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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1656-1659

Colonoscopy findings in lower gastrointestinal bleeding in Lagos: A comparative study based on age


1 ReMay Consultancy and Medical Services, Ikeja, Lagos, Nigeria
2 Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Pediatrics, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission08-Jun-2020
Date of Acceptance02-Aug-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. A Oluyemi
ReMay Consultancy and Medical Services, Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_341_20

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   Abstract 


Background: Lower gastrointestinal bleeding (LGIB) (hematochezia) is an important indication for colonoscopy, and may be caused by hemorrhoids, diverticulosis, and tumors. Aims: The aim of this study was to compare the endoscopic findings in the young (<50 years) versus older subjects (≥50 years) with LGIB in Nigeria. Subjects and Methods: This was a retrospective study of the endoscopic findings of all adults with LGIB from January 2017 to December 2019 in Lagos, Nigeria. The records of two centers that deliver outpatient gastrointestinal endoscopic services were ploughed for biodata, presenting complaints and findings in these individuals. These data were then analyzed and are thus presented. Results: A total of 1,774 colonoscopies performed during this period, 793 were for LGIB. Of those with LGIB, 548 (69.1%) were males, 245 (30.9%) were female, mean age was 50.7 (±14) years, and 403 (50.8%) were younger than 50 years old. The most frequent findings in patients younger than 50 years were hemorrhoids (316, 78.4%), tumors (35, 8.7%), and polyps (27, 6.7%), while in the older patients, they were hemorrhoids (259, 66.4%), tumors (74, 19%) and diverticulosis (55, 14.1%). Younger age was significantly associated with the presence of hemorrhoids (P < 0.005), while older age was significantly associated with the presence of tumors (P < 0.005) and diverticulosis (P < 0.005). Conclusion: Our study showed that hemorrhoids, tumors, and diverticulosis were the most common causes of LGIB in Nigerian patients - with younger age being significantly associated with hemorrhoids, and older age with tumors and diverticulosis. A third of the tumors in this study were found in younger patients. Unfortunately, this finding of such a high proportion of colorectal tumors being found in young Africans has been shown in previous reports - this work should help heighten concern and provoke further scientific probing into the phenomenon with a view to encouraging policy to help truncate its existence.

Keywords: Age, colonoscopy, hematochezia, colorectal cancer, Nigeria


How to cite this article:
Oluyemi A, Odeghe E, Adeniyi O. Colonoscopy findings in lower gastrointestinal bleeding in Lagos: A comparative study based on age. Niger J Clin Pract 2020;23:1656-9

How to cite this URL:
Oluyemi A, Odeghe E, Adeniyi O. Colonoscopy findings in lower gastrointestinal bleeding in Lagos: A comparative study based on age. Niger J Clin Pract [serial online] 2020 [cited 2022 Nov 30];23:1656-9. Available from: https://www.njcponline.com/text.asp?2020/23/12/1656/304425




   Introduction Top


During the course of the past decade, there has been a gradual increase in the use of colonoscopy in clinical management in Nigeria. This has reflected in the increasing body of published work to document the endoscopists' findings.[1],[2],[3],[4],[5],[6]

Data from our locality reveal that lower gastrointestinal bleeding (LGIB) is one of the most frequent indications for colonoscopy. LGIB in these parts appears to occur more commonly in men and in the older population, which is in agreement with most international published series.[7],[8],[9],[10] Common colonoscopic diagnoses in patients with LGIB include hemorrhoids, masses/polyps, diverticulosis,[1],[11],[13] which mirrors findings from international published works as well.[7],[8],[9],[10]

Presently, to the best of our knowledge, there is no local scientific work that critically examines differences in presentation and findings on an age basis. This article, by numbers, also presents one of the more robust endoscopy series from sub-Saharan Africa. The aims of this study were to determine the endoscopic findings, and diagnostic yield of colonoscopy in Nigerian patients undergoing the procedure for evaluation of LGIB, and to compare the findings in the young (<50 years) versus old (≥50 years) subjects.


   Materials and Methods Top


This was a retrospective study of the endoscopic records of all adults who had a colonoscopy for the evaluation of LGIB over a 3-year period (January 2017 to December 2019) at the endoscopy suites of two private diagnostic centers in Lagos, Nigeria (Arrive Alive Diagnostic and Imaging Services, and Clinix Healthcare Limited).

Ethical considerations

Ethical approval was obtained from the Lagos University Teaching Hospital Health Research Ethics Committee before the commencement of the study.

Statistical analysis

The following data were retrieved and entered into a proforma designed for this study: basic demographics, the indication for the procedure, and the endoscopic findings.

Data were analyzed using SPSS version 23 (SPSS Statistics for Windows, version 23.0, IBM Corp., USA). Basic descriptive statistics were performed and displayed as frequency tables. Continuous data and categorical data were compared using Student's t test, Chi-squared test or Fisher exact test, where appropriate. Valus of P < 0.05 were considered significant.

Role of the funding source

The study was funded solely by the authors. The corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.


   Results Top


Demographics of study participants

A total of 1774 colonoscopy procedures were performed in the study period; of these 793 (44.7%) were for LGIB.

Patients with lower gastrointestinal bleeding

Among the 793 patients with LGIB, there were 548 males (69.1%) and 245 females (30.9%), giving a male: female ratio of 2.2:1. The mean age of the subjects was 50.7 (±14) years, with a range of 21-100 years. A little more than half of the subjects (403, 50.8%) were younger than 50 years, while 390 (49.2%) were at least 50 years old.

Endoscopic findings in patients with LGIB

Colonoscopy was normal in 59 (7.4%) of the subjects, giving a diagnostic yield of 92.6%. The commonest findings were hemorrhoids (575, 72.5%), tumors (109, 13.7%), diverticulosis (72, 9.1%), and polyps (68, 8.6%). Others were colitis (37, 4.7%), melanosis coli (18, 2.3%), ulcers (10, 1.3%), fistulae (4, 0.5%), fissures (2, 0.3%), radiation colitis (2, 0.3%), and angio-dysplasias (1, 0.1%). Hemorrhoids were significantly commoner in males (P = 0.008), while tumors were nearly twice as frequent in the females as in males (P = 0.001). There was no association of the other findings with gender [Table 1].
Table 1: Colonoscopy findings of subjects with LGIB based on gender

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Colonoscopy findings in younger versus older subjects

The diagnostic yield of colonoscopy was similar in the younger and older subjects (p = 1.00). The commonest findings in patients younger than 50 years were hemorrhoids (316, 78.4%), tumors (35, 8.7%), and polyps (27, 6.7%), while in the patients aged at least 50 years, they were hemorrhoids (259, 66.4%), tumors (74, 19%) and diverticulosis (55, 14.1%). Younger age was significantly associated with the presence of hemorrhoids (P < 0.005), while older age was significantly associated with the presence of tumors (P < 0.005) and diverticulosis (P < 0.005) [Table 2].
Table 2: Colonoscopy findings subjects with LGIB based on age

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   Discussion Top


LGIB bleeding was an important indication for colonoscopy in our study, constituting more than two-fifths of all procedures. This finding and the male preponderance results, both mirror what has been reported in other local studies.[1],[2],[3],[4],[5],[6] The higher frequency of LGIB as an indication for colonoscopy in men than women could be attributed to the greater occurrence of hemorrhoids and diverticular disease (DD) in men than women.[14],[15] Another possible reason might be hormonal differences or greater access to health care in men because of factors such as differences in education and economic power. The frequency of DD was not significantly different in men versus women in our study- this finding closely approximates that from a recent publication that reviewed African DD studies.[16] Surprisingly, our study found that tumors at colonoscopy occurred twice as frequently in women than in men, in contrast to a study from Zambia where it was the same in both genders.[17]

The mean age of 51 years reported in this study is similar to what has been reported in other local and African studies,[8],[11],[12],[13] but is much less than findings from the west where LGIB commonly occurred in the 7th and 8th decades of life perhaps due to increased life expectancy in the western population.[18],[19]

Colonoscopy yielded abnormalities in 92.6% of those with LGIB in this study. These high figures are seen in other similar studies[11],[20] and are not to be compared to figures from research that only examined LGIB as part of their general colonoscopy audit results. LGIB has been reported to have a high endoscopic yield, especially if performed within 44 hours after the bleeding episode, after which time it may be difficult to detect any stigma of recent hemorrhage.[21] The high diagnostic yield of colonoscopy has resulted in guidelines from major gastroenterology bodies listing the procedure as an appropriate tool in the clinical management of LGIB.[22]

The commonest colonoscopy findings in this study were hemorrhoids, tumors, diverticulae, and polyps, as has been reported in other studies.[1],[6],[7],[23] Our age-centered comparative analysis revealed that hemorrhoids were significantly associated with younger age, while tumors and diverticulosis were significantly associated with older age, as in other studies.[7],[8],[17] The excess prevalence of tumors and diverticulosis with advancing age is predictable but what is of grave concern in our data is that it showed that a third of the tumors were encountered in younger patients. This important statistic reflects an often overlooked but frequently reported phenomenon that colorectal cancers (CRC) in Africa appear not to have identical characteristics with those from the West.

A systematic review of 53 years of published CRC data concurs that relatively younger patients continue to constitute an unsettling high proportion of patients with CRC in Nigeria.[24] Also, more recent countrywide data in Nigeria agree with this view [Table 3].
Table 3: High proportions of young patients having CRC from various loco-regional studies

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These local data are mirrored by those from across the African continent.[30],[31],[32] There is not yet a hypothesis-driven, robust, prospective research to tackle this unique African problem.[33]


   Conclusion Top


The findings in this study reinforce what has been documented in other studies, which is that hemorrhoids, tumors, and diverticulae are the commonest findings in patients with LGIB, with younger age being significantly associated with hemorrhoids, and older age with tumors and diverticulae. The unfortunate phenomenon of a high proportion of CRC being found in young Africans is by no means “negligible” as described by Graham, et al.[34], it is in need of science to explain its existence and policy to truncate its persistence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]


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