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Original Article

Clinical, Endoscopic and Histological Profile of Colorectal

Cancers Seen on Colonoscopy in Kano, North‑Western Nigeria
Yusuf Musa, Mansur Femi Mohammed1, Nurudeen Olalekan Muhammad2, Ibrahim Yusuf3, Abdulrashid Onimisi Abdulrahim4, Adamu Alhaji Samaila2,
Musa Muhammad Borodo2
Department of Internal Medicine, Federal Medical Centre, Katsina, Katsina State, 1Department of Internal Medicine, Ahmadu Bello University Teaching Hospital, Zaria,
Kaduna State, 2Department of Internal Medicine, Aminu Kano Teaching Hospital and Bayero University Kano, Kano State, 3Department of Histopathology Aminu Kano
Teaching Hospital and Bayero University, Kano, 4Department of Internal Medicine, Federal Medical Centre, Azare, Bauchi State, Nigeria

Abstract
Background: Colorectal cancer (CRC) is the most prevalent gastrointestinal (GI) cancer. With 5% risk of developing CRC in life, it became
the third leading cause of cancer death in developed nations. In Nigeria, it is the most common GI cancer. However, there are limited data on
CRC in the study area (North‑Western part of Nigeria). The aim of this study was to identify the clinical, endoscopic and histological profile of
CRC seen on colonoscopy. Methodology:   This was a retrospective descriptive study where colonoscopic and histological records of suspected
CRC in the study centre between January 2008 to December 2017 were evaluated. Results: Records of 135 patients were reviewed, and males
constituted 63.7%. The mean age was 46.61 ± 16.80 years, with 30–39 years as a modal group. Common presentations were diarrhoea (86.7%)
and bleeding per rectum  (68.9%). Areas affected were rectosigmoid colon  (63%), ascending colon  (14.1%), descending colon  (8.9%),
transverse colon (7.4%) and anal canal (6.7%). Histologically, adenocarcinoma was reported in 57.8%, mucinous adenocarcinoma in 8.1%
and signet ring cell adenocarcinoma in 3.7%. Tubular and villous adenomas were 3% each. Others were carcinoid tumours (1.5%), metastatic
adenocarcinoma, squamous cell carcinoma, basal cell carcinoma, GI stromal tumour, inflammatory myofibroblastic tumour, angiosarcoma and
adenoid cyst carcinoma reported in 0.7% each. Conclusion: Majority of the patients with CRC were in their young age. The most common
presentations were diarrhoea, weight loss and anaemia. The most common site of affectation was in the left colon, while the most common
histological finding was adenocarcinoma.

Keywords: Adenocarcinoma, anal canal, ascending colon, colonoscopy, colorectal cancer, descending colon, mucinous adenocarcinoma,
rectosigmoid colon, signet ring adenocarcinoma, transverse colon, tubular adenoma, villous adenoma

Introduction CRC is the fourth most common malignancy amongst men

and women in Nigeria.[10] The actual Nigerian incidence
Colonic and rectal malignancies are very common cancers
and prevalence of CRC are lacking. However, the estimated
globally.[1] Colorectal cancer (CRC) is the third most common
prevalence is about 3.4 cases per 100,000 population,[11] while
cancer in both sexes and the second most common cause of
the incidence is 6.4–8.7 and ≤6.3 per 100,000 in males and
cancer‑related deaths.[2‑5] Incidence and prevalence are on
females, respectively.[2,3] Similarly, the combined incidence for
the rise globally, but early detection and modern treatment
both sexes was 5.5–6.5/100,000.[5] CRC is recently found to be
facilities in industrialised nations have made its morbidity and
the most common gastrointestinal (GI) tumour in Nigeria.[7,12‑15]
mortality to be more glaring in unindustrialised nations.[5‑8] This
in part is related to the establishment of screening programmes, Cancer of the colon was found to have an incidence of 3.3 and
with early cancer detection in such nations, unlike what is 3.0 for males and females in West Africa in 2018, while rectal
obtainable in developing countries like Nigeria.[9,10]
Address for correspondence: Dr. Yusuf Musa,
Department of Internal Medicine, Federal Medical Centre, Katsina, Nigeria.
E‑mail: yusuf.musa@npmcn.edu.ng
Received: 02‑09‑2020 Revised: 01-10-2020
Accepted: 28-11-2020 Published: 25‑02‑2021
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How to cite this article: Musa Y, Mohammed MF, Muhammad NO, Yusuf I,
DOI: Abdulrahim AO, Samaila AA, et al. Clinical, endoscopic and histological
10.4103/npmj.npmj_288_20 profile of colorectal cancers seen on colonoscopy in Kano, North-Western
Nigeria. Niger Postgrad Med J 2021;28:22-6.

22 © 2021 Nigerian Postgraduate Medical Journal | Published by Wolters Kluwer - Medknow

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Musa, et al.: Colorectal cancers seen on colonoscopy in Kano, Nigeria
cancer had 2.7 and 2.1 for the two sexes.[2,3] CRC has a global
incidence of 19.7 for both sexes with 23.6 and 16.3 for males
and females, respectively.[2,3,5]
CRC, though previously reported mainly amongst the middle
aged and elderly worldwide,[1,6,7,9,11,13,16‑21] is now increasingly
reported amongst younger individuals even before the age of
20.[22‑25] Similarly, CRC has been postulated to be seen one or
two decades earlier in Africans compared to Caucasians.[26]
CRC has a variety of modifiable and non‑modifiable risk factors.
The non‑modifiable factors are ethnicity, hereditary cancer
syndromes, family history of CRC, male gender, advancing
age, long stature, history of adenomatous polyps, history of
inflammatory bowel disease, type 2 diabetes mellitus, previous
CRC, cystic fibrosis, abdominal radiation during childhood
and cholecystectomy amongst others.[5,6,11,12,16,17,21,22,27] On the
other hand, modifiable risk factors include obesity, physical
inactivity, consumption of excessive red meat, fat and
processed food, excessive calcium intake excessive alcohol
intake, low fibre intake, low Vitamin D, reduced fruits and
vegetable intake, cigarette smoking, low socio‑economic
status and some gut microbiota. However, high fibre diet,
fruits, vegetables and non‑steroidal anti‑inflammatory agents
are said to be protective.[5,6,11,12,16,17,21,22,27]
Early‑onset CRC is asymptomatic in  >80% of cases, but
non‑specific symptoms such as malaise, weight loss, lassitude,
abdominal pain, change in bowel habits and haematochezia
are less common. Similarly, late‑onset CRC (LOCRC) may be
asymptomatic or identified during routine screening exercise
on colonoscopy. However, advanced LOCRC (Stage III or IV)
may present with distant metastasis and/or complications,[22,25]
features of obstruction, perforation, bleeding, abdominal
pain, asthenia, anaemia, altered bowel habit feeling of mass
per abdominal, bowel perforation and other constitutional
features.[11,12,22,26]
CRC prevention involves screening and lifestyle and dietary
changes, exercise, weight reduction and removal of polyps
during screening. Drugs such as aspirin, bisphosphonates,
statins and hormones have been shown to have some protective
effect.
Screening methods include faecal occult blood testing,
faecal immune‑histochemical test and faecal DNA, flexible
sigmoidoscopy, computed tomography colonography,
double‑contrast barium enema and colonoscopy.[5,12,16]
The aim of this study is to evaluate retrospectively the clinical
profile of patients found with colonic tumour on endoscopy,
various sites of affectation and histology of such lesions.
Methodology
This is a retrospective descriptive study of CRCs diagnosed
over 10 years during endoscopy from January 2008 to
December 2017 in the Endoscopy Unit and Histopathology
Department, Aminu Kano Teaching Hospital, Kano, Nigeria.
Nigerian Postgraduate Medical Journal  ¦  Volume 28 ¦ Issue 1 ¦ January-March 2021
Aminu Kano Teaching Hospital is an institution in Kano city,
North‑Western Nigeria. It is equipped with an endoscopy
suite since 1992 and manned by gastroenterologists from the
Department of Internal Medicine. The unit receives requests
from Jigawa, Katsina, Bauchi, Yobe, Borno and Zamfara states.
The unit has also a colonoscopy suite which is equipped with an
Olympus adjustable procedure couch, Pentax EPK‑1000 video
colonoscope, Olympus Optera CV‑170 video system with
ADVAN AMM215WTD Monitor, TE‑NE Compact Trolley
assembly and CF‑H170 colonoscope. The common agents used
for bowel preparation are oral and rectal Bisacodyl (Dulcolax)
as well as castor oil and 20% diluted oral mannitol. Boston
Bowel Preparation Score is the most common guide used for
assessing the adequacy of bowel preparation.
The endoscopy register was reviewed, and all the patients
with suspected CRC between January 2008 and December
2017 were isolated and their relevant data such as sex, age
and symptomatology or indication for the procedure as well
as endoscopic findings were noted accordingly. The biopsies
taken were followed up at the Histopathology Department of
the same institution where previous histology registers were
checked for confirmation of histological diagnosis.
Variables were recorded on Microsoft Excel sheet version 2016
and transferred into computer‑based Statistical Program for
the Social Sciences (SPSS) software version 20.0 (SPSS Inc.,
Chicago IL, USA) for analysis. Qualitative variables were
summarised using mean and standard deviations and their
differences determined using the t‑test. Quantitative variables
were grouped into proportions, median, interquartile range
and percentages and their associations determined using the
X2 test. A confidence interval of 95% was used, and P < 0.05
was considered statistically significant.
Results
After thorough evaluation of the register, 135  patients
fulfilled the colonoscopic finding of CRC with male
preponderance (63.7%). The mean age of the participants was
46.61 ± 16.03 years, with a range of 15–80 years. The modal
age was 30 years while the modal age group is 30–39 years.
Overall young and middle‑aged participants seem to have
equal frequency of occurrence amongst the study participants.
Similarly, the most common presenting symptom was loose
stool, followed by weight loss, anaemia and rectal bleeding.
The detail distribution of age and clinical presentations is
shown in Table 1.
Rectosigmoid colon was the most common area of affectation,
followed by ascending colon. Conversely, anal canal was
the least affected. Anal canal, rectosigmoid and right colon
affectations were commonly seen amongst the young, middle
aged and elderly, respectively. Similarly, colonic polyps were
found to be more associated with rectosigmoid tumours.
The most common CRC seen on histology was adenocarcinoma,
followed by mucinous adenocarcinoma. Mucinous, signet ring
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Musa, et al.: Colorectal cancers seen on colonoscopy in Kano, Nigeria

adenocarcinoma and villous adenoma were more common studies.[7,20,28‑30]   Presence of CRC was found to be commoner
amongst the young  (45.5%, 80% and 75%, respectively), among younger individuals in our study, a finding somehow
while adenocarcinoma was more common in the middle different from commonly reported figures.[7,14,19,20,31] However,
aged  (46.2%). Table 2 shows the various tumour sites and these figures are in keeping with recently reported ones.[1,28]
histological subtypes identified.
Other histological lesions identified were metastatic
adenocarcinoma, squamous cell carcinoma, basal cell
carcinoma, GI stromal tumour, inflammatory myofibroblastic
tumour, angiosarcoma and adenoid cyst carcinoma.
Figures 1‑4 show the original pictures of the colonoscopic and
histologic findings of some of the patients.

Discussion
In this 10‑year review, CRC was more prevalent amongst males
with a M: F ratio of 1.75:1, a finding similar to many previous

Table 1: Age distribution and clinical presentations of

patients on colonoscopy
Figure 1: Suspected tumour seen at rectosigmoid colon on
Category Variable Frequency (%) endoscopy
Age distribution of study <20 3 (2.22)
participants (years) 20-29 16 (11.85)
30-39 30 (22.22)
40-49 23 (17.04)
50-59 27 (20.00)
60-69 23 (17.04)
70-79 10 (7.41)
≥80 3 (2.22)
Presentations at Melena 6 (4.44)
colonoscopy Abdominal pain 103 (76.30)
Abdominal swelling 11 (8.15)
Rectal bleeding 94 (69.63)
Weight loss 106 (75.52)
Constipation 25 (18.52)
Anaemia 104 (77.04)
Diarrhoea 117 (86.67)

Figure 2: Photomicrography of adenocarcinoma

Table 2: Colonoscopic and histological characteristics of
suspected colorectal cancer
Attribute Name Frequency (%)
Tumour Anal canal 5 (4)
site on Rectosigmoid colon 85 (63)
colonoscopy Descending colon 12 (9)
Transverse colon 10 (7)
Ascending colon 19 (14)
Left colon 4 (3)
Histological Histology not available 24 (17.78)
diagnosis of Carcinoid tumour 2 (1.48)
suspected Adenocarcinoma 78 (57.78)
tumours
Mucinous adenocarcinoma 11 (8.15)
Signet ring cell adenocarcinoma 5 (3.70)
Tubular adenoma 4 (2.96)
Villous adenoma 4 (2.96)
Others 7 (5.19) Figure 3: Photomicrography of mucinous adenocarcinoma

24 Nigerian Postgraduate Medical Journal  ¦  Volume 28  ¦  Issue 1  ¦  January-March 2021

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Musa, et al.: Colorectal cancers seen on colonoscopy in Kano, Nigeria
Figure 4: Photomicrography of signet ring adenocarcinoma
This is important to note in our day‑to‑day practice where
we commonly consider CRC in elderly individuals and also
consider the possibility of lowering the age limit for screening
colonoscopy in our setting.
All the patients present with a myriad of symptoms ranging
from diarrhoea to melena stool, with diarrhoea as the most
common. This shows how most of our patients present with
advanced disease as obtained in most developing nations
from previous studies.[1,19] This calls for more enlightenment
amongst the public and health workers, especially doctors to
have a high index of suspicion in any patient presenting with
some of the common features of CRC such as diarrhoea, weight
loss and anaemia regardless of their age at presentation.
Rectosigmoid colon is the most common site of affection
amongst the participants consisting of almost two‑third of the
study findings, while anal tumour was the least frequent. This
is similar to most of the reported cases in both developing and
developed nations.[1,7,13,18‑20,28,30,31]
Adenocarcinoma constitutes the most predominant histological
type of CRC identified on pathological analysis, followed by
mucinous adenocarcinoma and signet ring adenocarcinoma.
However, about 5% of the participants have no traceable
histology reports, and this may likely be due to the patients
taking their tissues outside the hospital for analysis. The
above histological findings go in tandem with various studies
reported previously where adenocarcinoma constitutes a modal
histology pattern.[1,7,13,18,28] Mucinous adenocarcinoma and
signet ring adenocarcinoma were more common amongst the
young participants as reported in some studies from Nigeria
and beyond.[7,8,14,19,31] The two histological subtypes are known
to have poorer outcomes. This is a serious cause for concern,
especially considering the category participants involved.
Conclusion
It is obvious that CRC mainly present late in North‑Western
Nigeria in advanced stage with overwhelming symptomatology.
Hence, the prognosis is usually guarded. It is, therefore,
Nigerian Postgraduate Medical Journal  ¦  Volume 28 ¦ Issue 1 ¦ January-March 2021
imperative for the stakeholders concern to employ possible
means of detecting these tumours earlier through screening
programmes that could detect pre‑cancerous lesions. The
modal age group affected by this potentially preventable
disease was in their young age, and more importantly, they
were affected by histological type with worst outcome, hence
the youths may need to be considered for CRC screening
programmes.
Acknowledgement
Drs. Yussuf A Maisuna, Mohammed A Nahuche, Yusuf S Umar,
Muhammad Manko and other supporting staffs at the
Endoscopy and Histopathology Department.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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