Rivers State, Nigeria, which recorded 57.1% of their patients as having haemorrhoids. This shows that haemorrhoids are uncommon in Ghana. Detection of tumours in the large bowel is the single most important reason for endoscopy either in symptomatic patients or for screening purposes [13]. Colorectal tumor was the endoscopic diagnosis for 15.0% of our patients. This is similar to 15.6% reported in the Nigerian series and 15.0% reported in Egyptian series. However, this is higher than 9.6% reported by Gyedu et al. [7] and 9.0% reported by Dakubo et al. [14] in Ghana. The study probably confirmed the fact that the incidence of adenocarcinoma of the colon and rectum is rising in Ghana [5]. This may be as a result of an increase in the life expectancy of the population and improvements in diagnosis. Additionally, most of the cancers were found in the rectum. Previous studies conducted in West Africa reveal that about 50% of colorectal cancers are located in the rectum.

Polyp detection rate in this study was 4.17% which is much lower than that in Western literature. However, this is slightly lower than other studies in African and Asia [11,15] but slightly higher than 3.0% detected by Dakubo et al. [6] in this country. The differences may be attributed to the age and sex of the participants and environmental factors including diet [16]. This may also reflect the population incidence or an underestimation due to missed lesion resulting from inadequate bowel preparation and lower caecal intubation rate. Diverticular disease was found in 12.50% of the patients which is higher than 3% reported by Dakobu et al. [6] and 5.5% from another study by Gyedu et al. [7] in this country. This is similar to 16.4% from study conducted in Cameroon by Kenfack et al. [17] and 16.5% by Nigerian study [18]. Previous literature has reported higher prevalence of the disease in the western countries, as high as 50% in North America adult population as compared to a 0.5% prevalence in the developing nations of Africa and Asia [19]. The classic high-fat diet and low fiber-diet of the western culture may be a major contributor of high prevalence of diverticulosis. The higher prevalence of this study compared to previous once in Ghana may be attributed to adoption of western diet and the ageing population by Ghanaians.

Inflammatory bowel disease was diagnosed in only one (0.83%) of our patient. This is very low compared to 25.0% and 18.0% reported in studies conducted in Egypt and Nigeria respectively [10,11]. Furthermore, higher percentages were also recorded in studies conducted by Al-Nakib et al.[16] amongst Kuwaitis, Al-Shamali et al.[20] amongst Saudis and Sahu et al. [21] amongst Indians. However, similar findings were found in previous studies conducted in Ghana by Dakubo et al. [6] which reported 0.5% of UC and Gyedu et al. [7] which reported none. Another study in Nigerian also reported only one case of UC in their patients [12]. The main reason may be due to racial and lifestyle differences, dietary factors, geographical and environmental variations. Another reason may be under-diagnosis likely because of low index of suspicion by clinicians and patients seeking other forms of treatment [22] or may be relatively uncommon in Ghana [23]. It has been established that inflammatory bowel disease is common in Europe, Scandinavia and the US but rare in the black populations of sub-Saharan Africa [24-26].

In 11.67% of our patients, the LGIE found no evidence of organic disease. This frequency is smaller than 23.6% and 41.6% reported in previous Ghanaian studies and 20% reported by Olokoba et al. [18] in Nigeria. In Europe, Exbrayat et al. [27] and Kmieciak et al. [28] reported normal cases in 68.1% and 57% of their patients respectively. The differences generally reflect the fact that colonoscopies are most often performed in patients already having digestive symptoms in Ghana and many African countries. However, in the western countries most colonoscopies are conducted in patients with no symptoms mainly for colorectal cancer screening. Moreover, variations observed in the different values would be related to the type of LGIE performed for the patients. In about 14.1% of our patients undergoing LGIE for bleeding per rectum, a primary endoscopic diagnosis of colorectal tumor or polyp was made. This is comparable to the 11.8% reported among similar patients in the Accra study [5] but lower than the 17.4-23.1% reported elsewhere in west Africa [10,29,30]. A diagnosis of haemorrhoids was made in 61.6% and was the commonest cause of LGIB. This is similar to findings of the Accra and Kumasi study [6,7] but higher than the 31.0% reported in a study conducted in Nigeria by Akere et al. [31]. This is in contrast to UK study which found diverticular disease as a common cause of LGIB [32].

Conclusion     

The commonest indication for colonoscopy was rectal bleeding, while the most frequent pathology was haemorrhoids. The proportion of our patient population found to have a colorectal tumor or polyps was not insignificant. Screening program for colorectal cancer in Ghana should be encouraged due to increasing number of tumour findings on colonoscopy. There is the need to establish more endoscopy centers in the country and more health professionals trained to perform them.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Amoako Duah, the principal investigator of the project and Forster Amponsah-Manu were involved in concept design, data analysis and drafting of the manuscript. Frempong Asafu-Adjaye, Sedina Asafu-Adjaye and William Erzuah Arthur 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 patient recruitment. 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

Table 2: indications of lower gastrointestinal endoscopy

Table 3: lower gastrointestinal endoscopy findings

Table 4: lower gastrointestinal endoscopy findings among patients presenting with bleeding per rectum

References