International Journal of Current Research and Review
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IJCRR - 10(4), February, 2018

Pages: 29-33

Date of Publication: 17-Feb-2018


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Indications & Yield of Colonoscopy - A Retrospective Study at Chennai Medical College Hospital & Research Centre - Irungalur, a Rural Tertiary Care Centre in South India

Author: S. Padma, R. Murugan

Category: Healthcare

Abstract:Colonoscopy is the one of the most important investigation to be done for patients presenting with symptoms of colonic diseases. The clinical presentation of lower GI tract diseases varies in different communities. The yield of colonoscopy also varies from place to place and the yield also depends on the various indications. Aim of the Study: To know the indications for colonoscopy in patients with symptoms of lower GI tract diseases and also to assess the yield of colonoscopy in various indications.
Materials and Methods: A retrospective study of patients who underwent colonoscopy from November 2014 to October 2016 at CMCH & RC was done. Data were collected from endoscopy register and analysed.
Results: A total of 513 patients who registered for colonoscopy were evaluated. Male: female ratio was 341:172. Among those 506 patients (98.6%) tolerated the procedure. Caecum could be reached for 91.3% of the patients. Most common indication was bleeding per rectum 25.49%, clinical suspicion of Irritable Bowel Syndrome (IBS) 17.7%, Constipation 15.2%.
The findings were normal study in 36.56%, haemorrhoids: 30.8%, polyp colon: 9.2%, Inflammatory Bowel Disease: 6.52%, carcinoma: 4.74%. Polypectomy was done in 10 cases. Overall yield of colonoscopy was 63.5%.
Conclusion: Colonoscopy is an effective procedure for diagnosing lower GI symptoms. The yield of colonoscopy is high in patients with symptoms of bleeding per rectum, carcinoma colon, anaemia, Ileocaecal kochs..

Keywords: Colonoscopy, Bleeding per rectum, Yield of colonoscopy

DOI: 10.7324/IJCRR.2018.1046

Full Text:

INTRODUCTION

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

Constipation

Chronic diarrhoea

Anaemia

Abdominal pain

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.

 

 

 

RESULTS

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).

DISCUSSION

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 alwhich 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.

CONCLUSION :

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.   

Acknowledgement:

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 :

Not applicable.

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.

References:

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  2. Neugut AI, Forde KA. Screening colonoscopy; had the time come? Am J Gastro enterol 1988;83:295-297.
  3. Endoscopic selection committee of British Society of Gastroenterology. Future requirements for colonoscopy in Britain. Gut 1987;28: 772-775.
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  5. Md Abu Sayeed, Rabiul Islam, Dilruba Siraji, Md Gofranul Hoque, A Q M Mohsen.Colonoscopy: A study of findings in 332 patients. JMCTA 2007;18(2):28-31.
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  9. Mohammed A. Al Shamali, Maher Kalaoui, Fuad Hasan, Abdulkareem Khajah, Iqbal Siddiqe, Basil Al-Nakeeb  colonoscopy : Evaluating Indications and Diagnostic Yield  Annals of Saudi Medicine, Vol 21.Nos 5-6 2001.
  10. S. Sahu, M. Husain, P. Sachan.  clinical spectrum and diagnostic yield of Lower Gastro intestinal endoscopy at a Tertiary centre Internet Journal of Surgery Volume 18 Number 1.
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A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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