SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 42 CASE SERIES Introduction Disease of the digestive system accounted for 2.6% of all deaths recorded in South Africa (SA) as per the 2017 Statistics SA estimates. 1 This was double the estimates recorded for Sub-Saharan Africa, which had about 1.3% in 2019. Endoscopy remains an important diagnostic and therapeutic tool for gastrointestinal diseases; 2.3 In addition, they also play an integral role in the surveillance for gastro-oesophageal and colonic malignancies. 2 Globally, the common symptoms for which gastroscopies are performed include abdominal pain, gastro-oesophageal reflux, and upper gastrointestinal disease, diarrhoea and unexplained weight loss. 4 The commonest upper gastroscopy findings in HIV negative patients in developed countries include gastritis, duodenitis, peptic ulcer disease, coeliac disease, upper gastrointestinal cancer and foreign body removals. 4 Endoscopy, with biopsy of suspicious lesion, is necessary in all HIV positive patients presenting with persistent upper gastrointestinal symptoms. 5 The most common symptoms for performing a colonoscopy include those of colorectal cancer screening, gastro-intestinal blood loss (including rectal bleeding, anaemia, and positive faecal occult blood test results), abdominal pain and diarrhoea or constipation. 4 The commonest findings in lower endoscopic procedures include colorectal cancer, advanced polyp, adenomatous polyps, inflammatory bowel disease, infectious colitis and colonic tuberculosis. 4 Hence, it is vitally important to have appropriate guidelines in place to prevent over-utilisation of this limited resource. Globally, it is estimated that around one-quarter (24.1%) of all gastroscopies and 35.5% of lower endoscopic procedures that are performed yield normal results. 4 The demand for endoscopies is increasing in resource-limited low-to-middle-income countries and this has resulted in an increase in waiting periods for these procedures. 6 The continued increase in demand for endoscopy, led primarily by colorectal cancer screening by colonoscopy, has also resulted in a relative shortage of physicians who can competently perform such endoscopies. One way of addressing this shortage is to train some family physicians to competently perform endoscopies and this has been shown to ease the waiting times. 4 The increased waiting periods for endoscopies has a significant impact on patients’ quality of life and the number of lost workdays 7 A study done at the Charlotte Maxeke academic Hospital in South Africa has shown that waiting times for gastroenterology services were prolonged when compared to developed countries. In this study, it was noted that patients with alarm features were generally not seen scoped early enough. 8 Upper gastrointestinal endoscopy is a valuable diagnostic tool but for an endoscopy service to be effective it is essential for it not to be overloaded with inappropriate referrals. A joint working party in Britain has considered the available literature on indications for endoscopy, and they have used this data to produce guidelines on what is appropriate and inappropriate indications for endoscopy referral which has helped ease the burden of inappropriate referrals. 5 Globally, endoscopy-related complications are rare (1.35%). 9 When complications do occur, they can include cardio-pulmonary complications, sedation- related complications, infections, perforations and bleeding. 9 Cardio-pulmonary complications are responsible for 50% of the mortality and mortality related to endoscopic procedures. These complications may be secondary to hypoxaemia which may be related to the procedure itself, the sedation, or the combined effect 10 . Bacteraemia associated with endoscopy may result from contaminated endoscopy equipment, improper cleaning and disinfection procedures, as well as problems related to equipment designs. 10 Colonoscopic procedures remain expensive and are associated with a low but significant complication rate. 6 The procedure is also time consuming and requires considerable expertise and usually requires 48 to 72 hours of patient bowel preparation. 11 Endoscopy remains a vital tool for the diagnosis and a therapeutical modality for gastrointestinal diseases. However, rational and judicious use of this limited resource is required. Although some of the developed countries have proposed guidelines for its prudent use, developing countries like South Africa have still not identified suitable criteria. In this study we will describe the commonest symptoms experienced by patients needing endoscopies and detail endoscopy findings in both patients with and without HIV-infection. Methodology Study design This was a retrospective, observational, descriptive, cross-sectional study that reviewed endoscopy results of outpatients who had endoscopies performed during study period. Setting The study was undertaken at the Edendale Hospital, Department of Surgery, gastro-enterology unit in Pietermaritzburg, KwaZulu Natal. Edendale Hospital (EDH) is a referral hospital providing regional and district level services and is located in Pietermaritzburg, in the uMgungundlovu health district. It is an academic hospital and forms part of Pietermaritzburg Metropolitan Hospital Complex which includes Grey’s Hospital as the tertiary center. EDH is the third largest public Hospital in South Africa with 900 beds and it services about fourteen clinics and some district hospitals. Patient Selection Inclusion Criteria • Files of all patients from the outpatient department, both medical and surgical outpatient, that were referred for endoscopy to the gastro- enterology unit from 01 January 2017 to 31 December 2018 at Edendale Hospital were reviewed to analyse the indications, findings and complications of endoscopies. • All patients 18 years and above were included Exclusion Criteria • All patients under the age of 18 years • All in-patients Measurements Endoscopies were performed by surgeons, registrars and trained medical officers. This study was designed to describe the demographic characteristics, indications, findings and complications of endoscopies performed at EDH in Pietermaritzburg over a period of two years, from January 2017 to December 2018. The following variables were collected and analysed: (i) Demographic: age, gender, and race of patient (ii) Clinical history: History of smoking and alcohol use