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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 12
| Issue : 2 | Page : 33-39 |
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Gastrointestinal endoscopy in Nigeria
Abraham Orkurga Malu
Department of Medicine, Adoose Specialist Hospital, Makurdi, Nigeria
| Date of Submission | 16-Nov-2020 |
| Date of Decision | 18-Nov-2020 |
| Date of Acceptance | 19-Nov-2020 |
| Date of Web Publication | 10-Dec-2020 |
Correspondence Address:
Prof. Abraham Orkurga Malu
Department of Medicine, Adoose Specialist Hospital, Makurdi
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2251-0079.302904
Materials for this review were obtained mainly through online search of relevant websites, survey of gastroenterologists in Nigeria, and personal communication with some leaders in various locations. Endoscopy became a reality because of the desire of medical practitioners over the centuries to look inside hollow organs to make accurate diagnosis and to treat such illnesses. From rudimental equipment in antiquity, endoscopy developed rapidly in the nineteenth century. Initial practitioners in Nigeria were foreign trained and were located in the first-generation teaching hospitals. The advance was slowed down with the downward trend of the economy in the 1990s and the early 2000s. Progress has picked up now due mainly to the establishment of more tertiary hospitals, training of specialists at the postgraduate colleges, and the influence of the professional body, Society for Gastroenterology and Hepatology in Nigeria. Endoscopy has contributed to help us define more precisely the epidemiology of diseases of the gastrointestinal (GI) tract in Nigeria, including peptic ulcer disease, Helicobacter pylori, reflux disease, GI bleeding, and disease of the lower gastrointestinal tract. It has provided means for treating many diseases locally, without the need for surgery. For endoscopy to grow rapidly, we must use our training center regularly, persuade our administrators to see the need for providing equipment and facilities, bring along our support staff by providing relevant training, maintain collaboration with foreign partners, and influence equipment suppliers to provide better services to us though replacement agreements and establishment of competent repair facilities in Nigeria.
Keywords: Endoscopy history, endoscopy in Nigeria, development of endoscopy, therapeutic endoscopy, problems maintaining services
How to cite this article:
Malu AO. Gastrointestinal endoscopy in Nigeria. Niger J Gastroenterol Hepatol 2020;12:33-9 |
| Growth of the Specialty of Gastroenterology | |  |
Materials for this review were obtained mainly through online search of relevant websites, survey of gastroenterologists in Nigeria, and personal communication with some leaders in various locations.
Gastroenterology is the specialty of internal medicine and pediatrics that deals with the anatomy, physiology, pathology, and therapeutics that involve disorders of the digestive system.
Among the earliest mention of people specializing in treating gastrointestinal (GI) diseases is Irynakhty, who lived around 225 BC and was an Egyptian court physician, specializing in gastroenterology, among other things.[1] The desire to look into human bodies and see what is causing disease has been with human from time immemorial. Hippocrates (460–375 BC) treated GI diseases and is reputed to have even tried to look inside body lumens.[2]
Training in gastroenterology involves theoretical knowledge and a good degree of hands-on skills. It is the development of endoscopy that has made gastroenterology, one of the most coveted specialties in most countries of the world. In the United States of America (USA), it has consistently been among the five top-earning specialties year after year.[3]
Physicians in many of the old civilizations centered on the Greek, Roman, and Arab cultures desired to and produced instruments that enabled them to look into body cavities. The endoscope could guide external light to provide illumination to look inside cavities. This was more or less the beginning of modern endoscopy that has transformed gastroenterology. However, viewing internal organs remained at a rudimental level till the beginning of the nineteenth century when advances in other branches of science made it possible for better equipment to be developed to look inside hollows of internal organs.
The earliest developments were in urology. It is worth highlighting Philipp Bozzini, who died of typhoid in 1809 at the age of 35, on whose grave is an epitaph which among others says:
“… in memory of the devout deceased soul of Philipp
Bozzini, medical doctor, German-born. This urologist
was the first who tried seriously to look into the hollow
cavities of the human body by ingeniously conducted
light...”[4]
The year 1868 was a landmark for GI endoscopy when Adolf Kussmaul used a professional sword swallower to pass a rigid endoscope into his stomach for inspection. This was a demonstration at a scientific meeting and possibly became the first gastroscopy and promoted interest in the field, including the interest of entrepreneurs in the manufacture of equipment.[5]
In 1898, the era of flexible endoscopes arrived with the development by George Kelling of the flexible lower segment of the endoscope and proximal controls.[6] In other areas of science, Michael Hoffman showed that light and images could be conducted around bends through a system of prisms properly placed. This brought on the possibility of flexible endoscopy.
The development of fiberglass technology involved many doctors and physicists working together to develop very fine, coated fiberglass, allowing for clear transmission of light and images, thus providing flexible endoscopes and removing the need for distal light sources. Prominent among the doctors and physicists who worked on this and interested others was Basil Hirschowitz, who was born in South Africa, but migrated to the USA. Rudolf Schindler used this technology and made Germany the center of endoscopy. During Nazi Germany, he, a Jew, was arrested and later deported to the USA. He moved with his knowledge, and endoscopy developed very rapidly in the USA.[7]
By 1963, fiberoptic endoscopy was fully established, with practitioners in the United Kingdom, Europe, and the USA. This was mostly limited to diagnostic endoscopy.
In 1983, fiberoptic endoscope days was numbered with the introduction of electronic endoscopes. Welch Alleyn produced the first of these electronic endoscopes. There was an electronic sensor mounted on the tip of the instrument. This transmitted images electronically to a processor, which then relayed them to a monitor. It removed the need to directly look down the endoscope or use a teaching attachment for teaching since the student and the teacher could both view images on the screen simultaneously.[8]
Colonoscopy was first attempted in 1963, with the flexible endoscope. The patient had to swallow a sort of string, which was allowed to progress to the anal canal, and an endoscope was then attached and gently maneuvered till it reached the cecum.[9] More recent developments include endoscopes with magnification, change in light color, those which can view beyond the stomach to the small intestine, and the use of capsule endoscopy for diagnosis. The latter has the disadvantage of the inability to take biopsies. It will only be a matter of time, I imagine, before capsules will contain a mechanism for taking biopsies of the tissues visualized.
Initially, the focus of endoscopic technology was on diagnosis; however, over time, it was noticed that even though the accuracy of diagnosis had improved, mortality and morbidity did not decrease much. The therapeutic potential of endoscopy was pursued, and gastroenterologists and equipment manufacturers began to look for ways to reduce morbidity and mortality through therapeutic endoscopy. This popularized endoscopy as not only a diagnostic instrument but also a viable therapeutic one. In fact, endoscopy has taken over many of the functions originally performed by the surgeon on the GI tract, such as control of bleeding, dilatation of strictures, drainage of some organs, removal of foreign bodies and of stones from the biliary tree, and treatment of obesity.[10],[11]
| Growth of Gastrointestinal Endoscopy in Nigeria | | |
Initially, endoscopy in Nigeria was performed only in the first-generation teaching hospitals of Ibadan, Lagos, Zaria, Enugu, and Ile-Ife. These were the teaching hospitals attached to the first set of universities in Nigeria. The endoscopy services were started in the late 1970s and the early 1980s. Specific dates of commencement are not easily available in some of the centers possibly due to poor record-keeping in the hospitals. A recent publication from Ibadan stated that “The use of these flexible fiberoptic endoscopes for both upper and lower GI tract examinations started in the University College Hospital Ibadan as far back as 1986.”[12] However, personal communication revealed that it was actually in January 1976 by Prof. Eric Akinniyi Lewis. In Ile-Ife, it was in 1978, and in Zaria, it was started in 1978 by Prof. PAJ Ball and Dr. Y. M. Fakunle. In Lagos, it was started probably in the early 1980s and services rendered for many ears but interrupted for a long time until it was resurrected in 2010! The commencement in Enugu was later, in 1986, by Drs. P. I. Okolo, S. O. Ukabam (physicians), and T. Nwabunike (surgeon).
The Structural Adjustment Program,[13] which led to economic hardships and brain drain of many of the experienced foreign-trained Nigerian doctors and lecturers, had a great effect on the development of endoscopy services. Some centers that had been pioneers in endoscopy stopped rendering services because of lack of trained personnel, lack of maintenance of faulty or aging equipment, and inability to purchase more up-to-date ones. Only a few centers in Nigeria remained active, though limited in what they could do. From a recent survey of endoscopy services in Nigeria, it was found that more centers got services interrupted over the years than those who had it rendered continuously [Figure 1]. Most of those that have services rendered continuously are in the later generations.
The growth of endoscopy services was slowed down for some years, and there were relatively few new centers established in the 1990s and the early 2000s. However, as new teaching hospitals and specialist hospitals came into existence, endoscopy services also spread more widely over the whole country. Private centers also began to contribute to endoscopy services [Figure 2] and [Figure 3]. | Figure 3: Map of Nigeria with location of States offering endoscopy services who responded to the survey
Click here to view |
Colonoscopy that was initially pursued vigorously mainly in Ile-Ife has also become a skill that is available and practiced widely. More than 75% of centers where endoscopy is carried out do so for both upper and lower GI tract [Figure 4]. | Figure 4: Proportion of centers offering upper and lower gastrointestinal tract services from survey
Click here to view |
| Development of Therapeutic Endoscopy in Nigeria | | |
Initially, services were limited to diagnosis, with very few therapeutic procedures. The latter developed gradually. There were limited skills, and the cost of materials for some of the procedures was not easily available to promote therapeutic endoscopy. Many centers tried to do what they could. In Jos, there were attempts to develop “relevant technology” for therapeutic endoscopy. The need arose because it was noticed that most bleeding from the upper GI tract in Northern Nigeria came from bleeding varices.[14] Many patients with this condition were dying from treatable causes, so they set out to try and reduce this unnecessary mortality, but buying disposable variceal bands then at about $300 per session of banding of varices was unrealistic. Donations of a few new banding devices were obtained, and it was decided to “recycle” them, so more patients would benefit from them, using reloading methods already pioneered by others.[15] They could buy hemorrhoidal bands or cut some rubber rings from urethral catheters and load them on the binding cylinders and use them over and over. They had to try various methods for loading the bands onto the cylinders, starting with using forceps, and then stuffed pipet tips and metal cones and finally proper reloading device [Figure 5], [Figure 6]. This is the method still used at the center today. It has saved innumerable lives there. | Figure 6: Esophageal varices and banding of varices using re-loaded bands
Click here to view |
There is now widespread availability of many therapeutic endoscopy services among the 19 centers that responded to the survey questions. These are still limited in number, in the regularity of their performance, and in scope when compared to the needs in the country. For instance, only one public center in the country carries out endoscopic retrograde cholangiopancreatography (ERCP) with any degree of regularity [Figure 7]. | Figure 7: Therapeutic procedures being performed in Nigeria and the number of centers doing so
Click here to view |
Maintaining services has been difficult in many of the centers, particularly the early ones, for many reasons. The problems militating against the widespread use of endoscopy services in Nigeria include are given below.
Lack of trained human resources, both medical and nursing
Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) has less than 100 active members who are trained endoscopists. One hospital in the USA, the Mayo Clinic, alone has more than 140 gastroenterologists, all of them trained in diagnostic and therapeutic endoscopy.[16] There are very few nurses trained to assist in endoscopy and cleaning/disinfection of endoscopic equipment in Nigeria, whereas many developed countries are training nurses (and general practitioners) to even run diagnostic endoscopy services for uncomplicated patients to extend services more widely and reduce the workload of gastroenterologists. Even though endoscopy is more easily available now, most endoscopy in Nigeria still focuses on diagnostic upper GI problems, with limited experience of colonoscopy and therapeutic endoscopy. Competence in lower GI endoscopy and therapeutic endoscopy on a range of diseases are compulsory skills to be acquired by all gastroenterologists before they receive certification in advanced countries.
Lack of awareness by healthcare professionals/administrators of the usefulness of endoscopy
In a town like Lagos, with over 17 million people,[17] there may be less than 10 active endoscopy units, and yet the workload at most of these centers is limited. In comparison, the Mayo Clinic alone has more than 20 active endoscopy rooms that run fully booked morning and afternoon clinics. One factor responsible for this is that medical practitioners do not readily consider endoscopy as the first option but cite the cost as a deterrent. However, the cost of procedures in government facilities is greatly subsidized compared to the investment in equipment and human resources. Matching the appropriate investigation to clinical condition is a skill that still needs developing among our colleagues, seeing that some doctors still request a barium meal or an ultrasound scan to investigate suspected peptic ulcer disease or varices!
Managers and policymakers also need to understand how these delicate instruments need constant maintenance and regular replacement since damage can lead to services being grounded. It is therefore not acceptable for a hospital to have just one upper and lower GI scopes and believe that it has provided enough for services to be maintained in a hospital.
The high cost of endoscopic equipment
No doubt, endoscopic equipment is expensive and fragile! One video endoscope may cost over $5,000 (approximately ₦ 1.9 million). With accessory equipment such as video system and light source, it may cost over $20,000 (approximately ₦7.7 million) to set up a standard unit with just one upper and one lower endoscope! Not many hospitals can afford this in the face of competing demands.
In developed countries, most endoscopy units have service agreements with supplying companies. When any scope is damaged, it is returned to the company, which gives replacement scope, so work is not interrupted. Service companies are easily accessible to endoscopy units, and they attend to requests promptly. Each unit also has several scopes so that even if there is a delay in the repair of equipment, services do not suffer. There are also trained technicians in the bigger hospitals who attend to simple faults such as blocked channels or faulty control knobs, within a short time. Lack of maintenance facilities has made it impossible for many endoscopy units in the country to maintain continuous service over a period of years. Frequently, new equipment has to be bought or the old one sent abroad for repairs. Since some units have only one scope at a time, services grind to a halt.
| Contribution of Endoscopy to Gastroenterology in Nigeria | | |
Despite the many limitations, endoscopy has contributed to the practice of medicine in Nigeria. The prevalence of peptic ulcer is not as rare as previously thought, and gastric malignancies are perhaps as common in Nigeria as elsewhere.[14],[18],[19] The accurate diagnosis and treatment of peptic ulcer and distinguishing it from nonulcer dyspepsia has also been important. It is through the use of endoscopy that we now know gastroesophageal reflux disease is not rare in Nigeria.[20],[21],[22] We also know that varices are common, particularly in Northern Nigeria[14],[23] and that GI bleeding with cirrhosis can also be from ulcers and other lesions. Helicobacter pylori infection rates and associated disease is much higher than in other countries.[24],[25]
We have now also demonstrated that colonic cancers are an important cause of morbidity and mortality in Nigeria. This information should help policymakers consider setting up a bowel cancer screening program for people over 45 years in Nigeria.[26],[27],[28]
We still have a lot of limitations. Even though video endoscopy is widely available, with most centers carrying out both upper and lower GI endoscopy, just one center carries out ERCP, a procedure that has been available for such a long time elsewhere. Management of pancreatic diseases endoscopically and bariatric procedures are also very limited. Notwithstanding, the scope of services has changed remarkably over the years. Whereas at the beginning, endoscopy in Nigeria was mainly diagnostic, it is now very broad, with many of the centers to some extent performing many procedures that were carried out only in very advanced centers.
In a lecture to the West African Society of Gastroenterology in 2000 in Kano, I highlighted the problems and suggested what we should do to improve the situation. I am happy to note that much has been achieved since then, as shown below.
“Establishing training centers and making sure all gastroenterologists are trained.” This is what I stated in 2000 while giving a guest lecture. I am happy to note that this is being achieved. The World Gastroenterology Organization (WGO), through our professional body, has established a training center for Nigeria at the Lagos University Teaching Hospital. I am happy that some other centers in Ibadan, Ile-Ife, and Kano are also partnering with other professionals outside Nigeria to develop training centers to improve on skills that are found in developed countries.
“Networking with professionals in other parts of the world.” This again was the desire in 2000. Through the SOGHIN and other individual efforts, we now have contact with people outside Nigeria who are very interested in teaming up with us to develop the specialty.
“Creating awareness in the healthcare profession of the usefulness of endoscopy.” Awareness among our colleagues and even the general public has grown substantially since then. We now have far more referrals than before, and some patients even “refer” themselves. Investigation requests are more appropriate (though there is still a need for improvement), and we are beginning to get long endoscopy waiting lists as there are still limited human resources, space, and equipment to meet the increasing demand. Gastroenterology is getting recognition as an enviable specialty in internal medicine, and general surgery focusing on gastrointestinal diseases is growing.
“Partnership with suppliers of equipment for replacement scheme/maintenance.” This is very slowly coming to fruition. There are some hospitals now where endoscope equipment suppliers are willing and have gone into agreements with providers to take damaged scopes for repairs and replace them with functional ones so services would not be interrupted. A number of companies now offer equipment from less expensive sources, which is an option to be considered.
| Looking Forward | | |
We have come a long way, but we still have far to go to catch up with the needs in our country and to have our practice at par with that from more developed countries. To do this, we must continue to make use of training opportunities provided by WGO centers, both locally and the others on the African continent and beyond. We should work toward developing our center in Lagos to be able to mount monthly courses in various fields. We still need more exposure to the way services are provided in more established centers outside this country. These need not be in the West only, but more and more opportunities are opening up in Asia and the Middle East.
As endoscopy becomes more widely available, we must standardize our methods so that one will be confident endoscopy findings reported in one center is what another center will easily accept. This is very important particularly as we do more colonoscopies and attempt therapeutic procedures. In this area, training of support staff for cleaning, disinfection, and sterilization of equipment and accessories needs to be given very high priority as well. National studies involving many centers on topical issues will lead to standardization of procedures and competencies. SOGHIN has brought out guidelines on a number of topics. There is a need also for guidelines on standards in the practice of endoscopy in Nigeria.
We must continue to cultivate and maintain relationships with our colleagues who practice outside Nigeria. It is pleasing to note that more Nigerians and other Africans practicing outside this country are willing and eager to help us develop our skills and centers. This momentum must be maintained.
There is a great need to have local companies that can repair endoscopes very well and marketing companies that can supply hire purchase and be prepared to replace faulty equipment. This has been a weak link in the growth of endoscopy services in Nigeria. We may need to consider (through SOGHIN) limiting ourselves to a few brands of endoscopes from manufacturers who are willing to sell and are prepared to establish service centers in Nigeria where damaged equipment can easily be sent for repairs.
With these points given priority, endoscopy services in Nigeria will be on par with many other countries in the next 20 years.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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