Objectives: Data on lower Gastrointestinal (GI) disease are generally sparse. In addition, the pattern of GI disease is changing over time.

      The objectives of this study were to identify the main indications and associated endoscopic findings in patients presenting for elective lower GI endoscopy at a major teach- ing hospital, thus provide database and identify the current pattern of lower GI disease in our community.

      Methods: This is a descriptive analytic study. We ana- lyzed data collected prospectively over a period of 12 years (2007-2019). These included demographic data of patients, symptoms and endoscopic findings.

      Results: The study included 1086 patients. Diagnostic endoscopies (colonoscopy and sigmoidoscopy) were done for 989 patients (95.5%) and therapeutic procedures for 48 patients (4.5%). The most common symptoms were rec- tal bleeding (51.3%), followed by change in bowel habits (12.6%), abdominal pain (7.7%), perianal pain (6.7%) and anemia (4.1%). We further analyzed these symptoms re- garding the endoscopic findings.

      Endoscopic findings showed prevalence of diseases once thought to be rare or non-existing. Colorectal tumors ac- counted for (10.1%) of the patients, most of which (80%) had rectal tumors and (34.5%) of these patients were below the age of 50.

      Conclusion: This study shows the current pattern of low- er GI disease. There are trends of ‘westernization’ of disease and rectal cancers in younger patients than classically re- ported. These findings would have a strong socio-economic impact on individual, society, and country as a whole. It provides important endoscopic database to policymakers, clinicians and researchers. It highlights the importance of endoscopy services, and focuses on areas needing further studies.

      Data on lower Gastrointestinal (GI) disease patterns, par- ticularly from developing countries, are sparse. Over the years, there have been changes in population demography, feeding habits, and pathology.

      Modern video-endoscopies are now available as well as ex- pertise. Data build up helps identifying the pattern of GI disease in the community. This could provide benchmarks for endoscop- ic practice and highlight areas of community needed research.

      The objectives of this study were to identify the most com- mon presenting symptoms (indications) and the endoscopic findings in patients presenting for routine lower Gastrointes- tinal Tract (GIT) endoscopy at Khartoum North Teaching Hos- pital (KNTH), Sudan. This knowledge would draw a picture of the current pattern of gastrointestinal disease and buildup da- tabase for the benefit of endoscopic units and health providers. It would allow us to compare and identify changes of disease pattern over time. It would highlight areas for future research and also allow making comparisons with regional and interna- tional data.

      As far as we know, this is the largest data collection in a Su- danese study for decades.

      Ethical approval was obtained from the research and ethics committee at the Ministry of Health and KNTH. Informed con- sents were obtained from patients for the endoscopy and par- ticipation in the study.

      We analyzed data collected prospectively on consecutive patients, who underwent lower GI endoscopies at KNTH over a period of 12 years (from February 2007 to November 2019). KNTH is one of the 3 major governmental teaching hospitals in the capital Khartoum (Sudan). Its catchment area includes over 2 million inhabitants and is increasing. It has a busy endoscopy unit where 3 experienced endoscopists (2 surgeons and one in- ternist) do diagnostic and therapeutic procedures. A pro-forma was designed to collect patient’s biodata, which included: Age, gender. In addition data on the type of GIT endoscopy -(Upper/ Lower/Diagnostic/Therapeutic)-, the main presenting symp- toms/ indication(s), as well as the endoscopic findings.

      Statistical analysis of the data was done using IBM SPSS Sta- tistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA).

      The video-endoscopes used were Olympus (Q150L) and Pen- tax (Pentax EPKi digital video processor and Pentax video colo- noscope)

      Pre endoscope preparation involved bowel preparation for either one day if polyethylene glycol (coloclean) was available, or 2 days-prep using bisacodyl 5 mg (12 tablets): 2 tablets/8 hours for 2 days. Phosphate enemas are taken on the night be- fore and again on the morning of the endoscopy in both meth- ods. The patient is kept over fluid diet the day before the endos- copy and is fasted overnight. We request viral screening blood tests for hepatitis B and C, as well as for HIV, so that standard precaution measures are taken. All patients were consented. Those who refused the procedure or participation in the study were excluded. Patients prepared for diagnostic sigmoidoscopy received per rectal local anesthesia with xylocaine gel (2%). Those for colonoscopy or therapeutic interventions received- in addition-intravenous sedation with pethidine (50 mg) and either midazolam (2.5 - 3 mg) or diazepam (5 mg) when mid- azolam was not available. Patients were assessed for sedation individually. All patients were monitored during the procedure using a standard operating room monitor, and remained under supervision for an hour in a recovery ward before they were al- lowed home. We had no mortality. One patient had perforation of the colon for which he was taken immediately to the oper- ating theatre. Generally, the procedure was stopped if the pa- tient was uncomfortable despite adequate sedation or in case of technical problems, such as excessive looping.

      A total of 1086 patients were included in the study. Diagnos- tic procedures were done in 989 patients (91.1%), and thera- peutic procedures in 48 patients (4.4%). The procedures failed or were not completed in 49 patients (4.5%). The total negative findings rate was (30.5%).

      The mean age was 47.4 years (sd = 17). More than half of our patients (54.5%) were under the age of 50 years.

      There was a significant predominance of male (70.4%), giv- ing a M: F ratio of 2.3:1.

      Themostcommonpresentingsymptomswere:Rectalbleeding (hematochezia) (51.3%) followed by change in bowel habits (de- fined as diarrhea, constipation or alternating) (12.6%), perianal pain (6.9%), abdominal pain (6.8%) and anemia (4.1%), (Table 1)

Table 1

Table 1: The presenting symptoms (indications) for lower GI endoscopy.

Table 2

Table 2: The endoscopic findings in cases of rectal bleeding/ hematochezia (N=532).

      We further analyzed the endoscopic findings of the com- monest symptoms:

• The most common causes of rectal bleeding were hemorrhoids 304 patients (57.1%), followed by Colorectal Can- cer (CRC)/ Colorectal (CR) tumors 35 patients (8.5%), and polyps 44 patients (8.3%). Tumor distribution was as follows: The rec- tum (7.3%), the colon (0.8%) and the anal canal (0.4%). There were 21 patients of Protocolitis (3.9%), 18 patients with diver- ticular disease (3.4%). No cause of bleeding was found in 5% of cases (Table 2).
• One hundred and twenty seven patients (127) presented with change in bowel The commonest causes were CR tumors (14.2%). These were distributed as follows: the rectum 14 patients (10.7%), colon 2 (2.3%), and anal 1 (0.8%). The next common causes were hemorrhoids 9 patients (7%), and polyps 8 patients (6.1%). These were followed by Protocolitis including inflammatory bowel disease (5.3%), and diverticular disease (3.8%) No cause was found in (62.2%) of cases.
• Eighty patients (80) presented with perianal pain. The most common causes of perianal pain were complicated hemorrhoids 22 patients (27.5%), anal fissures and fistula, each 13 patients (16.3%). These 3 pathologies accounted for (60.1%) of There was a case of anorectal tumor (1.3%). Almost one third of cases (31.3%) had negative findings.
• Sixty-nine patients (69) presented with abdominal pain. The most common causes of abdominal pain were polyps 10 patients (14.5%), CR tumors 9 patients (13%), Proto- colitis and inflammatory bowel disease 9 patients (13%), and diverticular disease 2 patients (3%). No cause was de- tected in 36 patients (52%)
• Forty-three patients (43) presented with The commonest causes of anemia were colorectal tumors and polyps; together accounting for (27.8%) of anemia cases. These are distributed as follows: rectal tumors 8 patients (18.6%), colonic tumors 2 patients (4.6%), polyps 2 pa- tients (4.6%). Ten patients had hemorrhoids accounting for (23.3%) of cases. Three patients had diverticular dis- ease (7%). In 18 patients (41.9%), no endoscopic finding of significance was found.

      Out of the 1086 patients, 316 patients had a ‘normal’ report, giving a negative finding rate of 30.5%. This leaves us with the remaining 721 patients with positive findings. The main sites of diagnosed pathology were ano-rectal area (78.7%) followed by the colon (19.7%) and combined sites (1.6%).

      The most common findings (pathologies) were hemorrhoids (36.4%) followed by rectal tumors (8.1%), colorectal polyps (7.2%), colonic tumors (1.6%) and anal tumors (0.4%). Diver- ticular disease (3.2%) was the fifth common disease together with anal fissures. The total proportions of Protocolitis (7.2%), and inflammatory bowel disease (1.6%) together with diverticu- lar disease (3.2%) amounted to 12%. Despite the lack of data, these diseases were not commonly known in Sudan about 3 de- cades ago (Table 3).

Table 3

Table 3: The endoscopic findings (macroscopic Pathology) in 1037 patients.

      Of all lower GI tumors (105 patients): Rectal tumors account- ed for (80%), anal tumors (3.8%), and the rest (16.2%) were co- lonic.

      It was also alarming that (34.5%) of patients with rectal car- cinoma were below the age of 50 and (7.2%) below 30 years (Figure 1). Colonic tumors were found in 17 patients (1.6%). Of those 5% were below the age of 50 years and 1% below 30 years.

Figure 1: The age distribution of patients with Rectal Cancer.

      Note: 29patients (34.5%) were below the age of 50 years and 6 patients (7.2%) below 30 years

      This is the largest study, regarding the number of patients, of the pattern of lower GI disease as revealed by endoscopic evaluation of the lower GI in this country.

      The age distribution of our patients showed that the major- ity are below the age of 50 years (and 50% below 40 years). The prevalence of GI disease in this young sector of the community would have adverse socio-economic effects on the individual, community, and country as a whole.

      The male predominance must be explained cautiously. Lower GI symptoms, particularly rectal bleeding, is quite com- mon in the community but only a fraction of patients reports to medical services [1,2]. In advanced countries this fraction is es- timated to be between 30-50% [3,4,5]. In developing countries, the problem of presentation for medical advice is expected to be even larger. Though there are no available data, the lack or remote location of medical services, as well as the social stigma or mere unawareness of the importance of lower GI symptoms hamper a large fraction of patients from reaching medical con- sultation.

      Most of our lower GI endoscopies were diagnostic. Thera- peutic endoscopies accounted for less than 5% (4.4%) of cases. This was simply due to the lack of the required (and requested) intervention instruments such as loop diathermy and snares. Therapeutic endoscopies carried out in our unit were mostly injection sclerotherapy and banding of hemorrhoids, and less frequently snaring of polyps.

      Because of this globally observed trend of CRC in younger patients, many centers of excellence have changed its recom- mendation for screening. For example in the United States, the US Preventive Services Task Force (USPSTF) has changed its rec- ommendation to screen the population from the age of 45 in- stead of 50 years [15]. National Institute for Health and Clinical Excellence (NICE) in the UK, advises urgent referral of patients aged over 40 with six weeks of rectal bleeding accompanied by diarrhea, and referral of patients aged 60 or more with rectal bleeding for six weeks without anal symptoms or diarrhea [16].

      Unlike studies from advanced countries such as the USA, en- doscopic screening and surveillance was not one of the indica- tions for lower GI endoscopy [6]. However, the other indications are pretty much similar. In our study, the commonest presenting symptom or indication for endoscopy was rectal bleeding. This conforms to most reports globally [6,7]. The main endoscopic finding in patients presenting with rectal bleeding were hemor- rhoids. These are followed by Colorectal (CRC) tumors and pol- yps. Rectal bleeding is, therefore, an important symptom that needs to be investigated by endoscopy.

      Classically, rectal cancer is known to affect people above the age of 50 years. However, we found an alarming proportion (30%) of patients who were below the age of 50 and even be- low 30 years of age (7%). Interestingly, this trend was observed recently in many countries; advanced and developing. Examples are Siegel et al in the USA and Gado in Egypt [8,9].

      This trend has also been observed in Sudan in most of the studies done in Sudan over the past 2 decades [10-14]. With the exception of only one study [13], the mean age ranged from (50-54) years, and the percentages of colorectal cancer patients under the age of 50 years ranged from (34.5% - 44%), and those below 30 years from (7-17%), (Table 4).

Table 4

Table 4: Sudanese Studies: age, gender, and site trends of colorectal cancer over the past 2 decades.

      We propose that in developing countries we must be selective. According to our study, rectal bleeding in CRC is most common- ly associated with change in bowel habits, abdominal pain and anemia.

      Some of our young rectal cancer patients gave a history of protracted rectal bleeding and prolonged treatment with end- less courses of anti-dysentery or anti-parasitic tablets. In a country where various types of dysentery are rife, this is a com- mon medical mistake. One of those young patients even had a hemorrhoidectomy without being endoscoped at all to present later with an advanced rectal tumor which was the real cause of the bleeding and most likely also the cause of the hemorrhoids.

      Rectal cancer was the commonest cause of change in bowel habits. This was also observed by Ellis and Thompson in the UK who noticed that the prevalence of cancer increased 3 folds when rectal bleeding was associated with change in bowel hab- its [1]. Colorectal, especially rectal cancers were also the main cause of anemia and second common cause of abdominal pain (after polyps). Both clinicians and patients should be aware that rectal bleeding in combination with any of change in bowel hab- its, anemia, and/or abdominal pain warrants urgent lower GI endoscopy since it increases the suspicion of malignancy.

      Changes in bowel habits in isolation of other symptoms, such as rectal bleeding, have a negative finding rate of (62.2%). With no yield in almost two thirds of cases and risk of complications (though very small), colonoscopy in that case would not be cost- effective. It would, therefore, be more prudent to investigate using barium enema or CT-enema scan first, and do endoscopy if a suspicious lesion was found.

Table 5

Table 5: Comparison between causes of rectal bleeding in emergency and elective situations in Khartoum.

      We searched for past data on the pattern of lower GI dis- ease in Sudan, but couldn’t find a comprehensive study. In our study, the total proportions of Protocolitis (7.2%), inflammatory bowel disease (1.6%) together with diverticular disease (3.2%) amounts to 12%. Despite the lack of data, these so called ‘West- ern diseases’, were not known to be common in the past. It seems that there has been a change of disease picture, which in turn could be due to change in environment and feeding habits. This suggestion requires further research.

      We hope that our study provides database that can help fu- ture studies and comparisons. We also hope that our data shed the light on important issues for policy makers and the health providers in general who are concerned with prevention and early detection of disease, particularly cancer in the young. Our study has pointed out important areas for further studies and research.

Limitations of the study

      This is a one-centre study, which may limit the diversity of the sample. Nevertheless, the large number of the sample and the time spread of the study, in addition to the central location of this secondary referral centre and teaching hospital minimize this limitation. Lack of financial and technical support has al- ways been a problem causing the endoscopy service to slow down or stop at times. Data were entered manually in a log- book because our service is not computerized. Manual entry of information was some of the time not followed strictly by all endoscopists. Biopsies are expensive to handle in labs and patients had to pay for them.

      Our study showed that the most common site of pathology was the anorectal area. It is the site of (78.8 %) of all pathology and (83.8%) of lower GI tumors. A simple rigid sigmoidoscopy (35 cm long) can thus discover and diagnose over 80% of lower GI pathology including tumors. We recommend rigid sigmoid- oscopy training to all doctors and specialized nurses. We also encourage policy makers and health service director to supply sigmoidoscopies to outpatient offices in hospitals and in health centers.

      Our data also showed that diverticular disease existed as a cause of rectal bleeding in elective cases. DD is the main cause of excessive rectal bleeding presenting as emergency [17]. A comparison of the causes of rectal bleeding in emergency and elective situations was done (Table 5). It confirms the change of the pattern of colorectal disease in this country since DD was not diagnosed as frequently as today.

      This study shows the current pattern of lower GI disease and endoscopic practice in our country.

      Most our patients are in the young, economically productive age. Consequently, this will be reflected negatively on the so- cioeconomic status of the community unless serious steps are taken in the areas of prevention, early detection (screening) and treatment.

      The pattern of lower GI disease is showing evidence of in- creasing prevalence of “Western” diseases, such as diverticular disease, and inflammatory bowel diseases. This may be due to the changes into “Westernized diet” with less fibers and more fat.

      The study confirms the global alarming trend of CRC, par- ticularly rectal cancer, affecting younger people. This trend has been observed for the past 2 decades but no action has been taken. We suggest that this is an area that needs urgent and extensive epidemiological research as well as health education to both patients and doctors on the importance of endoscopy and initiating screening programs.

      The study provides important endoscopic database to poli- cymakers, clinicians and researchers. It also highlights the im- portance of establishing a computer-based data network sys- tem and databank to collect and document the information obtained from all the endoscopic units in the country.

      Acknowledgement: We are grateful to the sisters, nurses, and staff of the endoscopy unit at Khartoum North Teaching hospital for their dedication and great work they have provided and still providing our patients. Their sfforts are invaluable in keeping the flow of the service and keeping the scopes and the atmosphere of work in almost perfect condition despite the great challenges we are facing.

      The authors declare that this manuscript is an original con- tribution. It has not been previously published and is not under consideration for publication elsewhere.

      Conflict of interest: The authors declare that they have no

      conflict of interest

      Guarantor of the article: Professor Gamal EHA El Shallaly, who is also the corresponding author.

      Ethical approval: The study was approved by the ethical committee at KNTH and the AAU. Informed consent was ob- tained from all individual participants included in the study.

      “All procedures performed in studies involving human par- ticipants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or compa- rable ethical standards.”

      Financial support: Nothing to declare. This study was self- funded. We have no intention of gaining financial benefits from this work or its publication.

      Author’s contribution: El Shallaly: Conceiving the idea, plan- ning and drafting the manuscript; Babiker A. B. Ibrahim: Con- ducting the study, collection of data, statistical analysis, tables and figures; Mohamed M. I. Elhajahmed: Conducting the study, collection of data, statistical analysis, tables and figures; Moda- ther M. E. Salih: Conducting the study, collection of data, statis- tical analysis, tables and figures; Mohammed F. E. Mohammed: Conducting the study, collection of data, statistical analysis, tables and figures; All authors have reviewed and approved the final draft submitted.

Study highlights:

      What is known?

• Data on lower GI disease are sparse
• Developing countries have high fiber diet protection
• Colorectal cancer affects patients over 50 years of age

What is new here?

• Establishing database on lower GI disease pattern
• Higher prevalence of “Western” style lower GI diseases
• Higher prevalence of rectal cancers in patients below

      50 years than reported globally