Upper Gastrointestinal Endoscopy in El Obeid, Western Sudan: Analysis of the First 1150 Cases.

 

Hussein Youssif Adam and El Bushra Ahmed Doumi,

 

Abstract:

Objectives: To study the pattern of upper gastrointestinal diseases as appeared after introduction of endoscopic services for the first time in El Obeid, Western Sudan.

Patients and Methods: This is a retrospective descriptive study. The records of individuals who underwent upper gastrointestinal endoscopies during 2003 to 2007 in El Obeid Police Hospital and El Obeid Teaching Hospital were reviewed. The data were analyzed for gender, age, locality and the outcomes of the procedure.

Results: 1150 upper gastrointestinal procedures were performed. There were 656 males (57%). The mean age was 42.5 years ( 17.1 STD). 65% were between 21 and 50 years of age. 26.3% of the persons endoscoped were found to be macroscopically normal. Of those who had positive endoscopic findings; 29.7% had oesophagitis, 36.9% chronic gastritis and 16.3% duodenitis. Cancer of the oesophagus was diagnosed in 5.9% of cases while cancer of the stomach in 4.5%. Duodenal ulceration was seen in 5.6% of patients and oesophageal varices were found in only 2.7% of cases.

Conclusion: Upper gastrointestinal endoscopy is a safe and useful procedure for investigating patients with gastrointestinal complaints. Expansion of the service with the provision of more endoscopes, more relevant accessories and training is recommended to supplement diagnosis and facilitate therapeutic measures. 

 

Key words: Endoscopy, gastrointestinal, Western Sudan.

 


 

Upper gastrointestinal diseases are leading causes of morbidity and mortality1, 2. Upper gastrointestinal endoscopy (UGIE) has become a corner stone in the diagnosis and treatment of many of gastrointestinal disorders3. The direct visualization of the entire oesophagus, stomach and duodenum with the facility to obtain material for analysis and to perform various therapeutic measures, make endoscopy superior to other diagnostic procedures4, 5.

Although UGIE was introduced 1973 in Khartoum6, 1983 in Wad Medani7 and later in many other hospitals across the country, this service only recently became available to the patients in El Obeid town.

The first series of UGIE performed in El Obeid town were analyzed, compared with literature and the impact of the procedure on local health services was outlined.

 

Patients and Methods:

Patients with a wide range of complaints such as epigastric pain, dyspepsia, indigestion, heartburn, vomiting, haematemesis, dysphagia, swallowed foreign bodies were accepted for UGIE. Informed consents were taken from the patients or their sponsors. The endoscopy was performed as an outpatient procedure. The patient fasted overnight and the endoscopy was carried out electively early in the morning.

The throat was anaesthetized with local 2% lignocaine spray. All patients were put on the left lateral position for the procedure, which was done without any sedation. 5 patients (0.4%) refused the procedure and they were excluded.

 The endoscopes used were the Olympus GIF type PQ20 and Karl Storz video endoscope 1380 IP, both were forward viewing instruments.

 

Results:

 

A total of 1150 patients underwent UGIE. There were 656 males (57%). The male: female ratio was 1.3:1. The age range was 12 to 95 years; the mean ( STD) was 42.5 ( 17.1) years. The age distribution was shown on table1.

 

 

Table 1: Age distribution.

 

Age groups in years

N

%

11- 20

064

05.6

21- 30

304

26.5

31- 40

277

24.1

41- 50

166

14.4

51- 60

129

11.2

61- 70

147

12.8

71- 80

059

05.1

> 80

004

00.3

Total

1150

100.00

 

 

65% were between 21 and 50 years of age. 483 patients (42%) were from El Obeid town and the rest were mainly from rural areas in Kordofan states. 302 (26.3%) of the patients endoscoped were found to be macroscopically normal.

 The pattern of positive endoscopic findings was shown on table 2.

Comparisons between the endoscopic diagnosis found in our study with similar studies done in Khartoum, Seychelles and Afghanistan were shown in table 3.

 

Discussion:

Sudan is a large country with varying environmental regions and the inhabitants belong to wide ethnic diversities with different cultures and social habits.

Our hospital serves more than 3.5 million people in Kordofan States, apart from others reporting from the nearby South and Darfur  regions. The population is experiencing rapid modernization and extra stress imposed by desertification, displacement, tribal conflicts and war. UGIE service became available only recently in 2003, and this is the first documentation of its impact on the local health system since its implementation.

 

 

Table 2:  Pattern of endoscopic findings.

 

Diagnosis

N*

%

Oesophagitis

247

29.7

Hiatus hernia

059

07.1

Oesophageal varices

022

02.7

Oesophageal cancer

049

05.9

Gastritis

307

36.9

Gastric erosions

041

04.9

Gastric ulcer

016

01.9

Gastric cancer

037

04.5

Duodenitis

136

16.3

Duodenal ulcer

047

05.6

 

* More than one pathology appeared in some patients.

 

 

 

In this study males predominated (57%), and 65% of cases were between 21 and 50 years of age. Similar to earlier report from Khartoum6, 26.3% of the individuals endoscoped were found to be macroscopically normal. However, this differs from other studies done in Sudan and elsewhere8-13. Many of such persons may qualify for non-ulcer dyspepsia syndrome. Screening for Helicobacter pylori was not feasible at the study time.

Inflammation of the fore gut was the commonest pathology found (82.9%) i.e. oesophagitis 29.7%, chronic gastritis 36.9% and duodenitis 16.3%. The prevalence of hiatus hernia (7.1%) and gastric erosions (4.9%) may add to this. In a similar society chronic gastritis was found in 25.8% of cases in Kenya14.

 

 

 

Table 3: The endoscopic findings in some studies.

 

Diagnosis

 

El Obeid*

N=833

%

Khartoum8

N=2698

%

Seychelles11

N= 591

%

Afghanistan12

N=311

%

Oesophagitis

29.7

07.7

15.9

 14.1

Hiatus hernia

07.1

05.0

02.8

11.6

Oesophageal varices

02.7

18.3

02.2

- -

Oesophageal cancer

05.9

06.0

03.0

25.7

Chronic gastritis

36.9

05.8

23.5

10.3

Gastric erosions

04.9

--

- -

04.5

Gastric ulcer

01.9

01.8

06.0

04.8

Gastric cancer

04.5

02.9

02.1

02.6

Duodenitis

16.3

05.4

- -

10.6

Duodenal ulcer

05.6

43.3

26.0

15.4

 

* This study.


 

Possible underlying causes may be ingestion of hot meals, Helicobacter pylori infection, consumption of alcohol and smoking. A more in depth look into these factors and others needs to be addressed. However duodenal ulcer had low prevalence and accounted for 5.6% of our patients, while it was reported as 10% from Gezira region in central Sudan. Higher incidence of duodenal ulcer was found in other parts of the world13-17. 

Comparable to Seychelles8, oesophageal cancer was seen in 5.9% of our patients. This is different from the 25.7% found in Afghanistan13. Whether the high prevalence of chronic oesophagitis predisposes to the condition, needs to be revealed. All patients were referred to higher centers for surgery or radiotherapy as both were not feasible here. In this study gastric cancer (4.5%) is not uncommon. Two peaks of the disease were noticed: at the beginning of the third decade and in elderly patients.  All patients were diagnosed in late stages and only palliation could be offered.

Oesophageal varices (2.7%) were rare compared to the 21.9% of cases reported from Gezira in Central Sudan7. Most of our patients were travelers to our town or citizens who had history of visits to the endemic Bilharzial area of El Gezira as seasonal workers in the past.

They presented with haematemesis and/or melena.

63 of our patients were more than 70 years old. Nevertheless we found the procedure in elderly persons safe, tolerable and without any complications. Similar observations were made before18.

 

 

Conclusion:

In conclusion; establishment of UGIE in the health delivery service here resulted in a high diagnostic yield of many gastrointestinal disorders. The frequency of diseases noted in this study gives an approximate epidemiological outline of upper gastrointestinal pathology in this community. Expansion of the service with the provision of more endoscopes, more relevant accessories and training, is recommended to supplement diagnosis and facilitate therapeutic measures.

 

 

 

 

 

 

 

 

References:

  1. Spiller R. ABC of the upper gastrointestinal tract (Clinical Review). Anorexia, nausea, vomiting and pain. BMJ 2001; 323: 1354-1357.
  2. Kolk H. Evaluation of symptom presentation in dyspeptic patients referred for upper gastrointestinal endoscopy in Estonia. Croat Med J 2004; 45(5): 592-8.
  3. Editorial. Endoscopy in general practice. BMJ 1995; 310: 816-817.
  4. Axon ATR, Bell GD, Jones RH, et al. Guidelines on appropriate gastrointestinal endoscopy. BMJ 1995; 310: 853-856.
  5. Agbakwuru EA, Fatusi AO, Ndububa DA, et al. Pattern and validity of clinical diagnosis of upper gastrointestinal diseases in south-west Nigeria. Afr Health Sci 2006; 6(2): 98-103.
  6. Suleiman SI, Salih SY, Ahmed ZE, Kimora K. Upper gastrointestinal fibreoptic endoscopy in Khartoum. Sud Med J 1977; 15(1): 19-24.
  1. Saeed OK, Ali EA, El Khatim M, El Sheikh AE. Review of 5000 gastrointestinal endoscopies in Wad Medani Teaching Hospital. Sud Med J 1996; 34(2): 42-49.
  2. Salam IM, Nagib AI, Ahmed Z, Kareem WMA, Sarag IME. Upper gastrointestinal fibreoptic endoscopy in Khartoum Teaching Hospital. Sud Med J 1986; 24(1-4): 30-36.
  3. Fedail SS, Arbab BM, Ahmed Z, Homeida MM, Gandour Z. Upper gastrointestinal fibreoptic endoscopy in Sudan. Analysis of 2500 endoscopies. Lancet 1983; 1: 817-19.
  4. Ahmed M K. The clinical presentation & endoscopic outcome of Sudanese patients with dyspepsia. Sud Med J 1992; 30(1): 21-27.
  1. Todorovic M. Results of upper gastrointestinal segment endoscopies in Seychelles, 1990- 1994. SMDJ 1997; 1-6.
  2. Ghazzawi I, Oweis S, Ajlouni Y. Upper gastrointestinal endoscopies in Jordanian Field Hospital in Afghanistan. JRMS 2004; 11(2): 62-64.
  3. Al Quorain A, Satti MH, AL Hamdan A, et al. Pattern of upper gastrointestinal disease in the Eastern Province of Saudi Arabia. Trop and Geographic Med 1991; 43(1, 2): 203-208.
  4. Lodenyo H, Rana F, Mutuma GZ, et al. Patterns of upper gastrointestinal diseases based on endoscopy in the period 1998-2001. Afr J Health Sci 2005; 12(1-2): 49-54.
  5. Ayoola EA, al-Rashed RS, al-Mofleh IA, et al. Diagnostic yield of upper gastrointestinal endoscopy in relation to age and gender: a study of 10,112 Saudi patients. Hepatogastroenterology 1996; 43(8): 409-15.
  6. Nkrumah KN. Endoscopic evaluation of upper abdominal symptoms in adult patients, Saudi Aramco-Al Hasa Health Center, Saudi Arabia. West Afr J Med 2002; 21(1): 1-4.
  7. Missalek W, Jones F, Mmuni K, Cutinha P. Value of fibreoptic oesophago-gastro-duodenoscopy: experience with 4000 procedures at Kilimanjaro Christian Medical Centre, Moshi, Tanzania. Trop Doct 1991; 21(4): 165-8.
  8. Malu AO, Wali SS, Kazmi R, et al. Upper gastrointestinal endoscopy in Zaria, northern Nigeria. West Afr J Med 1990; 9(4): 279-84.
  9. Safe AF, Owens D. Upper gastrointestinal endoscopy in octogenarians. Br J Clin Pract 1991; 45(2): 99-101.

 

 

 

 

1.  Consultant Physician and  Endoscopist, Police Hospital El Obeid.

2. Consultant General Surgeon and  Endoscopist, El Obeid Teaching Hospital El Obeid.