njcp_497_20R4_OA

Original Article
1 A 10-Year Review of Colonoscopy at Aminu Kano Teaching Hospital, 1
2 2
3 Kano Nigeria 3
4 4
5 Y Musa, YM Abdulkadir1, M Manko2, YS Umar3, AN Mohammed1, I Yusuf4, MM Borodo1 , AA Samaila1 5
6 6
7 Department of Internal Background: Colonoscopy is an investigation modality used for colorectal 7

Abstract
8 Medicine, Federal Medical
examination; it is the most accurate technique for the diagnosis and surveillance of 8
9 Centre Katsina, Katsina 9
important colorectal diseases such as cancers (colorectal cancer) and polyps. Most
10 AQ6 State Nigeria, 1Department 10
of Internal Medicine, Bayero studies on colonoscopy in Nigeria were conducted in southwest such as Ilorin, Ife,
11 11
12
University/Aminu Kano Ibadan, and Lagos. We therefore feel the need to get information from other regions 12
Teaching Hospital, Kano such as northwest, the area of this study. The aim of this study was to identify
13 Nigeria, 2Department of 13
14 the common indications as well as colonoscopic findings among patients who had 14
Medicine, Ahmadu Bello
15 University/Ahmadu Bello
colonoscopy in Aminu Kano Teaching Hospital, Kano. Methodology: It was a 15
16 University Teaching Hospital 10‑year retrospective descriptive study of patients who had colonoscopy between 16
17 Zaria, Kaduna State Nigeria, January 2008 and December 2017 at the study center. Colonoscopy register 17
18 3
Department of Medicine, was used to extract information concerning the patient’s age, gender, symptoms 18
19 Murtala Muhammad that necessitated the request for the procedure, and the endoscopic findings. 19
20 Specialist Hospital, Kano Results: A total of 839 patient records were reviewed, males constituted 62.2% 20
Nigeria, 4Department of
21
Histopathology, Bayero
of the patients. The mean age ± standard deviation was 43.86 ± 18.36 years, 21
22 University/Aminu Kano with a range of 8–96 years. The 30–39 years constituted the modal age group, 22
23 Teaching Hospital, Kano followed by 40–49 years and 50–59 years. The commonest indications for the 23
24 Nigeria procedure were rectal bleeding (52.4%), chronic abdominal pain (51.3%), and 24
25 diarrhea (48.8%). The cecal intubation rate was 98.2% with hemorrhoids as the 25
26 commonest finding  (42.3%) followed by suspected inflammatory bowel disease 26
27 lesions (18.1%) and suspected colorectal tumors (16.2%). Conclusion: The 27
28 commonest reason for colonoscopy was rectal bleeding while the commonest 28
29 colonoscopic finding was hemorrhoids. 29
Received:
30 30
09-Aug-2020;
31 31
Revision:
32 17-Feb-2021;
32
33 Accepted: 33
34 23-Mar-2021; Keywords: Abdominal pain, bleeding per‑rectum, bowel preparation, cecal 34
35 Published: intubation rate, colonic cancer, colonic diverticuli, colonic inflammation, colonic 35
36 ***** polyp, colonoscopy, constipation, diarrhea, hemorrhoids 36
37 37
38 38
39 Introduction available.[1] Indications could be as a screening tool for
39
CRC in normal risk individuals from the age of 50 years,
40
41
42
C olonoscopy is an important means of diagnosing,
surveillance, or segregating important large bowel
disorders ranging from inflammation, polyps to colorectal
to investigate gastrointestinal (GI) bleeding, suspected
CRC, chronic abdominal pain, unexplained changes in
40
41
42
43 cancer (CRC).[1] Indications could be diagnostic and 43
44 or therapeutic.[2] In average‑risk individuals for CRC, Address for correspondence: Dr. Y Musa, 44
45 colonoscopy is one of acclaimed screening modalities, Department of Internal Medicine, Federal Medical Centre Katsina, 45
46 while high‑risk individuals for CRC have colonoscopy Katsina State, Nigeria. 46
E‑mail: yusuf.musa@npmcn.edu.ng
47 as the only gold standard investigation of choice 47
48 48
This is an open access journal, and articles are distributed under the terms of the
49 Access this article online Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows 49
50 Quick Response Code:
others to remix, tweak, and build upon the work non‑commercially, as long as 50
appropriate credit is given and the new creations are licensed under the identical
51 Website: www.njcponline.com
terms.
51
52 52
For reprints contact: reprints@medknow.com
53 DOI: 10.4103/njcp.njcp_497_20 53
54 How to cite this article: Musa Y, Abdulkadir YM, Manko M, Umar YS,
54
55 PMID: ******* Mohammed AN, Yusuf I, et al. A 10-year review of colonoscopy at aminu 55
56 kano teaching hospital, kano nigeria. Niger J Clin Pract 2021;XX:XX-XX. 56

© 2021 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 1

 Musa, et al.: Colonoscopy at AKTH, Kano Nigeria

1 bowel habit, or when an abnormality is found on colonic Pentax EPK‑1000 video colonoscope, Olympus Optera 1
2 imaging. Similarly, patients with history of polyps, CV‑170 video system with CF‑H170 colonoscope. 2
3 CRC, and those with history suggestive of hereditary 3
4 The common agent used for bowel preparation was oral 4
CRC syndrome may need to be on surveillance
5 Bisacodyl (Dulcolax) 10–15 mg twice daily for 3 days 5
colonoscopies.[2] Positive results for fecal occult blood
6 with rectal Dulcolax a night prior to and morning of the 6
test especially using the fecal immunohistochemistry
7 procedure plus 20% mannitol diluted with soft drinks 7
is practically an indication for colonoscopy in most
8 300–500 ml taken orally a day to the procedure. Other 8
cases.[3] Unlike developed societies where colonoscopy
9 agents used include castor oil 2–4 bottles taken within 9
is routinely used for screening and other diagnostic as
10 2 days with 300–500 ml of 20% mannitol taken orally 10
11
well as therapeutic means, in Nigeria such services are 11
a day to the procedure. Bowel preparation is given for
12 scarcely available making data on it scarce as well.[2] 12
3 days with patients placed on low residue diet 3–2 days
13 It has been more than 30  years from the first published 13
to procedure, and clear fluid such as exotic drink, soda
14 series on availability and utilization of colonoscopy in 14
water, and other noncolored beverages taken a day to
15 Nigeria; however, it’s still in youthful stage in most part 15
procedure. Boston Bowel Preparation Score is the most
16 of the country.[4] However, there is generally observed 16
common guide used for assessing the adequacy of bowel
17 increase in colonoscopy utilization by both family and 17
preparation.
18 general physicians in developing societies due to newer 18
19 machineries, bowel preparatory methods, and conducive Colonoscopy registers for the procedures conducted 19
20 atmosphere for the procedure.[5] In African continent and during the stated time were reviewed, and relevant data 20
21 subcontinents, appreciating variable pathological findings on patients’ demography, presentation or indication for 21
22 on colposcopy still remains elusive from underreporting the procedure, and endoscopic findings were recorded 22
23 and poor detection methods with very long waiting accordingly. The biopsies taken were followed at the 23
24 time ranging from weeks to months.[6] Many quality histopathology department of the same institution for 24
25 histological diagnosis of presumed lesions identified 25
indices have been studied to optimize endoscopy
26 26
procedure from the perspective of both the patient and during the procedure.
27 27
the physician. Cecal intubation rate (CIR), adenoma Variables were recorded in a Microsoft Excel sheet
28 28
29 detection rate, withdrawal time, and quality of the version 2016, and after data cleaning, the data were 29
30 reporting are among the variables that determine the analyzed using a computer‑based Statistical Program 30
31 effectiveness of the procedure which defines quality for Social Sciences version 20.0 (SPSS Inc., Chicago 31
32 of the examination.[7,8] For screening studies, 95% CIR IL, USA). Qualitative/Continuous variables were 32
33 or more is the American Society for Gastrointestinal summarized using mean and standard deviations and 33
34 Endoscopy recommendation and 90% is acceptable for their differences determined using the t‑test. Quantitative/ 34
35 diagnostic colonoscopies. However, even among experts, Categorical variables were grouped into proportions, 35
36 the failure rate of accurate diagnosis is up to 30%, while 36
median, interquartile range, and percentages and their
37 the missed adenoma rate is between 33% and 46% due 37
associations determined using the χ2 test. A  confidence
38 to poor bowel preparation.[8] 38
39 interval of 95% was used, and a P value of <0.05 was 39
40 We conducted this study in order to share with the world considered significant. 40
41 our experience concerning lower GI endoscopy, and 41
42 we collaborate further with histopathologist to confirm Results 42
43 some of the identified lesions during the course of our A total of 839 patient records that had colonoscopy over 43
44 procedures. the period under review were analyzed. Over 62.2% (522) 44
45 of the patients were males with male‑to‑female ratio 45
46 Methodology of 1.7:1. The mean age ± standard deviation was 46
47 It’s a 10‑year retrospective descriptive study that 43.86 ± 18.36, with a range of 8–96 years; however, 47
48 analyzed all colonoscopies conducted at Aminu Kano 4.9%  (41) of the patients have no specific age recorded. 48
49 Teaching Hospital (AKTH), Kano, Nigeria from January The 30–39 years constituted the modal age group with 49
50 50
2008 to December 2017. AKTH has a diagnostic center 168 subjects (20.0%), followed by 40–49 years with
51 51
where the endoscopy suite receives requests from 160 (19.1%) and 50–59 years with 159 (19.0%). Table 1
52 52
Jigawa, Katsina, Bauchi, Yobe, Borno, and Zamfara depicts the age distribution of study subjects.
53 53
54 states. 54
Bleeding per rectum and abdominal pain constituted
55 The endoscopy unit has colonoscopy suite that is the modal presentation/indication for colonoscopy. 55
56 equipped with an Olympus‑adjustable procedure couch, There was statistically significant difference between 56

2 Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2021
 Musa, et al.: Colonoscopy at AKTH, Kano Nigeria

1 60 45 1
56.9 MELENA
2 PR BLEEDING 40 42.3
2
3 48.8
ABDOMINAL PAIN 3
50 35
4 DIARRHEA 4
ABDOMINAL SWELLING
5 30 5

PERCENTAGE
WEIGHT LOSS
6 40
CONSTIPATION 25 6
PERCENTAGES

7 AMEMIA 20 7
8 30
26.5
28.1 18.1 8
15 16.5
9 9
10 20
10
10
16.7 8.4
11 5 7 11
4.1
12 0 12
10 7.4 FINDINGS
13 HEMARRHOIDS COLORECTAL CANCER DIVERTICULOSIS
13
3.3
14 INFLAMATORY BOWEL POLYPS OTHERS 14
15 0 DISEASE 15
16 Figure 1: Indications for colonoscopy (original) Figure 2: Colonoscopic findings (original) 16
17 17
18 18
19 ANAL CANAL, 19
7%
20 20
21 21
22 ASCENDINGCOLON,
14%
22
23 23
24 24
TRANSVERSE COLON,
25 7% 25
26 RECTOSIGMOID, 63% 26
DESCENDING
27 COLON, 9% 27
28 28
29 29
30 30
31 31
32 32
33 Figure 3: Distribution of suspected colonic tumor (original) Figure 4: Hemorrhoid 33
34 34
35 35
36 36
37 37
38 38
39 39
40 40
41 41
42 42
43 43
44 44
45 Figure 6: Colonic polyp 45
46 46
47 Majority of the study subjects (92.7%) had good bowel 47
48 preparations with a minimum score of 6 or more 48
49 on Boston Bowel Preparation Score;[9] this leads to 49
50 Figure 5: Colonic inflammation
successful completion of the procedure in more than 50
51 51
90% (CIR of 98.2%).
52 males and female in the case of diarrhea as an 52
53 indication (P = 0.025) as well as weight loss (P = 0.045). Hemorrhoids were the commonest finding seen in 53
54 Such association was lacking in other presentations. 355 subjects (42.3%) while diverticulosis was the least 54
55 Figure 1 highlights various presentations or indications frequently identified lesions seen in 35 subjects  (4.2%). 55
56 for colonoscopy at the study center. Most of the patients with hemorrhoids fall within the 56

Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2021 3
 Musa, et al.: Colonoscopy at AKTH, Kano Nigeria

1 confirmed cases of Crohn’s disease, 20 ulcerative colitis, 1

2 6 each for both lymphocytic colitis and infective colitis 2
3 as well as 45  cases of nonspecific colitis. Others were 3
4 ischemic colitis and indeterminate colitis which were 4
5 recorded once during the study period. 5
6 6
7 Similarly, histological record of polyps removed revealed 7
8 adenoma in 80%, with 14.3% as hyperplastic polyp, 8
9 while inflammatory polyp  (from chronic schistomiasis) 9
10 and a fibro‑epithelial polyp were one each. 10
11 11
Figures 4–7 depict real colonoscopic images of the
12 12
common endoscopic findings.
13 13
14 14
15
Discussion 15
16 Figure 7: Suspected colonic tumor This is a study conducted to identify the common 16
17 presentation, demographic characteristics, and findings 17
18 Table 1: Age distribution of study subjects (original) on colonoscopies done over a period of 10 years in a 18
19 Age groups (years) Frequency Percentage tertiary public health facility in the northwestern part 19
20 Not available 41 4.9 of Nigeria. Predominant percentage of patients coming 20
21 1‑17 14 1.7 for colonoscopy were males similar to what was 21
22 18‑19 3 0.4 reported from various centers in Nigeria,[2,4,7] Zambia,[6] 22
23 20‑29 107 12.8 Lebanon,[10] Turkey,[5] and India.[3] This may be due to 23
24 30‑39 168 20.0 the general setting of our society where males are more 24
25 40‑49 160 19.1 financially capable than females. Majority of the patients 25
26 50‑59 159 19.0 were in their fourth to sixth decade of life; however, the 26
27 60‑69 108 12.9 mean age of presentation is about a decade lower than 27
28 70‑79 59 7.0 28
the one reported by researchers from Africa, Asia, and
29 80‑89 17 2.0 29
Middle East[2,4,5,7] but similar to Indian report.[3]
30 ≥90 3 0.4 30
31 There was no single screening colonoscopy requested 31
32 age range of 40–59, followed by those under 40 years throughout the study period, this is worrisome 32
33 with those over 60 years having the least frequency. especially with the increasing prevalence of colonic 33
34 The male‑to‑female ratio is that of 2:1. Details of cancer worldwide. Rectal bleeding was the commonest 34
35 presentation of our patents. We recorded very good 35
colonoscopic findings are shown in Figure 2.
36 bowel preparation during the study period despite 36
37 Young patients below the age of 40 years were using an improvised agent for that purpose, a factor 37
38 the commonest population with suspected that determines quality of every colonoscopic 38
39 inflammation  (44.59%), while those between 40 and 39
examination.[3,8,11] This is an important finding that may
40 59 years had about 39.86% with those above 60 years 40
allow other endoscopists in our society to adapt such
41 making 15.54%. The male‑to‑female ratio was 1.4:1. 41
42
cheap and readily available cleaning methods. The CIR 42
43 Similarly, colonic tumor was commoner among age was excellent; this may as well be the result of adequate 43
44 group 40–59 years having 36.76% followed by those bowel preparation recorded in most of the study subjects. 44
45 below 40 years (35.29%) with male‑to‑female ratio of The commonest colonoscopic finding was hemorrhoids 45
46 1.8:1, mostly seen at Recto‑sigmoid colon, followed which is similar to most researches in Africa, Asia, 46
47 by ascending, descending, and transverse colons in 47
Middle East, and Europe.[2‑7] Predominant percentage of
48 decreasing frequency with anal canal having the lowest 48
those with hemorrhoids fall under the middle age group
49 tumor frequency as shown in Figure 3. 49
which is the common age group affected worldwide.[12]
50 50
Other findings in order of decreasing frequency were
51 Suspected IBD was the next in frequency among the 51
proctitis, evidence of external compression, anal tag,
52 finding; this is contrary to the common thinking of IBD 52
53 anal fistula, angiodysplasia, anal fissure, rectal varices, 53
being rare in our society.[13] It cuts across all histological
54 worms, and entero‑colic fistula. 54
types of IBD; however, most of the analyzed samples
55 Review from histopathology register of our suspected yielded nonspecific colitis. However, contrary to most 55
56 inflammatory bowel disease  (IBD) samples revealed 4 reports, our patients were mainly in their youthful age. 56

4 Nigerian Journal of Clinical Practice  ¦  Volume XX  ¦  Issue XX  ¦  Month 2021
 Musa, et al.: Colonoscopy at AKTH, Kano Nigeria

1 Colonic tumor is the third most common finding experience from a private centre in Lagos, Nigeria. Orient J Med 1
2 among patients during the study period. As reported 2016;28:73‑8. 2
3 5. Colakoglu MK, Akdogan R, Rakici H, Ayvaz MA, Set T. 3
in most parts of the world, left colon is the most
Evaluation of colonoscopy requests in an open‑access endoscopy
4 affected site.[14‑17] However, most of the patients were at 4
unit. Ann Med Res 2018;25:601‑7.
5 younger age group as opposed to the common findings 5
6. Kayamba V, Nicholls K, Morgan C, Kelly P. A seven‑year
6 in the world;[15‑18] this is an eye opener with regard retrospective review of colonoscopy records from a single centre 6
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8 tumors in sub‑Saharan Africa and hence the need for 7. Onyekwere CA, Odiagah JN, Ogunleye OO, Chibututu C, 8
9 Lesi OA. Colonoscopy practice in Lagos, Nigeria: A report of an 9
more surveillance using both invasive and noninvasive audit. Diagn Ther Endosc 2013;2013:798651.
10 10
methods in order to detect the tumor early among our 8. Chen J, Athilingam P, Saloum Y, Brady P. Enhancing bowel
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teeming youths. preparation for screening colonoscopy: An evidence‑based
12 12
literature review. J Nurse Pract 2015;11:519‑25.
13 In conclusion, rectal bleeding is the commonest 13
9. Kastenberg D, Bertiger G, Brogadir S. Bowel preparation quality
14 indication for lower GI endoscopy; hemorrhoid is the scales for colonoscopy. World J Gastroenterol 2018;24:2833‑43. 14
15 most common finding during the procedure. Significant 10. Saber T, Bedran K, Ghandour F, El Khoury M, Khalil RB, 15
16 percentage of patients was found to have suspected IBD Farhat S. Results from a retrospective analysis of colonoscopies 16
17 and CRC. for Inflammatory bowel disease and colorectal cancer in a 17
18 Lebanese tertiary care centre. Br Med J Open Gastroenterol 18
19 Acknowledgments 2017;4:e000167. 19
20 Dr. Mansur F. Mohammed, Dr. Nurudeen O. Muhammad, 11. Rees CJ, Bevan R, Zimmermann‑Fraedrich K, Rutte MD, Rex D, 20
Dr. Abdulrashid O. Abdulrahim, Dr. Maryam Hussain, Dekker E, et al. Expert opinions and scientific evidence for
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colonoscopy key performance indicators. Gut 2016;65:2045‑60.
22 Dr. Dada, Dr. Ibrahim Mohammed, and endoscopic 12. Sun Z, Migaly J. Review of hemorrhoid disease: Presentation
22
23 nurses are gratefully acknowledged. and management. Clin Colon Rectal Surg 2016;29:22‑9. 23
24 13. Alatise OI, Otegbayo JA, Nwosu MN, Lawal OO, Ola SO, 24
Financial support and sponsorship
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26 Nil. disease in three tertiary health centers in southern Nigeria. West 26
27 Conflicts of interest Afr J Med 2012;31:28-33. 27
28 14. Khougali HS, Albashir AA, Daffaalla HN, Salih M. Demographic 28
There are no conflicts of interest. and clinicopathological patterns of colorectal cancer at the
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44 Author Query?? 44
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