Vol. 6(5), pp. 128-133, May 2014
DOI: 10.5897/IJMMS2014.1031
ISSN 2006-9723
Copyright © 2014
Author(s) retain the copyright of this article
http://www.academicjournals.org/IJMMS
International Journal of Medicine
and Medical Sciences
Full Length Research Paper
Lower gastrointestinal bleeding: Spectrum of
colonoscopy findings in Ado-Ekiti, Nigeria
Akande Oladimeji Ajayi1*, Ebenezer Adekunle Ajayi1, Olusoji Abidemi Solomon2 and
Ekemini Udo3
1
Department of Medicine, Ekiti State University Teaching Hospital, P.M.B 5355, Ado Ekiti, Ekiti State, Nigeria.
Department of Family Medicine, Ekiti State University Teaching Hospital, P.M.B 5355, Ado Ekiti, Ekiti State, Nigeria.
3
Gilead Specialist Hospital, P. O. Box 1076, Ado Ekiti, Ekiti State, Nigeria.
2
Received 10 March, 2014; Accepted 14 April, 2014
Lower gastrointestinal bleeding (LGIB) is a common ailment seen at emergency departments. It is a
significant cause of morbidity and mortality in the elderly worldwide. The aim of this study was to
determine the aetiology and management outcome of LGIB in our centre and compare it with results
elsewhere. Sixty-eight consecutive patients who underwent colonoscopy for LGIB were recruited into
this study. The study was carried out at the Ekiti State University Teaching Hospital (EKSUTH), AdoEkiti, Nigeria from January, 2010 to December, 2012. Ethical approval for the study was obtained from
hospital’s Ethics Committee and all the patients gave their individual signed consent. Relevant data
were retrieved and analyzed using statistical package for social sciences (SPSS) version 15.0 (SPSS,
Inc., Chicago, Illinois, USA) for statistical analysis using the t-test for quantitative variables and χ2 test
for qualitative variables. Differences were considered to be statistically significant if P value was less
than 0.05. The male: female ratio was 1.83:1. The mean age of the studied population was 56.04 ± 10.60
(age range 30 to 75). The indications for colonoscopy were; melena (11.8%), haematochezia (52.9%) and
both (35.5%). Findings at colonoscopy were; haemorrhoids (35.3%), colorectal cancer (16.2%), polyps
(14.7%), anal fissure (13.2%), arteriovenous malformations (5.9%) and diverticulosis (4.4%). Normal
findings were reported in 10.3%. While haemorrhoids, anal fissure, colorectal cancer, polyps and
diverticulosis were more prevalent in the male populations, arteriovenous malformation was more
prevalent in the females. Co-morbidities found included; diabetes (14.7%), chronic liver disease (14.7%),
hypertension (36.8%), diabetes and hypertension (16.2%) and renal disease (5.9%) of the studied
2
population. These findings were found to be statistically significant (χ = 68.535, p = 0.001, α = 0.05 that
is, 95% confidence interval). Haemorrhoids followed by colorectal cancer are the commonest
colonoscopy findings in our environment. It is recommended that colonoscopy should be embraced for
routine cancer screening and surveillance in our society.
Key words: Colonoscopy, lower gastrointestinal bleeding, emergency departments.
INTRODUCTION
Lower gastrointestinal bleeding (LGIB) is defined as
bleeding that occurs from the bowel distal to the ligament
of Treitz (Longstreth, 1997). It is a significant cause of
morbidity and mortality in the elderly worldwide. The
Ajayi et al.
incidence of LGIB increases with age and is more
common in men than women (Potter and Sellin, 1988).
The annual incidence of hospitalization for LGIB is
estimated to be 20 to 30 per 100,000 persons in a large,
Southern California health maintenance organization
(Longstreth, 1997). LGIB is approximately one-fifth as
common as upper gastrointestinal bleeding (UGIB)
(Kollef et al., 1997; Peura et al., 1997; Velayos et al.,
2004). While most patients with LGIB will stop bleeding
spontaneously, recurrent bleeding occurs in 10 to 40% of
patients (Chaudhry et al., 1998; Das et al., 2003). In contrast to UGIB, predictors of poor outcome in LGIB are not
that well defined. Hemodynamic instability, ongoing haematochezia and presence of comorbid illness have been
associated with poor outcome (Bhasin and Rana, 2011).
The causes of LGIB vary from one region of the world
to the other. In the countries of Western Europe and the
United States where diverticulosis coli is common, it is
one of the most common causes of LGIB unlike in Asia,
diverticulosis coli is uncommon and is much less
responsible as a cause of LGIB in the region (Longstreth,
1997). Colonoscopy when performed within 12 to 24 h of
bleeding or admission is the preferred diagnostic
procedure after stabilization in patients with lower
gastrointestinal (GI) bleeding. The diagnostic yield of
colonoscopy is more than radiographic tests, which
require active bleeding at the time of the radiological
examination. The diagnostic yield of urgent colonoscopy
in acute lower GI bleed has been reported to be between
75 to 97% depending on the definition of the bleeding
source, patient selection criteria and timing of
colonoscopy (Barnert and Messmann, 2009; Wong and
Baron, 2008). Literature is very scanty as regards the
aetiology of LGIB in Nigeria. The aim of this study is to
determine the aetiology and management outcome of
LGIB in our centre and compare it with results elsewhere.
MATERIALS AND METHODS
129
Inclusion and exclusion criteria
All patients age 18 years and above with LGIB were included in the
study, while patients with severe cardiopulmonary instability/failure
were excluded.
Data collection
The following were extracted from the patients or their relations:
age, gender, previous history of LGIB, use of aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDS), alcohol ingestion, use of native
concoctions, melena and haematochezia.
Procedure
Colonoscopy was performed within 48 h after adequate
resuscitations were carried out using intravenous normal saline,
blood transfusion and parenteral omepraprazole. The procedure
was carried out using video-colonoscopes (CF 130 Olympus).
Colon preparation was achieved by the oral administration of 3
liters of MovicolR and DucolaxR suppository, given 12 to 18 h before
the examination. Blood pressure and oxygen saturation were
monitored with mercury sphygmomanometer and pulse oxymeter,
respectively. Warm water (37°C) infusion method was used instead
of the traditional air insufflations. This method significantly gave a
better patient procedure tolerance, better evaluation of the mucosal
wall and adenoma detection rate. Findings at endoscopy were
documented.
Ethical clearance
Ethical approval for the study was obtained from the hospital’s
Research and Ethics Committee and all the patients gave their
individual written consent.
Statistical analyses
SPSS version 15.0 (SPSS, Inc., Chicago, Illinois, USA) was
deployed for statistical analysis using the t-test for quantitative
variables and χ2 test for qualitative variables. Differences were considered to be statistically significant if P value was less than 0.05.
Study location
RESULTS
This study was carried out at the Ekiti State University Teaching
Hospital (EKSUTH), Ado-Ekiti, Nigeria from January, 2010 to
December, 2012.
The male: female ratio was 1.83:1. The mean age of the
studied population was 56.04 ± 10.60 years (age range
30 to 75). Majority of the patients were in the age group
51 to 70 years (Table 1). LGIB was found to increase
steadily with age up to the seventh decade of life when a
sharp decline was noticed. The indications for colonoscopy were; melena (11.8%), haematochezia (52.9%)
and both (35.5%) (Table 2 and Figure 1).
Study population
Sixty eight consecutive patients who underwent colonoscopy for
LGIB were recruited into this study.
*Corresponding author. E-mail: dejiajayi2@yahoo.co.uk.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
130
Int. J. Med. Med. Sci.
Table 1. Age group distribution among the study participants.
Age group
-30
31-40
41-50
51-60
61-70
71Total
Frequency
1
7
15
20
22
3
68
Percentage
1.5
10.3
22.1
29.4
32.4
4.4
100.0
Cumulative %
1.5
11.8
33.8
63.2
95.6
100.0
100.0
Table 2. The indications for colonoscopy among the study participants.
Indication
Melena
Haematochezia
Melena/Haematochezia
Total
Frequency
8
36
24
68
Percentage
11.8
52.9
35.3
100.0
Age group
Figure 1. Indications versus age group.
Findings at colonoscopy were; haemorrhoids (35.3%),
colorectal cancer (16.2%), polyps (14.7%), anal fissure
(13.2%), arteriovenous malformations (5.9%) and diverticulosis (4.4%). Normal findings were reported in 10.3%
10.3% (Figure 2). While haemorrhoids, anal fissure,
colorectal cancer, polyps and diverticulosis were more
prevalent in the male populations, arteriovenous
malformation was more prevalent in the females. These
Ajayi et al.
131
Figure 2. Findings at colonoscopy among the study participants.
findings were not statistically significant (χ2 = 8.867, p =
0.181, α = 0.05 that is, 95% confidence interval). Comorbidities found included: diabetes (14.7%), chronic
liver disease (14.7%), hypertension (36.8%), coexistence
of diabetes and hypertension (16.2%) and renal disease
(5.9%) of the studied population (Figure 3). These
2
findings were found to be statistically significant (χ =
68.535, p = 0.001, α = 0.05 that is, 95% confidence interval). None of the patients had a previous history of LGIB.
15% of the patients were on aspirin as part of their routine anti-hypertensive medications. In all, seven patients
died, giving a mortality rate of 10.3%. These deaths were
recorded among those having colorectal cancers.
DISCUSSION
LGIB is a significant cause of morbidity and mortality in
the elderly worldwide. It is also one of the most common
gastrointestinal indications for hospital admission. The
incidence increases with age and is more common in
men than women (Potter and Sellin, 1988). Our study
equally confirmed this statement. The male: female ratio
was 1.83:1 with a male preponderance in all age groups.
This male preponderance is similar to what was reported
by (Olookoba et al., 2013) in the North Central region of
Nigeria. LGIB was found in this study to increase steadily
with age up to the seventh decade of life. This is similar
to similar studies elsewhere outside African continent by
Chait (2010), Comay and Marshall (2002) and Longstreth
(1997). This increase in incidence of LGIB with increasing
age can be adduced to two factors commonly found in
the elderly: (1) the increased incidence of gastrointestinal
disease specific to elderly patients and (2) co-morbid
diseases. Co-morbid diseases found in this study were;
diabetes mellitus (14.7%), hypertension (36.8%),
diabetes and hypertension (16.2%), chronic liver disease
(14.7%) and renal disease (5.9%). Majority of our
patients have at least one coexistent illness. This was
similar to the findings of (Al Qahtani et al., 2002;
Schmulewitz et al., 2003).
Findings at colonoscopy in our study were;
haemorrhoids (35.3%), colorectal cancer (16.2%), polyps
(14.7%), anal fissure (13.2%), arteriovenous malformations (4%) and diverticulosis (4.4%). Haemorrhoids
were the commonest cause of LGIB in this study similar
to the findings by Alatise et al. (2012), Dakubo et al.
(2008) and Olookoba et al. (2013). This was contrary to
the pattern in the Western world where diverticular
diseases, colorectal cancer and angiodyspasias were the
common findings at colonoscopy (Strate, 2005). Contrary
to the general belief that colorectal cancer is not common
in our environment, with the availability of colonoscopy,
this had been debunked as shown in this study where
colorectal cancer ranked as the second commonest finding (16.2%). This may in part be due to increased
132
Int. J. Med. Med. Sci.
Figure 3. Comorbidty versus indications for colonoscopy.
Westernization among the populace. The findings in this
study that showed haemorrhoids topping the list of the
findings at colonoscopy might be due in part to frequent
or chronic constipation, straining to have a bowel movement, diets low in fiber and pregnancy. Little information
exists as regards racial differences in LGIB. However,
this geographic variation may be due in part to dietary
and lifestyle factors. In this study, haemorrhoids, anal
fissure, colorectal cancer, polyps and diverticulosis were
found to be more prevalent in the male populations while
arteriovenous malformation was more prevalent in the
females. The reasons for these findings are not known.
The indications for colonoscopy in this study were;
melena (11.8%), haematochezia (52.9%) and both
(35.5%).
Most patients with LGIB have favorable outcomes
despite advanced age and comorbid conditions (Boley et
al., 1979). While most patients with LGIB will stop
bleeding spontaneously, continued or recurrent bleeding
during an acute episode occurs in 10 to 40% of patients
(Das et al., 2003). All the patients studied were managed
conservatively with fluid replacements, parenteral
omeprazole and blood transfusions. Those that required
advanced interventional endoscopy therapy were duly
referred after stabilization to other facilities. Endoscopic
polypectomy was carried out in those that had polyps.
Among those that had haemorroids, 25% had
haemorroidal banding while 75% had haemorroidectomy
successfully carried out. In all, seven patients died, giving
a mortality rate of 10.3%. These deaths were recorded
among those having colorectal cancers. Most of these
patients presented in the late advanced form.
Colonoscopy was carried out in this study within 12 to
48 h of admission and it was found to be safe and
effective. This was similar to the findings in the studies of
Strate and Syngal (2003). Generally, the diagnostic yield
of colonoscopy ranges from 45 to 95% (Al Qahtani et al.,
2002), the diagnostic yield in this study was 89.7%. The
high yield obtained here was similar to the findings of
Olookaba et al. (2013), much higher than that of Dakubo
et al. (2008), Ismaila and Misauno (2011) and Mbengue
et al. (2009). This finding was contrary to the low yield
Ajayi et al.
found by Al-Shamali et al. (2001) (21%) in the Saudis and
Sahu et al. (2009) (48%) in the Indian patients. These
observed differences may be due to the varying spectrum
of colonic diseases across the world regions and the
water method used in this study as against the traditional
air inflation.
Conclusion
Haemorrhoids followed by colorectal cancer are the
commonest colonoscopy findings in our environment. It is
recommended that colonoscopy should be embraced for
routine cancer screening and surveillance in our society.
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