Colonoscopy is the main investigative procedure in patients with suspected lower GI tract diseases. Suspicion of colonic diseases arise when the patients having symptoms such as anaemia, diarrhoea, constipation, abdominal pain, bleeding per rectum, features of malignancy like weight loss, loss of appetite, altered bowel habits7. The current practice is to perform colonoscopy for all the patients who present with symptoms of lower GI tract diseases and it is the better first line investigation1. Colonoscopy is useful to know the exact site of lesion, to confirm the diagnosis by biopsy, or removal of suspected cancerous lesions in polyps2. There are still some controversies regarding open access endoscopic service versus a strict criteria for doing the procedure3,4,5. Selection of the patients for colonoscopy based on symptoms is important, because the colonoscopy helps to detect the malignant lesions as well helps to treat the benign lesions also. Data has been reported from various studies documenting the indications and the yield of colonoscopy in various symptoms of colonic disease6,7. Only few studies are reported regarding the evaluation of indications & the yield of colonoscopy in South India.
The aim of the study is to know the indications of colonoscopy in various symptoms of colonic disease and assess the yield of colonoscopy in these indications in our hospital, a tertiary care centre, in rural part of South India.
MATERIALS AND METHODS
It is a retrospective study of the available data from the colonoscopy procedures performed by the medical gastroenterologist at Medical Gastroenterology Department Chennai Medical College Hospital and Research Centre, Irungalur, Tiruchirapalli, Tamilnadu, South India. Data from November 2014 to October 2016 was reviewed.
Patients with any of these symptoms of (Table.2)
Bleeding per rectum
Clinical suspicion of Irritable Bowel Syndrome
Clinical suspicion of carcinoma colon
Right Iliac Fossa mass & Right Iliac Fossa pain
were included. Patients who attended the Gastroenterology outpatient department, as well as cases referred from the wards were scrutinised by the Gastroenterologist and selected for colonoscopy. Colonoscopy was done after proper bowel preparation. Colonoscopy was done without sedation. Biopsies were taken by the Gastroenterologists discretion. Diagnostic yield was regarded as positive for each of the indication, if the lesion found could account for the symptoms of the patient. Data analysis includes all the cases posted for colonoscopy, including the cases where the colonoscopy not reached up to caecum.
Total of 513 cases selected for colonoscopy.506 cases had undergone colonoscopy. The number of males and females were 66.4% and 33.62% respectively .Age and sex distribution shown in Table.1.
The caecum and terminal ileum was reached in 462 cases(91.3%).The commonest indications for colonoscopy were bleeding per rectum 129 cases(25.49%), and other indications were clinically suspected Irritable Bowel Syndrome (IBS)90 cases(17.79%), constipation 77 cases (15.22%), chronic diarrhoea 39cases(7.71%), clinically suspected IleoCaecal Kochs 35 cases(6.92%),anal fissures 24 cases (4.74%),anaemia 23 cases(4.55%),fistula in ano 17 (3.36%), abdominal pain 12cases(2.37%), clinically suspected colon cancer 11 cases (2.17%),Right Iliac fossa pain & mass 8 cases(1.58%), and surveillance scopy (which includes colonoscopy done for Inflammatory Bowel Disease, melena, Alcoholic Liver Disease, Hepatomegaly, Portal Hypertension, Recto-Vaginal fistula, etc.(Table.2).
Colonoscopic findings were, Normal study in 185 cases(36.56%), haemorrhoids in 156 cases (30.8%), polyp colon 47 cases(9.29%), Inflammatory Bowel Disease (Chrons -9 &ulcerative colitis-24) in 33 cases (6.52%),carcinoma colon in 24 cases(4.74%), kochs lesion in 12 cases(2.37%), proctitis in 9 cases(1.78%), diverticular disease in 6 cases (1.19%),solitary rectal ulcer in 5 cases(0.99%), non specific ulcers rectum in 4 cases(0.79%), pancolitis in 4 cases(0.79%), & others (caecal teleangectasia, porta hypertensive colopathy, pseudomembranous colitis, pin worm infestation, Gastro-Jejunocolic fistula, extraneous compression etc.) in 21 cases(4.15%) (Table.3).
Out of 47 polyps diagnosed by colonoscopy, 15polyps were dimunitive,8 were sessile,20 were <1cm,4 were multiple colonic polyps. Polypectomy done in 10 cases with endoscopic suspicion of malignancy. On Histo-Pathological Examination 1 was carcinoma,1 was adenomatous, 2 were hyperplasticpolyps,1 was inflammatory polyp, features of non specific colitis in 3,1 was juvenile polyp, one report not traceable.
Of the 24 malignant lesions diagnosed by colonoscopy, the commonest site was recto sigmoid in 7 cases, hepatic flexure in 5 cases, rectum in 4 cases, sigmoid &ascending colon each 3 cases, transverse colon 1 case, synchronous lesion in 1 case .Of the 24 cases, 18 cases were adeno carcinoma, 1case was melanoma, 2 lesions turned out to be chrons, one lesion was kochs by histo-pathological examination, one case was recurrence and one report was not traceable.
The overall diagnostic yield was 63.46%
Of the 129 cases presenting with bleeding per rectum, cause identified were haemorrhoids in 93, polyp 12, carcinoma 6, pancolitis 1, IBD 2, kochs lesion 1,caecal telengectasia 1,non specific ulcer rectum 1 and normal study12.Diagnostic yield in bleeding per rectum was 90.7% (Table.4).
Of the 90 patients with Irritable Bowel Syndrome , normal study in 44, IBD in 14, haemorrhoids in 10, polyp in 9, carcinoma in 3, proctitis in 3, kochs lesion in 2, diverticulitis in 2, pan colitis in 1, solitary rectal ulcer in 1,non specific ulcer rectum in 1.Diagnostic yield was 51.1% (Table.5).
Of the 77 patients with constipation, normal study in 50, haemorrhoids in12, polyps 4, proctitis 2, carcinoma 2, kochs lesion1, solitary rectal ulcer 1, others 5.Diagnostic yield was 35.1%(Table.5).
Of the 39 patients with chronic diarrhoea, the colonoscopic findings were normal study in 17, Inflammatory Bowel Disease in 8, haemorrhoid in 4, polyp in 3, pancolitis 2, proctitis 2, solitary rectal ulcer 1, & others 2. Diagnostic yield was 56.41% (Table.5) .
Of the 23 cases of anaemia, the colonoscopic findings were, normal study in 11 cases. haemorrhoids 5, polyp 3,carcinoma 3, others 1.Diagnostic yield was 52.2% (Table.5).
Of the 11cases of clinically suspected carcinoma, the colonoscopy findings were, normal study in 1 case, haemorrhoids in 1, polyp 1, carcinoma 7, diverticulitis 1 Diagnostic yield was 90.9% (Table 5).
Of the 35 cases of clinically suspected Ileo Caecal Kochs the colonoscopy findings were normal study in 11 cases, haemorrhoids in 7 cases, features of Inflammatory Bowel Disease in 4 cases, kochs in 4 cases, polyps 3,diverticlitis in 2,proctitis 1 case, carcinoma in 1, non specific ulcer 1,and others 1Diagnostic yield was 68.6%.(Table.5).
There are still controversies regarding open access endoscopy versus strict criteria for doing the procedure6,15. Doing endoscopy based on strict selection criteria are bound to miss patients with significant and potentially treatable colonic pathology. The answer lies in better selection of patients for the procedure based on diagnostic yield5. No strict criteria or double contrast enema were used in our study for the selection of the patients before the procedure. Cases were selected by the gastroenterologist based on clinical symptoms and signs.
In our study in addition to the seven major indications described by Berkowitz6, Al Shamali9 patients with fistula in ano, and fissure in ano also had undergone colonoscopy.The most common indication was bleeding per rectum 25.49%, these were also the indication for colonoscopy in the study by Berkowitz et al6 Sahu et al10 Olokoba AB et al.8
Complete examination up to caecum was possible in 91.3% of cases similar to the study by Md Abu Sayeed et al5.(94%),Most of the lesion were limited to rectum and anal canal, the reason being the haemorrhoids was the most common finding in the study, which was similar to the study by H. N. Dinesh et al.1
The overall diagnostic yield in this study was 63.44% which is less compared to the study by Bo Ismalia M A etal11& Olokoba AB et al8 who reported 79% & 79.6% respectively & higher compared to the study by Sahu et al10 who reported 48%.
In this study the yield of colonoscopy in bleeding per rectum was 90.8% which is similar to the study by Md. Abu Sayeed et al5 who reported 92%.The haemorrhoids were present in 63% of the cases of bleeding per rectum which is almost similar to study Robert J etal16where the incidence was 60.5%.The colonoscopic yield for malignant neoplasms in bleeding per rectum is 4.61% which is less compared to the study by Berkowitz et al6 which was 8.9%.
In our study the diagnostic yield was high in patients with clinical suspicion of colonic carcinoma was 90.9%.which was high compared to the study by Al Shamali et al9which was 53%.
The diagnostic yield of anaemia was 52.1% in our study, which was 47.7% by Berkowitz etal6.The colonoscopic yield of malignancy was 13% which was high compared to the study by Berkowitz et al6 who reported 2.2% in anaemia and it was almost equal to 11% reported by Rockey DC et al19
The yield of colonoscopy in suspected Irritable Bowel Syndrome patients was 51.1%. The most common lesion was Inflammatory Bowel Disease, haemorrhoids, polyps. Haemorrhoids, polyps, diverticulosis were the commonest lesion in a study by William D Chey et al16.
The diagnostic yield of colonoscopy in constipation was 35.06% & incidence of malignancy in constipation was 2.9%which was low in our study compared to the study by M Mojoli et al18where diagnostic yield was 39.4%.& the malignancy was 6.3%.
In developing countries where infective diarrhoea is still common, selecting the patient for colonoscopy was difficult. In this study the diagnostic yield for diarorhea was 56.4% , which was high compared to the study by Al Shamali et al9 which was 35%.The most common finding was Inflammatory Bowel Disease which was consistent with his study. No malignant lesions were reported.
Malignant lesions by colonscopy were seen in 24 cases. Of the HPE, 18 cases were adeno carcinoma, one was melanoma, 0ne lesion in ascending colon and two lesions in hepatic flexure turned out to be kochs and chrons diseases. Of the 18 cases the commonest indications were bleeding per rectum, anemia, IBS, constipation, clinically suspected colonic carcinoma. One case was diagnosed in fistula in ano that indicates the usefulness of open access endoscopy.
In our study even though diagnostic yield was low in constipation, malignancy was diagnosed in younger patient which indicates that open access colonoscopy is ideal where the facilities and expertise are available. Over the past few years there were so many articles about the appropriateness of colonoscopy and the use of guidelines for this purpose. Dayna et al13have discussed the general indications for colonoscopy and the indications in our study was also similar to their guidelines. Even though there are so many guidelines, an open access to colonoscopic evaluation is ideal to rule out colonic disease. Limitations in our study it was a retrospective study.
In our study colonoscopy was done in all the patients presenting with symptoms of lower GI tract. It indicates that colonoscopy should be the primary investigation in patients with lower GI tract diseases. An open access colonoscopy seems ideal if facilities and expertise are available. This study was done in outpatient settings which contribute additional knowledge and also reassurance as to quality and safety of colonoscopy performed in outpatient settings. Colonoscopy has also has great therapeutic value, because colonoscopic biopsy helps to arrive a diagnosis and it has saved many patients from extensive surgery. Even though the diagnostic yield is significant in our study, further prospective studies to be done to have still more better yield in both diagnosis and therapeutic use.
The Authors acknowledge with thanks the great help rendered by Gasteroenterologist and the Department of Gasteroenterology in CMCH&RC for providing access to the records for analysing the data for this study.
The Authors thank the Officials at CMCH&RC for the encouragement and support provided for bringing out the study which gives an insight into the Upper GI Disease pattern among the rural population around the Institution.
The Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The Authors are also grateful to Authors/Editors/Publishers of all those articles, Journals and books from where this article has been reviewed and discussed.
ETHICAL CLEARANCE :
Ethical clearance for the use of clinical data and preparation of this Research paper has been obtained from the Management of CMCH&RC , Irungalur. Tiruchirappalli Dt. Tamilnadu.
INFORMED CONSENT :
SOURCE OF FUNDING :
There is no source of funding for this study.
CONFLICT OF INTEREST:
There is no conflict of interest in the preparation and submission of this Research Paper.