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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 47-51

An audit of evolving colonoscopy practice in two tertiary hospitals in South-East Nigeria


1 Department of Surgery, Federal Medical Centre, Owerri, Nigeria
2 Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria
3 Department of Internal Medicine, Federal Medical Centre, Owerri, Nigeria

Date of Submission29-Dec-2021
Date of Acceptance17-Jan-2022
Date of Web Publication24-Feb-2022

Correspondence Address:
Dr. Christopher Nonso Ekwunife
Department of Surgery, Federal Medical Centre, Owerri.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njgh.njgh_12_21

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  Abstract 

Introduction: Colonoscopy is quite essential in the management of gastrointestinal pathologies. Its practice in most developing countries is suboptimal. Aim: The aim of this study was to determine the common indications and findings at colonoscopy in a patient population in South-eastern Nigeria, as well as to assess the documentation of quality indicators of colonoscopy service. Materials and Methods: The endoscopy records of patients who underwent colonoscopy at two tertiary institutions (Federal Medical Centre, Owerri and Imo State University Teaching Hospital, Orlu) from January 2014 to December 2016 were reviewed. Information on patient demographics, colonoscopy indications, colonoscopy findings, and polyp detection were sought for. Data analysis was done with SPSS version 21. Results: Two hundred and nineteen patients had colonoscopy within the period. Age range of the patients was 16 to 94 years (mean age: 55 ± 14.8 years). The most common indications for colonoscopy were bleeding per rectum 100 (45.7%) and change in bowel habit 36 (16.4%). Tumors in the colon/rectum were seen in 44 (19.9%) patients and polyp detection rate was 10.9% (n = 24). Records were not comprehensively kept. Conclusion: The high percentage of findings of tumors in patients undergoing colonoscopy in our population suggests that this service should have an expanded coverage to enable earlier diagnosis of colorectal malignancies. A better endoscopy record and data management will also be helpful.

Keywords: Colonoscopy, findings, indications, Nigeria


How to cite this article:
Ekwunife CN, Osuagwu C, Enendu SE, Onyekpere C, Ekwunife CU. An audit of evolving colonoscopy practice in two tertiary hospitals in South-East Nigeria. Niger J Gastroenterol Hepatol 2021;13:47-51

How to cite this URL:
Ekwunife CN, Osuagwu C, Enendu SE, Onyekpere C, Ekwunife CU. An audit of evolving colonoscopy practice in two tertiary hospitals in South-East Nigeria. Niger J Gastroenterol Hepatol [serial online] 2021 [cited 2022 May 25];13:47-51. Available from: https://www.njghonweb.org/text.asp?2021/13/2/47/338250




  Introduction Top


Colonoscopy is at the heart of the management of colorectal disorders. From the pioneering work of Wolff and Shinya in the 1970s, it has advanced to become an indispensable tool in gastroenterology.[1],[2] Its use is also evolving especially with heightened interest in computer-aided diagnosis made possible by refinements in artificial intelligence.[3] It is anticipated that this will reduce the inter-investigator variability of findings and diagnoses, as colonoscopy requires some skills from the endoscopists.[4] Its current unparalleled utility in improved survival for colorectal cancers has seen massive investment in screening colonoscopy. This has also contributed to the wide disparity in the volume of colonoscopies being performed in developed and developing countries. Most colonoscopies in developing countries may still be for diagnosis or less commonly for therapies in symptomatic patients. In Nigeria specifically, there is lack of evidence to support organized population-based colorectal cancer screening.[5] Nevertheless, access to colonoscopy has been on the increase, although the volume of reports from the southeastern part of the country seems rather low comparatively.[6],[7],[8] Therefore, the aim of this study was to determine the common indications and findings at colonoscopy in a patient population in South-eastern, Nigeria, as well as to assess the quality of colonoscopy service. It is our hope that this publication will contribute to the body of knowledge in this region of the country.


  Materials and methods Top


We reviewed the endoscopy records of all patients who had colonoscopy over a 3-year period, from January 2014 to December 2016, at Federal Medical Centre Owerri and Imo State University Teaching Hospital, Orlu. Patients’ demographics, colonoscopy indications, and findings as well as cecal intubation and polyp detection rates were obtained from the records. We also assessed the quality of documented records.

Informed consent was obtained prior to the procedures. Three-day bowel preparation was used in the majority of the patients: low residue diet and tablet bisacodyl commenced 3 days prior to the procedure, 3–6 sachets of magnesium sulfate (Epsom salt) in divided doses, and clear fluids a day before the procedure. Standard 4-L preparation of polyethylene glycol or sodium picosulfate/magnesium citrate (Picolax) was used much later in the study period. Scopes used were Pentax FG-29 fiberscope and EPM 3300 Video Endoscope system. Statistical analysis was done with SPSS version 21.


  Results Top


A total of 219 colonoscopies were done within the study period. The age range of the patients was 16–94 years with a mean age of 55 ± 14.8 years. There was a preponderance of males, accounting for 129 (58.9%) of the patients. The overarching indication for colonoscopy was rectal bleeding [Figure 1]. Altered bowel habit came a distant second among the indications. In only 3(1.4%) patients was colonoscopy done for screening for colorectal cancer. Colonoscopy was normal in 56 (25.6%) patients [Table1]. Hemorrhoid was the principal endoscopic diagnosis in 54 (24.4%) patients, whereas tumors were seen in 43 (19.9%) patients, half of which were located in the rectum [Figure 2]. Polyps were found in 24 (10.9%) patients. The cecal intubation rate was 81.7%. Two intraprocedural colonoscopy quality indicators (withdrawal time and the quality of bowel preparation) were not documented in the records.
Figure 1: Indications for colonoscopy

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Table 1: Findings at colonoscopy

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Figure 2: Sites of tumour seen at colonoscopy

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  Discussion Top


There are obvious challenges to the optimal use of colonoscopy services in developing countries. Apart from the apparent financial limitations these countries face, there is also the problem of dearth of epidemiological research data that will underpin the needed investment.[9] In Nigeria, publications on colonoscopy while steadily increasing do not involve a very large number of patients. There is no national database comparable to advanced countries like the United States where the Survey of Endoscopic Capacity (SECAP) estimates that 15 million colonoscopies were done in 2012.[10] A 2001 working group of the British Society of Gastroenterology recommended an annual workload of 800–1000 colonoscopies per 100,000 population for an average district general hospital.[11] This dwarfs the 219 cases we did over a 3-year period for a population that is in excess of 3 million. It is anticipated that the report of our modest efforts at offering this service will complement other publications from other hospitals in our country. Ultimately a more comprehensive national database will be generated in the long run.

Our study has more males (58.9%) than female subjects (41.1%). This mirrors the data from multiple centers in Nigeria.[6-8],[12-16] However, the gender disparity is not as wide as in two studies where the male: female ratio is as wide as 2–3:1.[13],[14] On the contrary, Joukar et al.[17] had more females in an Iranian study published in 2012. There is a higher prevalence of colorectal cancer in males which may contribute to the noted higher volume of colonoscopies in them. However, sociocultural barriers may deter women from accessing this service.[9],[18]

Our results show that the indications for colonoscopy are fairly consistent with earlier reports in our subregion [Table 2]. Hematochezia and change in bowel habit constitute the top two indications as also seen by Osinowo et al.,[16] Akere et al.,[7] Onyekwere et al.,[8] and Olokoba et al.[14] Although this may represent the findings in other developing countries, it is not necessarily so in the advanced economies. Even where rectal bleeding is the most common indication for colonoscopy in a study conducted in the United Kingdom its percentage contribution is comparatively low at 19.9%.[11] This discordance can be readily attributable to the negligible volume of screening colonoscopy done in our setting. The series were done by Akere et al.[7] and Onyekwere et al.,[8] showed colonoscopy done for screening to be 3.2% and 4.3%, respectively, against our proportion of 1.4%. Our low numbers may be attributed to the predominantly rural population setting. However, colonoscopies for screening are as high as 42.3% in the United States and 12% in Russia.[19],[20] For the foreseeable future, a greater number of our patients will be presenting on account of alarm symptoms. Among the colorectal cancer alarm symptoms, rectal bleeding has the highest positive predictive value.[21] This scenario can be further exploited by wider public enlightenment on seeking early medical attention for rectal bleeding as rectal bleeding as an initial symptom is associated with less advanced stage and improved survival from colorectal cancer.[22] This does not in any way detract from ensuring appropriateness of the indication for colonoscopy in young patients with bright red rectal bleeding and who do not have risk factors for colorectal cancer. For this cohort of patients, flexible proctosigmoidoscopy may suffice.[23] Ultimately this may reduce the chance of hemorrhoids being the reason for and the most common finding at colonoscopy as shown in reports across our population.[6],[8],[12],[13]
Table 2: Comparison of colonoscopy indications in Nigerian literature

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Our diagnostic yield rate of 72.4% is respectable when compared with the recent study by Akere et al. who had 74%, although Ray-Offor and Ibeanusi[24]had a higher figure of 83%. The yield rate has a relationship to awareness of appropriate indications for colonoscopy by referring physicians especially in an open-access endoscopy service. Colorectal tumors constitute about one-fifth of our finding, a figure higher than that reported by other researchers [Table 3]. These tumors were predominantly left sided, but conclusions cannot be drawn from this due to the small volume of cases. Nevertheless, this points to the possibly emergent problem of colorectal neoplasia in our local environment, considering polyp detection rate of 22.9% in our setting.[7] In our study, it is only 11.8%. Although this is much lower than the 49% in a Western series, it could be surmised that colonic polyps may not be as rare among black Africans as was once thought.[25] The information on polyp detection rate is also important as a surrogate marker for adenoma detection rate (ADR), a quality indicator tool for a colonoscopy service. The recommended ADR of 25% may not be realizable in our practice at the moment. However, an optimal cecal intubation rate is vitally important. Our figure of 81.7%, whereas lower than the recommended 90%, compares favorably with other similar reports.[8],[16]
Table 3: Comparison of colonoscopy findings in Nigerian literature

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Our review brings up limitations that can be further evaluated in the future. Other quality indicators like withdrawal time and bowel preparation score were not recorded. It is anticipated that software should be installed for electronic capture of all relevant endoscopic data in the hospitals.


  Conclusion Top


The volume of colonoscopies in Imo State is low. Majority of the patients are referred on account of rectal bleeding. Colorectal tumors constitute a major finding. Public enlightenment is necessary in order to bring the benefits of this service to a greater number of clients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wolff WI Colonoscopy: History and development. Am J Gastroenterol 1989;84:1017-25.  Back to cited text no. 1
    
2.
Huang EH, Marks JM The diagnostic and therapeutic roles of colonoscopy: A review. Surg Endosc 2001;15:1373-80.  Back to cited text no. 2
    
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Mori Y Artificial intelligence and colonoscopy: The time is ripe to begin clinical trials. Endoscopy 2019;51:219-20.  Back to cited text no. 3
    
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Wexner SD, Garbus JE, Singh JJ; SAGES Colonoscopy Study Outcomes Group. A prospective analysis of 13,580 colonoscopies: Reevaluation of credentialing guidelines. Surg Endosc 2001;15: 251-61.  Back to cited text no. 4
    
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Knapp GC, Tansley G, Olasehinde O, Alatise OI, Wuraola F, Olawole MO, et al. Mapping geospatial access to comprehensive cancer care in Nigeria. J Glob Oncol 2019;5:1-8.  Back to cited text no. 5
    
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Ismaila BO, Misauno MO Colonoscopy in a tertiary hospital in Nigeria. J Med Trop 2011;13:172-4.  Back to cited text no. 6
    
7.
Akere A, Oke TO, Otegbayo JA Colonoscopy at a tertiary healthcare facility in Southwest Nigeria: Spectrum of indications and colonic abnormalities. Ann Afr Med 2016;15:109-13.  Back to cited text no. 7
    
8.
Onyekwere CA, Odiagah JN, Ogunleye OO, Chibututu C, Lesi OA Colonoscopy practice in Lagos, Nigeria: A report of an audit. Diagn Ther Endosc 2013;2013:798651.  Back to cited text no. 8
    
9.
Ahmed F Barriers to colorectal cancer screening in the developing world: The view from Pakistan. World J Gastrointest Pharmacol Ther 2013;4:83-5.  Back to cited text no. 9
    
10.
Joseph DA, Meester RG, Zauber AG, Manninen DL, Winges L, Dong FB, et al. Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity. Cancer 2016;122:2479-86.  Back to cited text no. 10
    
11.
Bowles CJ, Leicester R, Romaya C, Swarbrick E, Williams CB, Epstein O A prospective study of colonoscopy practice in the UK today: Are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004;53:277-83.  Back to cited text no. 11
    
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Alatise OI, Arigbabu AO, Agbakwuru EA, Lawal OO, Ndububa DA, Ojo OS Spectrum of colonoscopy findings in Ile-Ife Nigeria. Niger Postgrad Med J 2012;19:219-24.  Back to cited text no. 12
    
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Picardo NG, Ajayi NA, Ajayi IA Lower gastrointestinal endoscopy in Enugu, Nigeria: An experience with 151 cases. Niger J Gastroenterol Hepatol 2017;9:15-20.  Back to cited text no. 13
    
14.
Olokoba AB, Obateru OA, Bojuwoye MO, Olatoke SA, Bolarinwa OA, Olokoba LB Indications and findings at colonoscopy in Ilorin, Nigeria. Niger Med J 2013;54:111-4.  Back to cited text no. 14
    
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Ngim EO, Okonkwo UK, Kooffreh Ada M Pioneering video colonoscopy in South-South, Nigeria: A six month prospective study. IOSR-JDMS 2014;13:24-7.  Back to cited text no. 15
    
16.
Osinowo A, Lawal O, Lesi OA, Olajide T, Adesanya A Audit of colonoscopy practice in Lagos University Teaching Hospital. J Clin Sci 2016;13:29-33.  Back to cited text no. 16
    
17.
Joukar F, Majd SK, Fani A, Nazari N, Mansour-Ghanaei F Colonoscopy outcome in North of Iran (Guilan): 2006-2009. Int J Clin Exp Med 2012;5:321-5.  Back to cited text no. 17
    
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Friedemann-Sánchez G, Griffin JM, Partin MR Gender differences in colorectal cancer screening barriers and information needs. Health Expect 2007;10:148-60.  Back to cited text no. 18
    
19.
Antipova M, Burdyukov M, Bykov M, Domarev L, Fedorov E, Gabriel S, et al. Quality of colonoscopy in an emerging country: A prospective, multicentre study in Russia. United European Gastroenterol J 2017;5:276-83.  Back to cited text no. 19
    
20.
Joseph DA, Meester RG, Zauber AG, Manninen DL, Winges L, Dong FB, et al. Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity. Cancer 2016;122:2479-86.  Back to cited text no. 20
    
21.
Rasmussen S, Haastrup PF, Balasubramaniam K, Elnegaard S, Christensen RD, Storsveen MM, et al. Predictive values of colorectal cancer alarm symptoms in the general population: A nationwide cohort study. Br J Cancer 2019;120:595-600.  Back to cited text no. 21
    
22.
Stapley S, Peters TJ, Sharp D, Hamilton W The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: A cohort study using medical records. Br J Cancer 2006;95:1321-5.  Back to cited text no. 22
    
23.
Freitas CD, Sartor MC, Correa MF, Froehner Junior I, Martins JF, Kotze PG, Zanoni EC, D’Assunção MA Appropriateness of colonoscopy indication for colorectal neoplasm detection in patients under 50 years old with hematochezia. J Coloproctol (Rio de Janeiro) 2012;32:40-9.  Back to cited text no. 23
    
24.
Ray-Offor E, Ibeanusi SE Diagnostic yield of colonoscopy. J Clin Gastroenterol Hepatol 2018;2:11.  Back to cited text no. 24
    
25.
Alatise OI, Arigbabu AO, Agbakwuru AE, Lawal OO, Sowande OA, Odujoko OO, et al. Polyp prevalence at colonoscopy among Nigerians: A prospective observational study. Niger J Clin Pract 2014;17:756-62.  Back to cited text no. 25
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