Colonoscopy Findings at Divine Mercy Hospital-Father Bash Foundation, South-Western Uganda: A 6 Years Retrospective Analysis ()
1. Introduction
Colonoscopy is a procedure that involves the placement of a flexible tube with a fibre optic camera on its tip, through the rectum, in order to visualize the colon [1]. It is a key investigation required for diagnosis of several disease conditions involving the lower gastrointestinal tract [2]. Lower GI symptoms requiring colonoscopy include GI bleeding, chronic constipation, recurrent abdominal pain, chronic diarrhoea and mucoid stools among others [3]. Colonoscopy is the gold standard for screening and diagnosis of colorectal cancer [4]. Other benign lesions that are commonly encountered at colonoscopy include: polyps, colorectal adenomas, inflammatory bowel disease and other forms of colitis, as well as internal hemorrhoids and diverticulosis [5] [6]. The procedure also gives room for minimally invasive therapeutic modalities like polypectomy [5]. Advances in colonoscopy have greatly improved clinical practices in modern gastroenterology [7].
In many African countries, colonoscopy services can only be accessed in a few health facilities [6] [8] [9] and many patients are treated empirically while others are referred to urban centres where the service can be accessed [10]. This is attributed to few trained health personnel to handle these procedures, lack of equipment and inadequate infrastructure [11] [12].
In low- and middle-income countries, the prevalence of colorectal cancer has been reportedly low compared to developed countries. This is attributed to the limited access to colorectal disease screening services especially colonoscopy [13]. A study was done in Ethiopia, Kenya, Malawi and Zambia to evaluate the gastrointestinal endoscopy capacity by interviewing digestive healthcare professions in various health facilities and it was discovered that endoscopy capacity is severely limited in sub-Saharan Africa despite the high burden of gastrointestinal diseases in this region [14].
In Uganda, there is limited local research to guide policy and programming for CRC prevention. This prompted a stakeholders engagement workshop in Kampala in March 2024 where limited CRC screening was reported as a major barrier to CRC diagnosis [15].
Therefore, this study aimed at describing the various indications and findings at colonoscopy at Divine Mercy Hospital in South Western Uganda.
2. Methods
2.1. Study Setting and Design
This was a 6-year retrospective record review of endoscopy reports for patients done colonoscopy at DMH from October, 2018 to September, 2024. This period was considered because it is the period when the endoscopy unit at DMH was established. DMH is a private not for profit institution under Father Bash Foundation in Mbarara City. The hospital has a complete set of endoscopy equipment of the Olympus type. There are three functional gastroscopes and two colonoscopes. Colonoscopies were done by a trained endoscopist who was also a general surgeon. The procedures were done under sedation by an experienced anesthetist to optimize patient comfort. For patients that required biopsy sampling, the specimens were picked and put in appropriate containers where they were preserved in 10% formalin solution and later taken to lancet laboratories for histopathological analysis. After the procedure, the findings were explained to the patient and a written report was printed and given to the patient (or his/her attendants). The hospital also kept a copy of the report, both electronic and hard copy. DMH is a referral centre for patients who require colonoscopy in Ankole and Kigezi subregions, serving a population of approximately 5.3 million as per the report from Uganda Bureau of statistics, 2024.
2.2. Study Population
We included all reports of patients done colonoscopy at DMH during the study period.
2.3. Study Procedure
In November and December 2024, with the help of a trained research assistant who was a qualified theatre nurse with additional training in gastrointestinal endoscopy procedures, we were able to retrieve all the reports for patients who underwent colonoscopy at DMH from October, 2018 to September, 2024. From these reports, the study variables that were extracted included: patients age, gender, indication, findings at colonoscopy. Records of patients with suspicious lesions warrantying biopsy at colonoscopy were further reviewed in the hospital electronic database to establish the histopathological diagnosis as per the histology results processed by Lancet laboratories.
Ethical approval was sought from Mbarara University of Science and Technology Research Ethics Committee (MUST REC) and administrative clearance was also obtained from DMH administration. A waiver of consent was sought from MUST REC since the study was entirely dealing with retrospective data without any need to interface with patients. Data was kept confidential – we deidentified the information.
2.4. Data Analysis
Data was entered in Microsoft Excel spread sheet and the Principal Investigator (PI) cross checked all the entries made. Statistical analysis was done using Stata version 17 (StataCorp. 2021. Stata: Release 17. Statistical Software. College Station, TX: StataCorp LLC). Descriptive statistics was done to answer the objectives of this study. Patient demographic information, indications, colonoscopy and histology findings were summarized in frequency tables. Categorical variables were summarised as proportions (percentages). Continuous variables which were normally distributed were summarised using mean and standard deviation. Additionally, a cross tabulation comparing independent variables (age, gender, indication) and the occurrence of malignancies was made. A student’s t-test and or chi square p-value < 0.05 was considered significant.
3. Results
3.1. Patient Characteristics and Indications for Colonoscopy
Reports of 389 patients who had undergone colonoscopy were retrieved. The mean age of participants was 54.1 (±18.7) years. Majority were males (63.5%), and majority presented with lower GI bleeding (57.3%) as shown in the Table 1.
Table 1. Showing patient characteristics and indication for colonoscopy.
Variable |
Number |
Percentage |
Mean Age (±SD) |
54.1 (±18.7) |
|
Age category |
|
|
<50 years |
162 |
41.65 |
≥50 years |
227 |
58.35 |
Gender |
|
|
Female |
142 |
36.5 |
Male |
247 |
63.5 |
Indications |
|
|
Anorectal pain |
30 |
7.7 |
Constipation |
48 |
12.3 |
Lower GI bleeding |
223 |
57.3 |
Diarrhea |
5 |
1.3 |
Lower abdominal pain |
82 |
21.1 |
Rectal prolapse |
1 |
0.3 |
3.2. Colonoscopy Findings
Of the 389 patients, 120 (30.8%) had normal findings at colonoscopy. Tumors were seen among 55 patients, with anorectal tumors dominating (n = 32). Other common findings included hemorrhoids (n = 95, 24.4%), non -specific colitis (n = 54, 13.9%), and inflammatory bowel disease (n = 27, 6.9%) as shown in the Table 2.
Table 2. Showing colonoscopy findings.
Findings |
Number |
Percentage |
Anal fissure |
10 |
2.6 |
Anal warts |
1 |
0.3 |
Anorectal tumor |
32 |
8.2 |
Non-specific Colitis |
54 |
13.9 |
Colon tumor |
23 |
5.9 |
Colonic polyp |
11 |
2.8 |
Diverticulosis |
14 |
3.6 |
Hemorrhoids |
95 |
24.4 |
Inflammatory Bowel Disease |
27 |
6.9 |
Normal |
120 |
30.8 |
Rectal prolapse |
2 |
0.5 |
3.3. Biopsy Results
Biopsies were taken from patients with endoscopic diagnosis of tumors, polyps, IBD and severe forms of colitis. Among 106 patients who had biopsy samples picked, 49 (46.2%) patients had confirmed cancer. Of these, 30 patients had anorectal cancer while 19 patients had colon cancer. 5 patients had right sided colon cancer. The commonest histological type was Adenocarcinoma with varying grades of differentiation (n = 48). We were unable to access histology results for 23 patients (21.7%) in their medical documents, while the rest had benign conditions as shown in the Table 3.
Table 3. Showing histology findings.
Biopsy finding |
Number |
Percentage |
Adenocarcinoma |
48 |
45.3 |
Inflammatory bowel disease |
8 |
7.5 |
Inconclusive |
3 |
2.8 |
Inflammatory polyp |
4 |
3.8 |
Low Grade Leiomyosarcoma |
1 |
0.9 |
Non-specific colitis |
19 |
17.9 |
Missing results |
23 |
21.7 |
3.4. Characteristics of Patients with Malignancy at Histology
The mean age of participants with malignancy was statistically higher compared to the mean age of patients without malignancy (p-value = 0.002). The proportion of participants with LGIB was statistically higher among the group with malignancy compared to the proportion of participants with LGIB in the non-malignancy group (p-value = 0.037). Early onset cancer (diagnosed before 50 years of age) occurred in 28.6% of patients with malignancy as shown in the table below (Table 4).
Table 4. Showing characteristics of patients with malignancy at histology.
Characteristic |
Malignancy
(n = 49) |
No Malignancy
(n = 57) |
p-Value |
Mean Age (SD) |
60.1 (18.1%) |
48.6 (18.6%) |
0.002* |
Age category |
|
|
0.007* |
<50 years |
14 (28.6%) |
31 (54.4%) |
|
≥50 years |
35 (71.4%) |
26 (45.6%) |
|
Sex |
|
|
0.282 |
Female |
24 (49%) |
22 (38.6%) |
|
Male |
25 (51%) |
35 (61.4%) |
|
Lower GI bleeding present |
|
|
0.037* |
No |
7 (14.3%) |
18 (31.6%) |
|
Yes |
42 (85.7%) |
39 (68.4%) |
|
4. Discussion
Majority of our patients were males with a male to female ratio of 1.7:1. This was consistent with studies done in south western Nigeria [3] and Zanzibar [16] where the male to female ratios were 3.5:1 and 1.2: 1 respectively. However, the explanation for this male predominance remains uncertain.
The mean age of our patients was 54.1 (±18.7) years. The youngest patient was 8years while the oldest patient was 91years. Colonoscopy was done in only 5 patients below 18years of age. In a large study that was conducted on 1858 patients, Naseer et al., reported a mean age of 51.7 (±18.5) years [1] which was quite similar to our study. However, in Ethiopia, Gudissa et al., reported a mean age of 43.5 years (SD = 15.67) with age range of 15 - 84 years [17]. The wide age range in our study could perhaps explain this variation in the mean age.
Lower Gastrointestinal bleeding (LGIB) is a threatening symptom that makes patients and their caretakers worried hence the need to seek medical services at the nearest health facility. In this study, LGIB was the most common indication for colonoscopy and this was also reported by Obonna et al., in Nigeria [3]. However, a study done by Qu et al., in Zanzibar, LGIB was the third most common indication after chronic diarrhea and abdominal pain [16]. Anorectal pain and chronic constipation were among the other indications for colonoscopy. One patient, who was a 27 years old male, had rectal prolapse as the indication for colonoscopy but the colonoscopy report revealed normal findings. Similarly, a 32 years old male had anal warts but his colon had normal findings. We were unable to establish his serostatus from the available data.
The most common benign finding at colonoscopy was presence of hemorrhoids which accounted for the largest portion of patients with LGIB. Other benign lesions identified at colonoscopy were colitis, inflammatory bowel disease, polyps, anal fissures and diverticulosis among others. Ismaila and Misauno also found hemorrhoids in 58.1% of the patients that were done colonoscopy and the other benign lesions were quite similar to the ones reported in our study [18]. This similarity could be explained by the fact that these studies were done in African countries whose communities share similar socio-economic status, environmental factors and health seeking behaviors. This study did not establish any causal factors for these findings.
Forty-nine patients had malignant lower GI conditions confirmed at histology and of these, 14 (28.6%) were below 50years of age. The CDC recommends that adults aged 45 to 75 years should be screened for colorectal cancer [19]. Although colorectal cancer (CRC) is more common in patients above 50 years of age, there are rising cases of early onset colorectal cancer among patients below 50 years and this may be partly attributed to lifestyle changes, obesity and dietary habits [20] [21]. Several studies have reported advanced age as a risk factor to colorectal cancer and these patients usually present with hematochezia and anemia [16] [22] [23]. Although males had a significantly higher predominancy among patients who had colonoscopy (63.5%), those with confirmed malignancy were almost in equal proportions without gender predilection. Male gender has been reported as a risk factor for CRC in some studies [20]. The histopathological diagnosis was predominantly adenocarcinoma, with varying degrees of differentiation. Other studies in literature have also reported adenocarcinomas as the most common histological diagnosis among patients with colorectal cancers [24]-[26].
A number of patients (30.8%) had normal colonoscopy findings. This finding resonates well with some studies done in Nigeria that found normal colonoscopy findings in 24% [3] and 20.9% [18]. This was mainly observed among patients who presented with lower abdominal pains for which colonoscopy was requested by the attending doctor but it is presumed that the abdominal pain could have been due to other causes.
5. Conclusion
In South Western Uganda, the most common indication for colonoscopy was lower GI bleeding. Hemorrhoids, colitis and inflammatory bowel disease were the main benign findings at colonoscopy. Several patients also had lower GI malignancies and these were predominantly adenocarcinomas. This study highlights the importance of colonoscopy in diagnosing and managing lower GI conditions in a resource-limited setting.
Recommendation
Patients with lower GI symptoms should undergo colonoscopy to obtain a clear diagnosis that in turn helps the health worker to institute a proper plan of management.
Limitations
This was a retrospective study that mainly looked at colonoscopy reports which had limited variables that would be extracted for statistical analysis, thus indepth analysis could not be done to establish the possible risk factors for these colonoscopy findings.
We had some missing histology results, this may be attributed to some patients who may prefer to go with their samples to be processed by their primary healthcare physician, thus the hospital lacks record of such histological results.
Acknowledgement
We acknowledge the support and guidance from the Faculty of Medicine at Mbarara University of Science and Technology as well as the theatre team and administration at Divine Mercy Hospital.