The Profile of Patients Referred for Diagnostic Colonoscopy in Rwanda. Case of Kigali University Teaching Hospital

Abstract

Background: Divergent to the past, gastrointestinal (GI) pathologies like inflammatory bowel disease and colorectal cancer (CRC) are increasingly becoming a burden in young and economically developing countries as a result of western world lifestyle adoption. However, the practice of colonoscopy which is the best tool for the diagnosis of lower GI conditions remains suboptimal in some of these countries. During the last two decades, Rwanda records an improvement in the diagnosis of GI diseases and observed the burden of colorectal pathologies. Hence, updated local data about clinical and socio-demographic factors associated with variable colonoscopy findings in the adult population are scanty. Objectives: The point of this study was to document the clinical and demographic characteristics defining colonoscopy findings in Rwanda and the significance of related diagnostic intervals (DI= time from symptom onset up to colonoscopy diagnostic finding). Methods: The study was a single-center cross-sectional study of 225 symptomatic patients who underwent diagnostic colonoscopy exams at Kigali University Teaching Hospital (CHUK). A questionnaire assessing the relationship between colonoscopy findings with patients’ symptoms and socio-demographic factors has been set. All clinical information was collected between January and June 2022 for all patients of 15 years of age and above referred to the endoscopy unit with mixed lower GI symptoms. Mixed chi-square statistics and effective binary logistic regression models were fitted to explore the significance of clinical and socio-demographic factors associated with overall colonoscopy findings in Rwanda. Special emphasis has been put on the pathologies of high prevalence and substantially attracting public attention. Results: 225 participants who met the inclusion criteria were enrolled in the study. 54.2% were female and more than half were older than 50 years of age. 95.6% were outpatients, residents of Kigali city for the most part and over 99% had at least one type of health insurance for medical cost coverage. Only 44.9 percent of participants had single symptoms by the date of data collection. The main percentage presented with rectal bleeding as the chief complaint counting for 39.1% of haematochezia compared to change in bowel habits (30.2 percent had constipation, 2.7 percent had diarrhea). Abdominal pain was indicated in 20.0% of patients as the main symptom and was presented as the second symptom in other 23.1% of the study population. Given findings, only 16.4% had normal colonoscopy examinations and in 83.6% various colorectal pathologies have been diagnosed. The most commonly detected abnormal findings were dolichocolons with 36.4%, 15.1% were colorectal tumors, 12.0% of colon polyps, 12.4% of colitis, hemorrhoidal disease were detailed in 19.8% and less than 5% counts for other uncommon disorders of the colon rectum. Both colon tumors and hemorrhoids were statistically associated with age (p = 0.007 and 0.005) and sex (p = 0.004 and 0.001 respectively) while the extent of dolichocolons was almost similar in both sexes (51.2% in female vs 48.8%, p = 0.290) and slightly dominant in older group (58.5% vs 41.5%, p = 0.369). Being younger than 50 years had a protective value of 65.9% (OR 0.341 [0.146 – 0.797]) for colon tumors and with a 2.139 increased relative risk to have hemorrhoids as opposed to elder group while being female sex records 3.064 [1.380 – 6.801] odds for colon tumors and 70.3%, OR = 0.297 [0.145 – 0.606] protective risks comparing to males. No single finding has been proven to be statistically relevant as association with behavioral risk factors like tobacco and alcohol consumption. Regarding colonoscopy findings and related symptoms presentation, 82.4% of patients with colon tumors had hematochezia (p <0.001) which was also the leading symptom in hemorrhoids at 66.0% (p =0.006) and 44.4%( p =0.403) of polypoid lesions; patients with dolichocolon presented mainly with constipation (46.3%) and abdominal pain (15.9%), and the last was the chief complaint in 42.9% of colon inflammation cases with a p value of 0.002. Even though there are delays in primary medical consultation in patients with lower GI symptoms, longer intervals have been documented in the health sector referral system (mean intervals of 5.80[112] versus 7.89[1-17]). Around 42.6% of symptomatic adults failed to consult in the first six months of symptoms onset whereas 57.4% wait for more than six months to be transferred for a colonoscopy exam from the first date of medical consultation. The overall mean diagnostic intervals for symptomatic patients at CHUK were 13.68[1-29] and no demographic factor has been statistically proven to improve that timing. Conclusion: Colonoscopy is crescively becoming a popular diagnostic tool in Rwanda. Though the long diagnostic intervals, the limited number of normal exams in addition to highly frequent lifethreatening conditions from both hemorrhagic and non-hemorrhagic symptoms (15.1% of colorectal neoplasm, 12.0% colon polyps, 36.4% of dolichocolon and 12.4% of colitis) call attention to the extreme need of strengthening diagnostic endoscopy services in Rwanda and consideration of preventive screening modalities among the risky population and timely referral of patients