Abstract
Objective:
To find out the indications, effectiveness, safety and outcome of colonoscopy at King Hussein Medical
Center.
Methods: A retrospective analysis of the colonoscopy
records for patients who underwent elective colonoscopy over a 7-year period (January
2000-October 2006) at King Hussein
Medical Center in Amman,
Jordan was done.
Data collected included the number of the patients, age, gender, reason for
doing the procedure, endoscopic findings, and any immediate complication. For all patients colonic preparation using Dulcolax (Biscodyl
5 mg tab) and Fortrans (Macrogol 4000-64 gm) or castor oil with normal saline and
uni-stiffness endoscopes were used. Almost all colonoscopies were done with
sedation using Mipiridine 25 mg and Midazolam 3 mg intravenousely.
Results: A total of 3865 colonoscopies
were included in the study, 42% percent of patients were aged less than 50
years. 89% of the colonoscopies were done for patients referred from physicians
as outpatients and 11% for patients who were already in hospital. The number of
endoscopies performed during the year 2006 per month was considerably higher
(mean 65) than that done during the year 2000 (mean 30). The main indications
for colonoscopies were rectal bleeding (39%),
constipation (17%), and diarrhea in 12%. In 3749 (97%) patients, the procedure was
completed up to cecum. Normal colonoscopy was reported in 72.5% of patients. The most common abnormal findings were colonic
cancer (29%), colonic polyps in 24% and
inflammatory bowel disease in 16%. Other common
findings were diverticulosis (13.4%), melanosis coli (2.4%),
and vascular ectasias in 2.5%. Internal hemorrhoids was a coexistent finding in
(n=30) those diagnosed as colonic cancer and (n=18) in those diagnosed as
colonic polyps, but it was the only colonoscopic finding in 130 patients
(12.2%). Colonic polyps were also found
as coexistent finding in 47 patients diagnosed as colonic cancer. Seven (0.018%) patients had a major
complication related to the procedure in
the form of colonic perforation (n=4), minor bleeding which did not necessitate
blood transfusion (n=2), and stuck snare wire due to
looping around a normal colonic mucosa that mandated removal by lapratomy (n=1).
Conclusions: Colonoscopy at King Hussein Medical
Center; is
safe and effective in establishing a definitive diagnosis, and rarely
associated with major complications such as perforation or bleeding.
Keywords: Colonoscopy, King Hussein
Medical Center, Safety, Outcome.
JRMS March 2010; 17(1): 15-20
Introduction
Gastrointestinal disorders are extremely
common in the general population.(1,2) Which group of patients should be investigated and
when, remains controversial. Accurate evaluation of symptoms
is important because of the implications for investigation, management and
morbidity, although it is often difficult to reach an accurate diagnosis on
clinical grounds alone.(3) The diagnosis of colonic diseases by
classical symptoms is often incorrect.(4) Physical examination and
routine hematological and biochemical investigations are also usually
unhelpful.(5)
At this point, the clinician needs to decide whether a further investigation is
necessary. The patients' perception of their presenting symptoms also plays a
significant role in the management strategy. Patients may or may not be
bothered by their presenting symptoms.(6) Instead, psychosocial factors, including fear
of serious disease, may be the important factor for their attendance to a
doctor.(7) Colonoscopy is the investigation of choice for screening
individuals at risk for early cancerous or premalignant lesions, thereby helping
to minimize the impact of cancer on communities.(8)
Colonoscopy was introduced in the 1960’s and it became a very useful
method in the diagnosis and therapy of colonic diseases.(9,10) Colonoscopy is very
helpful in investigating gastrointestinal bleeding, unexplained changes in
bowel habit or suspicion of colon cancer. A colonoscopy is often used to help
in diagnosing inflammatory bowel disease. In older patients an unexplained drop
in haemoglobin (a sign of anemia) is an indication to do a colonoscopy as this
may be due to colon cancer.
We studied colonoscopies done in our
gastroenterology unit at King Hussein Medical
Center to determine the
indications for colonoscopies, the spectrum of endoscopic findings, and any
reported complication. This is the first
report on this service in Jordan.
Methods
A retrospective evaluation of the lower endoscopy service at King Hussein Medical
Center was conducted. The records for all patients aged 16 years or more who underwent colonoscopy between January 2000 and
October 2006 were reviewed. Repeated
colonoscopies were excluded. Data
collected included the number of the patients, age, gander, indication,
endoscopic findings, and any complication reported.
Colonic preparation before all lower gastrointestinal
examinations called for the administration of the following: 1-Biscodyl 5mg tab
(Dulcolax) and Macrogel 4000-64 gm (Fortrans) or 2- caster oil and normal
saline.
The endoscopy room set up, the instruments, and the number
of nursing staff were the same for all the patients. There were two or three
endoscopists for each list of colonoscopies. One of the experienced
endoscopists who had performed at least 500 colonoscopic procedures, observed
or completed the patients' procedures. Uni-stiffness endoscopes were used (CF-240AI/AL or
CF-260AI; Olympus Optical, Tokyo,
Japan, or
Pentax EC 3840L).
The patients were evaluated well before, and during the procedure in
order for the endoscopist to be ready for dealing with any complications. Conscious sedation with intravenous Midazolam
(Dormicum) and Mipiridine 25 mg were provided at the patients' request.
Otherwise, they did not receive analgesia. Conscious sedation was administered
via routine, continuous venous access. Intravenous Hyoscine butylbromide
(Buscopan) was used as an antispasmodic agent if the patient had no
contraindications (e.g. prostatic hyperplasia requiring therapy, narrow-angle
glaucoma, and tachyarrhythmia) when needed. The examination was considered complete
when the cecum was reached. Entering the terminal ileum is not needed in all
the procedures, unless indicated in cases of chronic diarrhea, suspicion of
terminal ileum lesions, or for training purposes.
We arbitrarily subdivided the service into seven periods,
each one of one year, to compare the workload in form of the number of
colonoscopies done per month and yearly.
Results
Between January 2000 and October 2006, 3,865
colonoscopies were performed on patients aged 16 years and above. The mean age
of patients was 51.5 years (range 16-86), 42% of patients were aged less than 50,
women had 1,159 (30%) and men 2,706 (70%) examinations. The vast majority of
the patients were healthy, 154 (4%) of patients had one or more chronic
diseases, for example, 51 patients had ischemic heart disease. A total of 3440
(89%) endoscopies were done for patients referred from gastroenterology clinic as outpatients and 425 (11%) for patients who were already in hospital. The main indications for colonoscopies were rectal bleeding (39%), constipation (17%), and diarrhea in 12% of the cases. The other indications wereabdominal pain (9%), alternation in bowel habit (6%), family history of colonic cancer (4%, iron deficiency anemia (3%), melena with normal upper endoscopy (2.6%), abdominal distention (2.7%), weight loss (1.8%), searching for a primary of metastasis cancer (1.4%), post intestinal obstruction searching for underlying cause (0.9%) and abdominal mass by CT scan in 0.6%, as shown in Table I. The procedure was completed up to caecum in 3,749 (97%) patients, 72.5% of endoscopies (n=2,802) performed had normal findings, and the rest (n=1,063, 27.5%) had abnormal endoscopic findings.
|
Table I. Indications
|
|
Number (n = 3865)
|
%
|
|
Rectal bleeding
|
1507
|
39
|
|
Constipation
|
657
|
17
|
|
Diarrhea
|
464
|
12
|
|
Abdominal pain
|
348
|
9
|
|
Alternation in bowel
habit
|
232
|
6
|
|
Family history of colonic cancer
|
155
|
4
|
|
Iron deficiency anemia
|
106
|
3
|
|
Abdominal distension
|
108
|
2.7
|
|
Melena with normal
upper endoscopy
|
104
|
2.6
|
|
Weight loss
|
73
|
1.8
|
|
Metastasis cancer; searching for the primary
|
54
|
1.4
|
|
Post intestinal
obstruction
|
35
|
0.9
|
|
Abdominal mass by CT scan
|
22
|
0.6
|
|
Table II. Colonoscopic findings
|
Finding
|
Number (n = 3865)
|
%
|
|
Normal Endoscopy
|
2802
|
72.5
|
|
Abnormal Endoscopic findings
|
1063
|
27.5
|
|
Colonic cancer
|
308
|
29
|
|
Colonic polyps
|
250
|
23.5
|
|
Inflammatory bowel disease
|
162
|
15.2
|
|
Diverticulosis
|
142
|
13.4
|
|
Internal hemorrhoids
|
130
|
12.2
|
|
Melanosis coli
|
31
|
2.9
|
|
Vascular ectasias
|
27
|
2.5
|
|
Familial adenomatous
polyposis
|
8
|
0.8
|
|
Behcet ulcer
|
3
|
0.3
|
|
Pneumocystoides intestinalis
|
2
|
0.2
|
|
|
Table III. Number of colonoscopies during the period of study
|
Year
|
Number of patients
|
Mean number per month
|
%
|
|
2000
|
360
|
30
|
9
|
|
2001
|
487
|
40
|
12
|
|
2002
|
511
|
42.6
|
12.7
|
|
2003
|
505
|
42
|
12.6
|
|
2004
|
664
|
55.3
|
17
|
|
2005
|
687
|
57.2
|
17.1
|
|
2006(10months)
|
651
|
65
|
19.6
|
|
Total
|
3865
|
332.1
|
|
|
Table IV. Complications reported during the period of the
study
|
Complications
|
Number (n = 3865)
|
%
|
|
Abdominal distension
|
464
|
12
|
|
Abdominal pain
|
278
|
7.2
|
|
Sedation overdose
|
8
|
0.21
|
|
Perforation
|
4
|
0.1
|
|
Minor rectal bleeding
|
2
|
0.05
|
|
Stuck snare wire around normal colonic mucosa
|
1
|
0.026
|
|
The most common abnormal finding over all
was colonic cancer in 308 (29%) patients. Other common findings according to frequency were colonic polyps in 250 (23.5%),
inflammatory bowel disease in 163 (15.2%),
diverticulosis
in 142 (13.4%), hemorrhoids 130 (12.2%),
melanosis coli in 31 (2.9%), vascular ectasias in 27 (2.5%), familial
adenomatosis polyposis in eight (0.8%), Behcet ulcer in three (0.3%) and
pneumocystoides intestinalis in two (0.2%) patients as shown in Table II. Within these seven years of the study, there were 308
cases of carcinoma diagnosed.
The number of endoscopies
performed during the time period 2006 was considerably increased (n=651, 19.6%
in 10 months) in comparison with that done during the 2000 period (n=360, 9% in
12 months) (see
Table III). The number of colonoscopies
was increasing every year starting from 2000. There were no significant
differences between the seven period groups in the indications for the colonoscopies,
spectrum of abnormal
Table V. Patients’ characteristics and colonoscopic performance parameters
|
Characteristics
|
Patients (n = 3,865)
|
%
|
|
Age
|
|
|
|
Mean age (years)
|
52.1
|
|
|
Age range
|
16–86
|
|
|
Age less than 50 years
|
1623
|
42
|
|
Gender
|
|
|
|
Men
|
2706
|
70
|
|
Women
|
1159
|
30
|
|
Referral from
|
|
|
|
Gastroenterology
clinic (Outpatients)
|
3440
|
89
|
|
Medical
or surgical ward (Inpatients)
|
425
|
11
|
|
Sedation
|
|
|
|
Conscious sedation (Midazolam 3mg & pethidine 25mg IV)
|
3802
|
98
|
|
No sedation
|
63
|
2
|
|
Biopsies and treatment
|
|
|
|
Biopsy performed
|
1318
|
34
|
|
Polypectomy performed
|
250
|
6
|
|
Limit of colonoscopy
|
|
|
|
Incomplete colonoscopy (inability to reach caecum)
|
116
|
3
|
|
Complete colonoscopy (up to caecum)
|
3749
|
97
|
|
Complete colonoscopy with ileoscopy
(up to terminal ileum)
|
1623
|
42
|
findings, or the rate of cancer detection. Seven (0.018%) of the
patients had a major complication related to the procedure in the form of perforation (n=4), minor bleeding not necessitating
blood transfusion (n=2), and stuck snare wire due to
looping around a normal colonic mucosa that mandated removal by laparotomy
(n=1). Minor
complications according to frequency were abdominal distension (n=464, 12%),
abdominal pain (n=278, 7.2%), and sedation overdose (n=8, 0.21%) which treated
by the specific antidote without necessitating hospital admission (see Table IV).
Discussion
Endoscopy unit at King
Hussein Medical
Center was established in
1980. King Hussein
Medical Center
is a teaching
hospital, receives referrals from all medical sectors in different parts in Jordan.
It mainly serves the military personnel
and their dependents. This may explain why our
patient sample was relatively young with 42% being less than 50 years
old (see Table V). At the same time most (70%) patients were men, which may
also reflect our culture where most women are modest and therefore when offered
colonoscopy try to avoid doing the procedure.
Colonoscopy is a widely used diagnostic and therapeutic intervention.
The procedure is usually well tolerated, with less than 0.5% of
patients developing bowel perforation. Perforation usually manifests
soon after the procedure with generalized abdominal pain. In our study colonoscopy
was safe and well tolerated. There were seven major complications related to
the procedure, two patients presented in the same day of colonoscopy to the
emergency department with minor rectal bleeding and they were hemodynamicaly
stable without drop in hemoglobin, which did not mandate blood transfusion. Four
patients had colonic perforation; two of them had normal colonoscopy, one occurred
while trying to bypass a tumor in the descending colon, and one post
polypectomy in the ascending colon. All four patients were referred to surgery
and underwent laparotomy and suturing of the perforation site and the patient
with the tumor additionally had right hemicolectomy. In one patient, while trying to remove a
transverse colon polyp, the snare stuck around normal mucosa, and the endoscopist
was unable to take it out with different maneuvers. The patient was sent to the theatre with the
scope and the snare inside where he had laparotomy for removal of stuck snare.
Minor complications were noticed in about
20% of the patients in the form of abdominal pain, distension, sedation and
overdose. No treatment apart from giving
an antidote and reassurance was provided for these minor complications.
Patients left the endoscopy unit in a very good condition and were mostly
asymptomatic.
Although colonoscopy has been performed for decades, reducing patient
discomfort and improving their satisfaction remains difficult.(11) Around 4% of patients take
unplanned leave from work on the day after colonoscopy. Attention has been focused on improving the
comfort and safety of the procedure to promote compliance with recommended
screening.(12) Residual bowel gas is a key contributor to
abdominal pain after colonoscopy, and several methods have been tried to
eliminate insufflated gas. Abdominal distension is not usually dangerous, but
it is time-consuming for medical personnel to follow up and explain.(13,14)
According to a consensus statement of the American Society of
Gastrointestinal Endoscopy (ASGE) revised in 2000, colonoscopy is generally
indicated for the surveillance of colonic neoplasia and evaluation of unexplained
anemia, rectal bleeding, and identification of abnormalities on barium enema,
chronic diarrhea and inflammatory bowel diseases.(15) In some
reports, abdominal symptoms such as pain or abnormal bowel habits were reported
as an indication for colonoscopy.(16,17)
In our study the main indications for
colonoscopies were rectal bleeding (39%),
constipation (17%), and diarrhea (12%). Screening colonoscopy still not
widely recommended in Jordan,
especially in patients followed up in public hospitals.
Colonoscopy is generally performed with intravenous sedation and
analgesia because it can sometimes be a painful procedure. Many different
sedative and analgesic agents such as Nitrous oxide, diazepam, midazolam, hyoscine
butylbromide, meperidine and midazolam, propofol, midazolam and propofol have
been used for successful colonoscopy and patient comfort.(18)
In the present study we used meperidine 25mg and midazolam 2mg intravenously, which can be
repeated in the same doses according to patient’s tolerance. This may be more
safe, but patients will have repeated discomfort
because they
are conscious and feel the distension or looping pain during manipulation of
the scope.
Normal examination was a frequent finding in
72.5% of scoped patients. This is one of the usual characteristics of endoscopy services, where the negative results are as of value as the
positive ones, and provide relief to the patient and his physician.(19)
At the same time it may reflect a weak indications or low threshold for
referring for colonoscopy to relieve patients stress.
Colonic cancer (29%) and colonic polyps (23.5 %) were the most common
abnormal findings all over the duration of the study period. Inflammatory bowel
disease (15.2%) was the third frequent finding as in other studies.(20) This may be explained by our patients'
sample, as most of the colonoscopies were done to rule out cancer or
inflammatory bowel disease. We do not know whether this is the actual
prevalence of colonic polyps in our locality, or that we were under diagnosing
this abnormality because of missing polyps in our procedures. This may need further investigations and
comparative prospective studies. Diverticulosis was found in 13.4% of our
patients, which is lower than that found in Western countries.(21)
This may be related to our sample which was relatively young, or may reflect
the life style in our locality in eating high fiber food, which is protective
against diverticulosis.(22)
About 16% of patients diagnosed with cancer
have no alarming symptom, and may be missed due to inaccurate history
taking. Early detection of cancer, which
may reflect low indication threshold for doing the colonoscopy, provides better
prognosis for the patients.
Rectal bleeding in our patients was a
frequent complaint, most of them were younger than 50 and referred from
surgeons to check for colonic pathology, but in about three quarters, the
endoscopy showed hemorrhoids or normal findings. This means that rectal
bleeding was a poor predictor for the endoscopic findings (25%) of patients, and
may be explained by misunderstanding what the patient has meant by rectal
bleeding, poor clinical evaluation by the surgeon, exaggeration from the
patient himself, or healed or missed lesion at the time of endoscopy.
It is traditionally believed that a specialist consultation can select
suitable patients for colonoscopy and so a better diagnostic yield. However, it
is generally agreed nowadays that attempts to justify doing the procedure by
assessing the diagnostic yield are not appropriate. A negative endoscopic
finding is as important as a positive one in the management strategy of lower gastrointestinal
symptoms.(13,16,17,23)
In evaluation of workload in the form of the numbers of colonoscopies
performed, it is clearly noticed that the workload has considerably increased throughout
the years starting from 2000 with 30 colonoscopies per month till 2006 with 65
colonoscopies per month. This may indicate that colonoscopy services became
more popular and more acceptable culturally because of more patient education and
feedback. Our endoscopy unit was established with two endoscopists in 1987,
this number increase to four during the years 1994-2003 and reached seven
endoscopists from 2004 till now.
Conclusion
Indications for colonoscopy should not be too strict. Colonoscopy should
be regarded as a useful, safe, and effective examination in patients
who have gastrointestinal complaints. A rapid and definitive diagnosis can be made.
We believe that a negative endoscopic result is as valuable as a positive one, because it
provides relief to the patient and his treating physician.
References
1.
Richard Hobbs
FD. ABC of colorectal cancer, the
role of primary care. BMJ 2000; 321:1068-1070.
2.
Newman RJ, Nichols DB, Cummings DM. Outpatient Colonoscopy by Rural Family Physicians. Annals
of Family Medicine 2005; 3:122-125.
3.
Imperiale
TF, Wagner DR.
Results of screening colonoscopy
among persons 40 to 49 years of age. NEJM 2002; 346:1781-1785.
4.
Lieberman DA, Weiss DG, Bond JH. Use of colonoscopy to screen asymptomatic adults for colorectal
cancer. NEJM 2000; 343:162-168.
5. Yilmaz M, Aydin A, Karasu Z, et al. Risk factors associated with changes in oxygenation and pulse rate during colonoscopy. The Turkish Journal of Gastroenterology 2002; 13: 4, 203-208.
6.
Jensen
DM, Machicado GA, Jutabha R. Urgent Colonoscopy for the diagnosis and treatment of
severe diverticular hemorrhage. NEJM
2000; 342:78-82.
7.
Crosland
A, Jones R. Rectal
bleeding: prevalence and consultation behaviour. BMJ 1995; 311:486-488.
8.
Rockey DC, Cello JP. Evaluation of the gastrointestinal tract in patients with
iron-deficiency anemia. NEJM 1993; 329:1691-1695.
9.
American
Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointes
Endosc 2000; 52:831-7.
10. Bercowitz I, Kaplan M. Indications for
colonoscopy: An analysis based on indications and diagnostic yield. S Afr Med J 1993; 83:245.
11. Forbes GM, Collins BJ. Nitrous oxide for
colonoscopy: a randomised controlled study. Gastrointest Endosc 2000;
51(3):271-7.
12. Wong B, Chan CK, Wong KW, et al.
Evaluation of a new referral
system for the management of dyspepsia in Hong Kong:
Role of open-access upper endoscopy. Journal
of Gastroenterology and Hepatology 2000; 5: 1251-9.
13. Bradshaw N, Holloway S, Penman I, et
al. Colonoscopy
surveillance of individuals at risk of familial colorectal cancer. Gut
2003; 52:1748-1751.
14. Bowles CJA, Leicester R, Romaya C, et
al. A prospective study of
colonoscopy practice in the UK
today: are we adequately prepared for national colorectal cancer screening
tomorrow?. Gut 2004; 53: 277-283.
15. Hamilton W, Sharp D. Diagnosis
of colorectal cancer in primary care: the evidence base for guidelines. Family
Practice 2004; 21: 99–106.
16. Harris J, Froehlich F, Gonvers J. et
al. The
appropriateness of colonoscopy: a multi-center, international, observational study. Int J Qual
Health Care 2007; 19(3):150-157.
17. Esfandyari T, Harewood GC. Value of a negative
colonoscopy in patients with non-specific gastrointestinal symptoms. J
Gastroenterol Hepatol 2007; 22(10):1609-1614.
18. Manes G,
Imbesi V,
Ardizzone S,
et al. Appropriateness
and diagnostic yield of colonoscopy in the management of patients with
ulcerative colitis: a prospective study in an open access endoscopy service. Inflamm Bowel
Dis 2008;14(8):1133-8.
19. Thiis-Evensen
E, Seip B,
Vatn MH,
et al. Impact of a
colonoscopic screening examination for colorectal cancer on later utilization
of distal GI endoscopies. Gastrointest
Endosc 2006; 64(6): 948-54.
20. Burnand B,
Harris JK,
Wietlisbach V. Use, appropriateness, and diagnostic yield of
screening colonoscopy: an international observational study (EPAGE). Gasrrointest
Endosc 2006; 63(7):1018-26.
21. Cappell MS. Safety and efficacy of colonoscopy after myocardial
infarction: an analysis of 100 study patients and 100 control patients at two
tertiary cardiac referral hospitals. Gastrointest
Endosc 2004; 60(6):901-9.
22. Ian FY, Donald GO,
Neville EH.
Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in
patients undergoing colonoscopy for diarrhea. Journal of Gastroenterology
and Hepatology 2002; 17: 276-278.
23. Spiegel
BMR, Kanwal F, et al. The impact of somatization on
the use of gastrointestinal health-care resources in patients with irritable
bowel syndrome. Am J Gastroenterol 2005; 100(10):2262-2273.