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High rates of gastroesophageal cancers in patients with dyspepsia undergoing upper gastrointestinal endoscopy in Uganda

Georg Thieme Verlag KG
Endoscopy International Open
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Background and study aims Dyspepsia is the most common presenting symptom in the gastrointestinal clinic of Mulago National Referral hospital. The etiology is essentially not fully described in our patient population. This study was therefore conducted to establish the causes of dyspepsia based on endoscopic diagnosis among patients with dyspepsia seeking care at the National Referral hospital of Uganda. Patients and methods This retrospective study conducted in the endoscopy unit of Mulago hospital reviewed 356 patient endoscopy reports spanning January 2018 to July 2020 with a focus on those with a referral indication of dyspepsia. Age and sex were the independent variables of interest while the endoscopy findings as reported by the endoscopist were the outcome variable of interest. Results Of the 356 endoscopy reports reviewed, 159 met the inclusion criterion of dyspepsia as the indication. Participant mean age was 47.7 years (± 16.53) with the majority (25.79 %) in the fifth decade while the male to female ratio was 1. The majority of patients had organic dyspepsia (90.57 %) while the commonest finding was gastritis 69 (43.4 %). Gastroesophageal cancers represented (18) 11.32 % of all findings. There was a positive association between age > 50 years with gastroesophageal cancers (7.639) as well as age < 50 years and functional dyspepsia (2.794); however, all these were not statistically significant (P = 0.006 and (P = 0.095, respectively). Conclusions Organic/structural dyspepsia comprises over 90 % of investigated dyspepsia with 11 % comprising cancer among patients seeking endoscopy at the National Referral Hospital of Uganda.
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Introduction
Dyspepsia, which by definition is the presence of one or more of
the symptoms of epigastric pain, bloating, post-prandial full-
ness, early satiation, and retrosternal pain [1], is estimated to
affect up to 50 % of individuals globally [2] with an estimated
higher prevalence in low and middle income countries, particu-
larly Africa with the highest prevalence of uninvestigated dys-
pepsia [3]. In one community study conducted in rural Uganda,
more than 50% of the respondents reported having had symp-
toms of dyspepsia [4]. The majority of dyspepsia in Africa is un-
investigated with patients often treated symptomatically. This
creates a challenge as treatable diseases including malignan-
cies are often missed only to present in very advanced stages.
Thepaucityofinformationondyspepsiainsub-SaharanAfrica
(SSA) also affects development of clinical and policy strategies
of mitigating causes including cancer of the stomach which is
the most prevalent gastrointestinal malignancy in SSA. SSA is
projected to have a more than 73% increase in gastrointestinal
cancers by 2030, way more than the 59% global estimate [5].
With uninvestigated dyspepsia masking this growing burden,
there is a need to fully understand the characteristics of dys-
High rates of gastroesophageal cancers in patients with dyspepsia
undergoing upper gastrointestinal endoscopy in Uganda
Authors
Ronald Mbiine1, Cephas Nakanwagi2, Olivia Kituuka1
Institutions
1 Department of Surgery, Makerere University College of
Health Sciences, Kampala, Uganda
2 Endoscopy Unit, Mulago National Referral Hospital,
Kampala, Uganda
submitted 20.1.2021
accepted after revision 12.3.2021
Bibliography
Endosc Int Open 2021; 09: E997E1000
DOI 10.1055/a-1480-7231
ISSN 2364-3722
© 2021. The Author(s).
This is an open acce ss article published by Thie me under the terms of the C reative
Commons Attribut ion-NonDerivative-NonCommercial License, permitting copying
and reproducti on so long as the original work is given appropriate credit . Contents
may not be used for comme rcial purposes, or adapted, remixed , transformed or
built upon. (http s://creativecommons.org/licens es/by-nc-nd/4.0/)
Georg Thieme Verlag KG, Rüdigerstraße 14,
70469 Stuttgart, Germany
Corresponding author
Ronald Mbiine, P.O. Box 7072 Mulago Hill Road, Kampala,
Uganda
mbiineron@gmail.com
ABSTRACT
Background and study aims Dyspepsia is the most com-
mon presenting symptom in the gastrointestinal clinic of
Mulago National Referral hospital. The etiology is essential-
ly not fully described in our patient population. This study
was therefore conducted to establish the causes of dyspep-
sia based on endoscopic diagnosis among patients with
dyspepsia seeking care at the National Referral hospital of
Uganda.
Patients and methods This retrospective study conduct-
ed in the endoscopy unit of Mulago hospital reviewed 356
patient endoscopy reports spanning January 2018 to July
2020 with a focus on those with a referral indication of dys-
pepsia. Age and sex were the independent variables of in-
terest while the endoscopy findings as reported by the
endoscopist were the outcome variable of interest.
Results Of the 356 endoscopy reports reviewed, 159 met
the inclusion criterion of dyspepsia as the indication. Parti-
cipant mean age was 47.7 years (±16.53) with the majority
(25.79 %) in the fifth decade while the male to female ratio
was 1. The majority of patients had organic dyspepsia
(90.57 %) while the commonest finding was gastritis 69
(43.4 %). Gastroesophageal cancers represented (18)
11.32% of all findings. There was a positive association be-
tween age > 50 years with gastroesophageal cancers
(7.639) as well as age <50 years and functional dyspepsia
(2.794); however, all these were not statistically significant
(P= 0.006 and (P= 0.095, respectively).
Conclusions Organic/structural dyspepsia comprises over
90 % of investigated dyspepsia with 11 % comprising cancer
among patients seeking endoscopy at the National Referral
Hospital of Uganda.
Original article
Mbiine Ronald et al. High rates of Endosc Int Open 2021; 09: E997E1000 | © 2021. T he Author(s). E997
Article published online: 2021-06-17
peptic symptoms in our population seeking care for dyspepsia.
In one study in western Uganda, the majority of dyspeptic pa-
tients had gastritis [6] while in a study done in Kenya a signifi-
cant majority had functional dyspepsia [7], contrasting with a
study in Nigeria where only 8% of the participants had func-
tional dyspepsia [8]. Other studies conducted in Uganda are
representative of specific regions [9] and therefore non-gener-
alizable. This variability in findings, therefore, warrants a char-
acterization of dyspepsia in Uganda at a national referral center
that receives a more diverse patient population from all regions
in Uganda. This research, therefore, characterizes the etiology
of dyspepsia as seen on upper gastrointestinal endoscopy of pa-
tients seeking care at the National Referral Hospital of Uganda.
Patients and methods
This was a retrospective study conducted in the Endoscopy Unit
of Mulago National Referral Hospital of Uganda. This hospital
has a bed capacity 1500 at any given time and has 100% occu-
pancy consisting of primarily referrals from other hospitals
around the country. The gastrointestinal outpatient clinics
comprise one medical and one surgical outpatient unit, which
are attended by patients referred from other hospitals with an
average attendance of 2500 to 3000 patients per year. It is from
this population that patients referred for upper gastrointestinal
endoscopy are sent to the endoscopy unit. The endoscopy unit
also directly receives referrals from other hospitals in the re-
gion.
Despite receiving patients from all over the country, the ma-
jority of patients seeking care at the endoscopy unit are from
the surrounding central region of Uganda. Endoscopy services
are provided by experienced physicians and surgeons in the
unit and the diagnoses made are based on their observation of
the clinical characteristics of the disease entity. Where neces-
sary, biopsies are performed on suspicious tissues for further
evaluation. For gastritis, endoscopic gastritis,which refers to
the diagnosis of gastritis based on observations seen on endos-
copy, was the primary method of diagnosis and in severe forms,
biopsy with histological diagnosis of gastritis would be per-
formed. Diagnosis of gastritis is occasionally further classified
into superficial, hemorrhagic, erosive, atrophic, and metaplas-
tic.
Endoscopy reports of all patients that underwent an upper
gastrointestinal endoscopy procedure between January 2019
and January 2020 were reviewed. The referring doctorsdiag-
nosis or reason for recommending an endoscopy as written on
thereferralnotewasreviewedforinclusioninthestudy.
Inclusion criteria
Referral reports with the diagnosis or reason for referral regis-
tered as either dyspepsia or uninvestigated dyspepsia by the re-
ferring doctor were included in the study. For referral notes that
had a different diagnosis besides dyspepsia, the diagnosis or
reason for referral was compared to the definition of dyspepsia
based on the ROME IV criteria [10] of having any of the follow-
ing: epigastric pain, epigastric fullness, early satiety, or burning
epigastric pain. When the referral reason or diagnosis met the
ROME IV criteria, the patient was included in the study. Reports
whose reason for referral was reported that did not meet the in-
clusion criteria, including some listed as dysphagia, odynopha-
gia, gastrointestinal bleeding, or screening endoscopy, all were
excluded from the study. For referral notes in which more than
one reason was included, such as dysphagia with dyspepsia,
these were also included as long as the indication of dyspepsia
was included in the referral note/endoscopy request. The en-
doscopies were performed by qualified endoscopists in the
unit.
The primary outcome variable of interest was the endo-
scopic diagnosis as reported on the endoscopy report by the
endoscopist. The findings were classified as organic/structural
if a physical lesion was observed on endoscopy while the pres-
ence of normal findings was classified as functional dyspepsia.
Other variables included the participant demographics includ-
ing the age, sex, tribe, and region.
Variables were captured in an Epi-data database and later
exported to Stata 16 software for analysis. Statistical analysis
took on a descriptive approach. All variables were categorical
and therefore described using proportions along with their per-
centages.
Results
In total, 356 patient endoscopy reports were evaluated and of
these, 159 met the inclusion criteria.
The male to female ratio of the study population was one
while the mean age was 47.70 years 16.53) with the majority
(25.79 %) in the fifth decade of life (Table 1). On the primary
outcome variables of the endoscopic diagnosis, 90.57% of pa-
tients had organic dyspepsia, meaning that there was a diagno-
sis of a structural disease while 9.43% of the participants had
normal findings despite the dyspeptic symptoms (Table2), a
condition referred to as functional dyspepsia.
The most common findings on endoscopy were gastritis fol-
lowed by gastroesophageal reflux disease. Gastroesophageal
Table1 Participant demographic characteristics.
Parameter Frequency Percentage or ± SD
Age
< 30 29 18.24
3140 27 16.98
4150 28 17.61
5160 41 25.79
6070 17 10.69
> 70 17 10.69
Mean age 47.698 ± 16.53
Sex
Male 79 49.69
Female 80 50.31
E998 Mbiine Ronald et al. High rates of Endosc Int Open 2021; 09: E997E1000 | © 2021. The Author(s).
Original article
cancers (gastric and esophageal cancer) comprised 11.32% of
all diagnoses (Table 3). Of the 18 patients who had a diagno-
sis of gastrointestinal cancer, 61% had gastric cancer while the
rest had esophageal cancer (Table 4).
On evaluation for the association between the two indepen-
dent variables of age and sex with the primary outcome vari-
able, age was stratified into two categories: <50 years and > 50
years. We found no associationbetween age and gastritis with a
chi square coefficient of 0.612 while the presence of gastro-
esophageal cancers was strongly associated with age >50 years
with a positive coefficient of 7.639 (P=0.006) while that of
functional dyspepsia was 2.794 (P= 0.095). However, these
variables were not statistically significant in our study popula-
tion. In regard to the location of the cancer, there was no asso-
ciation with age or sex. Similarly, there was no association be-
tween sex and the overall endoscopy diagnosis.
Discussion
We conducted this study with the intention of describing
endoscopy findings among patients who underwent upper gas-
trointestinal endoscopy for dyspepsia as it is the most common
presenting symptom and indication for upper gastrointestinal
endoscopy at the Gastrointestinal Surgery Clinic in Mulago Na-
tional Referral hospital in Uganda.
We found that the majority of patients who presented for
upper gastrointestinal endoscopy were aged 51 to 60 years. In
Uganda, it is recommended but not mandatory that the pres-
ence of dyspeptic symptoms should be investigated with
endoscopy in patients aged >50 years. The public health train-
ing and awareness campaigns about gastric cancer could ex-
plain the higher proportion in this age group. Globally screen-
ing for gastroesophageal cancers is recommended in dyspeptic
patients aged > 40 years [11, 12] and this is in keeping with our
findings.
Our study reveals a very high prevalence of organic dyspep-
sia of > 90 % which could imply that by the nature of our study
setting being a national referral hospital, the most severe and
persistent symptomatic patients could possibly be the ones
seeking care at the national referral hospital, and hence, likely
to have more organic causes. This, therefore, is a potential
source of bias. Second the majority of referrals often come
late, due to either financial constraints associated with the pro-
cedure or perceptions such as disease progression after biopsy.
All these could explain the high rate of organic dyspeptic find-
ings being representative of late presentation. However, when
the prevalence of organic dyspepsia among patients with dys-
pepsia is compared with studies conducted in the African re-
gion, there is a striking similarity. In Kenya, the prevalence was
slightly lower at 8 % [7], implying a 92 % prevalence of organic
dyspepsia. while in a similar study in Ibadan, Nigeria, the prev-
alence of functional dyspepsia among dyspeptic patients was
lower at 6% [13], implying a prevalence of organic dyspepsia
of 94 %. Overall, the global prevalence of functional dyspepsia
is approximately 11 % to 29.2 % [3]. Our findings along with the
studies in SSA demonstrate that the majority of dyspepsia is
duetoanorganiccause.
The finding that gastritis was the most prevalent condition in
our study population was not surprising as it is similar to the de-
scribed findings in other regions of Uganda [6] and
SSA [14, 15]. Not surprisingly, there was no association be-
tween the age and sex in gastritis or any other endoscopic find-
ings among the study population.
Gastroesophageal cancer presentation, especially in early
stages, mimics any other benign causes of dyspepsia [16],
hence increasing the likelihood of missed early diagnosis [17]
in patients with dyspepsia. In our study population, the preval-
Table2 Endoscopic findings.
Diagnosis Frequency Percentage
Normal findings 15 9.43
Gastritis 69 43.4
Gastric ulcers 31.89
Duodenal ulcers 53.14
Hiatal hernia 42.52
GERD 31 19.5
Gastric cancer 11 6.92
Esophageal cancer 74.40
Esophagitis 21.26
Others 12 7.55
GERD, gastroesophageal reflux disease.
Table3 Dyspepsia classification.
Dyspepsia classification Frequency Percentage
Functional dyspepsia 15 9.43
Organic dyspepsia 144 90.57
Table4 Location of gastroesophageal malignancies.
Tumor type and location Frequency (N) Percentage (%)
Esophagus (7)
Proximal third 1 5.56
Mid third 5 27.78
Distal third 1 5. 56
Stomach (11)
Upper stomach (cardia and
upper body)
3 16.67
Middle stomach (angle,
middle body)
3 16.67
Lower stomach (lower body,
antrum, pylorus)
5 27.78
Mbiine Ronald et al. High rates of Endosc Int Open 2021; 09: E997E1000 | © 2021. The Author( s). E999
ence of gastroesophageal cancers among patients with dyspep-
sia was rather strikingly high at 11.32% when compared to lar-
ger studies in Hong Kong [18] and Canada [19], in which the
prevalence was less than 1%. However, it should be noted that
the above studies had a significantly larger sample size. Never-
theless, these findings raise a red flag for a potentially higher
prevalence of gastroesophageal malignancies among dyspeptic
patients in Uganda. This further emphasizes the need for more
purposeful investigation for gastroesophageal malignancies in
patients in SSA who present with dyspepsia, especially in the
fourth decades and above.
Its projected that SSA will have the highest burden of gastro-
esophageal cancers globally by 2030 [5] and this is a red flag
our results seem to agree with. Typically esophageal cancer
presents with dysphagia and patients with dysphagia were ex-
cluded; however, its important to recognize that dyspepsia,
especially retrosternal pain, may point towards early esopha-
geal cancer, hence requiring early screening [20].
Conclusions
More than 90% of dyspepsia in patients seeking care in Mulago
hospital is associated with a structural/organic lesion, including
gastritis, among other causes. There is a higher prevalence of
gastroesophageal cancer among patients with dyspepsia who
are aged >50 years. We recommend that patients aged >50
years who have dyspepsia that has not been investigated under-
take a mandatory endoscopic evaluation as the likelihood of
having a gastroesophageal malignancy in this population is
very high.
Acknowledgements
The authors thank the wonderful staff of the Endoscopy Unit of
Mulago National Referral Hospital.
Competing interests
The authors declare that they have no conflict of interest.
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E1000 Mbiine Ronald et al. High rates of En dosc Int Open 2021; 09: E997E1000 | © 2021. The Author(s).
Original article
... In this study, we found a female preponderance, which is in keeping with studies from other parts of the country and Ghana but in contrast with others that reported either a male preponderance or equal sex distribution from Nigeria and Uganda. [1,[13][14][15][16][17] We noted, however, that these referenced studies did not consider our age-specific inclusion criteria. The higher frequency of dyspepsia in females than in males has been attributed to differences in gastric emptying, sex hormones, and psychological stresses as adduced from other non-age classified studies. ...
... As the maximum age of our patients was lower than in other studies, it is not surprising that the mean age in this study was also lower than in other studies. [14,15,17] It is, however, similar to what was reported in a study from Ife, also in southwest Nigeria, which might be explained by their inclusion of children, though the maximum age of their patients was higher than ours. [19] Alarm features and an increase in the severity of GI disease have been documented to be more prevalent with increasing age. ...
... In our study, the yield of UGIE was 81.2%, similar to other studies from within and outside Nigeria, but higher than in Saudi (50%) and lower than in Uganda (91%). [3,8,17,21,23] Our high yield may be a result of the high background prevalence of H. pylori infection in Nigeria and its association with gastroduodenal lesions, though we did not examine this relationship. [13,24,25] Despite this high yield, most of our findings were minor (erosions), and major findings (ulcer, varices, cancer) were infrequent (68.2% vs. 12.9%). ...
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Background and Objectives Recent guidelines from international gastroenterology bodies recommend that upper gastrointestinal endoscopy (UGIE) should not be routinely performed in patients with dyspepsia who are younger than 60 years old as the yield for major abnormalities is low. The objectives of this study were to determine the spectrum of UGIE findings in patients with dyspepsia who are younger than 60 years and to document the association of alarm features with UGIE findings in them. Materials and Methods This is a retrospective study of the UGIE records of adult patients younger than 60 years with dyspepsia at five centers in Lagos, Nigeria, between June 2016 and December 2020. UGIE findings were categorized as major (gastric or duodenal ulcers, esophageal varices, masses suspected to be cancer, strictures, and foreign bodies), minor (erosions or inflammation), or normal. Results There were 1499 adult patients with dyspepsia who were younger than 60 years, 796 (53.1%) females, mean age 40.9 ± 9.8 years, and 158 (10.5%) with at least one alarm feature. Major findings were seen in 194 (12.9%), minor findings in 1023 (68.2%), and no abnormalities were seen in 282 (18.8%). Alarm features, or age 40 years and above, were associated with major findings. Half of all gastric cancers were seen in patients younger than 50 years, and of these, 70% occurred within the 40–49 age group. Conclusion This study shows that the prevalence of UGIE findings in patients with dyspepsia who are younger than 60 years is high, and major findings are common in those with alarm features or who are aged 40 years and above. We recommend endoscopy for the evaluation of dyspepsia in those who have alarm features or are aged at least 40 years.
... Симптомы, проявляющиеся на ранней стадии, могут быть неотличимы от симптомов доброкачественной диспепсии, в то время как наличие установленных «тревожных» симптомов может означать прогрессирующее заболевание. Это представляет собой дилемму с точки зрения определения критериев и приоритетов для исследования симптомов верхних отделов желудочно-кишечного тракта, особенно в системах здравоохранения, где потенциальный спрос на эндоскопию может превышать допустимый уровень [24,25]. ...
... Диспепсические симптомы, а также «тревожные» симптомы, которые обычно выявляют у пациентов с более высоким риском развития диспепсии органного генеза, распространены не только у пациентов, консультирующихся у врача общей практики, но и в общей популяции [25]. Гастроэзофагеальная рефлюксная болезнь, язвенная болезнь желудка и функциональная диспепсия являются наиболее частыми причинами диспепсических симптомов. ...
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Relevance. Despite numerous efforts made in recent decades, the arsenal of cancer diagnostics is still significantly limited. The purpose of study : to analyze the problem of differential diagnosis of early stage stomach cancer and non-oncological diseases of the abdominal cavity. Materials and methods . In the course of the work, current literary sources of domestic and foreign authors on a given topic were analyzed. Results . The early stages of malignant neoplasms of the stomach are usually asymptomatic or accompanied by nonspecific signs, such as dyspepsia. Symptoms of the development of malignant tumors of the stomach at an early stage may be indistinguishable from the symptoms of benign dyspepsia, while the presence of established "alarming" symptoms may mean a progressive inoperable disease. However, the evidence supporting the use of "alarming" symptoms as selection criteria for endoscopy still remains contradictory, since the presence of "alarming" symptoms in the clinical picture is not always associated with the detection of malignant neoplasms, it is also worth noting that the overall prevalence of these symptoms in the population of patients suffering from dyspeptic disorders is high, while while the number of patients with a history of gastrointestinal cancer is relatively low. Conclusion . Despite the observed trend of decreasing morbidity and mortality, malignant neoplasms of the stomach remain an important part in the structure of oncological diseases. Many of the risk factors remain insufficiently studied and should be the subject of further research to achieve more specific, targeted preventive measures.
... The same study also denoted that the greatest proportional burden of upper digestive system diseases was in southern SSA. 4 Future projections indicate that low-and middle-income African nations, especially those in SSA, will experience a 73% increase in GI cancer cases by 2030, with uninvestigated dyspepsia being a significant contributing factor. 5 Consequently, enhancing the availability and quality of GI endoscopy services is imperative to improve the diagnosis and prognosis of GI conditions in lowand middle-income African nations. To this end, this editorial explores the recent progress and future directions for expanding gastrointestinal endoscopy in these regions, emphasizing the urgent need for advancements in this field. ...
... This emphasizes the prevalence of advanced disease in remote areas and the lack of access to care 21 . Previous studies recommend that patients over 40 years old with dyspepsia undergo UE to rule out gastroesophageal cancers 22,23 . However, in this study, dysphagia is the most ominous presenting symptom, where nearly half of all patients presenting with dysphagia were diagnosed with advanced esophageal cancer, and all patients with ESCC presented with dysphagia and had obstructing tumors. ...
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Background: The availability of upper endoscopy (UE) is limited in many rural low- and middle-income countries (LMIC). Few studies have evaluated use of elective endoscopies to address esophago-gastric diseases in remote Eastern Uganda. Objective: This research assesses the impact of introducing UE on diagnosing gastrointestinal diseases endemic to the area. Methods: This is a retrospective, cross sectional, single center study evaluating patients who received elective UE from Kyabirwa Surgical Center in rural Eastern Uganda, between 2020 to 2022. Primary outcome variables were presenting symptoms, endoscopic diagnoses and respective treatments. Results: 350 endoscopies were performed for 333 patients, (1:1 male-to-female ratio, average age 48). Abnormalities were found on endoscopy in 73% of patients, revealing diagnoses of esophageal cancer (16.4%, N=64), gastritis (16.7%, N=65), hiatal hernia (8.7%, N=34), esophagitis (7.4%, N=29), ulcer (6.2%, N=24), and candidiasis (5.1%, N=20). Most patients presented with epigastric pain alone (40%, N=133) or dysphagia (39%, N=130). 51% of patients with dysphagia had esophageal cancer on endoscopy, of which 28.1% had an interval palliative stent placed. Conclusions: The introduction of UE into a rural LMICs is possible and can verify baseline prevalence of endemic upper gastrointestinal diseases. Confirmation of diagnosis by endoscopy can direct medical management and interventional therapy. Keywords: Diagnostic and therapeutic upper endoscopy; ambulatory surgery center; rural Eastern Uganda.
... As a result, patients often present with more advanced disease [2][3][4]. Though there are a paucity of data, Uganda suffers from a high burden of gastrointestinal symptoms including dyspepsia due to untreated peptic ulcer disease and an unusually high burden of esophageal malignancy [5][6][7][8][9]. Furthermore, most health care resources, particularly complex, and procedural services, such as surgery and endoscopy capabilities, are concentrated in urban areas. ...
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Background There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities. Methods This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively. Results The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication. Conclusion Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities.
... Dyspepsia is an extremely common issue among the general public, with roughly 50% of the global population being estimated to have experienced symptoms of dyspepsia at some point in their life. [10] In recent years, clinical cases of dyspepsia without any structural or organic abnormality-commonly referred to as functional dyspepsia [11,12] -have become quite common. Despite the growing popularity of functional-as opposed to organic or structural-dyspepsia in the clinic, gastroduodenal endoscopy remains one of the mainstays of diagnosis. ...
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ABSTRACT Background Dyspepsia, one of the most commonly encountered complaints across the world, can manifest as epigastric pain, burning sensations, bloating, or nausea. The primary aim of this study was to explore the prevalence of endoscopic findings in younger dyspeptic patients and compare these findings with those observed in aged people. Additionally, the research also aimed to assess the overuse of endoscopic procedures in these patients and to probably redefine standards for this invasive procedure in our setting. Methodology The study was a retrospective analysis of patients who had endoscopy for dyspepsia. The patients were categorized into low risk and high risk based on age and the presence or absence of alarming features. The Chi-square test was used to analyze the data. Results Sample for this study includes 183 individuals with a mean age of 39.4 (±12.4); out of which 89 (%) were males and 94 (%) were females. Patients aged 45 years or older were at higher risk of having significant findings on endoscopy (18/51 patients, 35.3%) compared to patients younger than 45 years (20/132 patients, 15.1%; P=0.003). Conclusion Endoscopy in younger dyspeptic patients was found to have a low yield. Consequently, in these patients approaches other than endoscopic that are less invasive or non-invasive should be considered for diagnosis and treatment before resorting to endoscopy.
... On the other hand, Helicobacter pylori infection prevalence reach as high as 80% in African countries and gastritis and peptic ulcer disease are the most common manifestations [9,11,12]. Although diseases related to infectious etiology are more prevalent in Africa, GI neoplasias are being increasingly observed [9,13,14]. Approaching these diseases shall be a health priority as all of these diseases are associated with significant morbimortality. The associated GI bleeding complications, in case of portal hypertension and peptic ulcer disease, can be fatal, and timely diagnosis is vital for better prognosis in oncological cases. ...
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Background and study aims The prevalence of digestive diseases seems to be high in African countries. Nonetheless, the human and material resources are scarce. The aim of the Portuguese volunteering project described in this report was to develop the specialty of digestive endoscopy in Sao Tome and Principe, a lower-middle-income country in Africa. Methods Beginning by assessing the local needs and available resources and managing immediate issues related to this field, we aimed to provide the tools necessary to improve gastroenterological and endoscopic care in the country. The first step included training of the local teams, through the development and accomplishment of an adapted curriculum for a 3-year medical gastroenterological fellowship and a short-term nursing fellowship, both in Portugal, and the organization of regular gastroenterological and endoscopic theoretical and practical sessions in Sao Tome and Principe. Second, the endoscopy facilities of the unit were significantly optimized. Third, a web platform was designed to provide telemedicine incorporating real-time endoscopic imaging available remotely. Results Through these sequential steps achieved in collaboration with Portuguese and local teams, this 5-year project provided the basis for gastroenterology care in this country. Conclusions At the present time, Sao Tome and Principe has an autonomous, efficient and skilled team and unit to provide care for patients with gastrointestinal diseases who need endoscopic procedures.
... As such, the report from Uganda in this issue of Endoscopy International Open offers potentially important data on the local situation [1]. This study reports findings in dyspeptic patients, based on referrals for endoscopy to their national referral center. ...
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Introduction: Upper gastrointestinal (UGI) symptoms are among the commonest complaints for which patients seek medical attention. Characteristics of patients undergoing UGI endoscopy (UGIE) at the district hospital in Ghana are largely unknown. This study was to document the demographic characteristics, indications and endoscopic findings of patients undergoing UGIE at the district hospital in Ghana. Methods: This study used a cross-sectional design to consecutively recruit 371 patients referred to the Endoscopy Unit of the St. Dominic Hospital, Akwatia for UGIE. Demographic data and indications for the UGIE were recorded. Endoscopic findings per each participant were recorded. Helicobacter pylori (H. pylori) infection was confirmed by rapid-urease examination of gastric antral and body biopsies at endoscopy. Results: There were 159(42.9%) males out of the 371 patients. The age ranged from 4 to 94 years with a median age of 46 years. Dyspepsia was the commonest indication occurring in 282(76.0%) patients. The commonest endoscopic diagnosis was gastritis which occurred in 261(70.4%) patients. The prevalence of H. pylori obtained by immediate rapid-urease-campylobacter like- organism (CLO) test was 44.9%. Conclusion: The main indication for UGIE in the studied patients was dyspepsia and most of these patients had gastritis on endoscopy. Only few patients had normal findings. The prevalence of H. pylori in this population was low compared with most of the previous studies done in the country. There is the need to establish more endoscopy centres within the district hospitals in the country and more health professionals trained to perform them.
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Aim: To investigate the current prevalence and management of dyspepsia in rural Eastern Uganda. Methods: Residents older than 18 years of age across 95 study sites in Namutumba District, Eastern Uganda were surveyed. Each respondent was administered a questionnaire about dyspepsia and pertinent health-seeking behaviors. Health workers at 12 different clinics were also assessed on their competence in managing dyspepsia. Proportion-based analysis was used to determine self-reported outcome variables reported in this study, including: prevalence of dyspepsia; breakdown of symptoms; initial diagnosis location; management strategies; and appropriate medication usage. Results: 397 residents (average age of 41.2 years) participated in this study (54.4% males, 45.6% females). 57.9% self-reported currently having dyspepsia, of average duration 4.5 years. Of this subset, 87% reported experiencing epigastric pain, and 42.2% believed that ulcers were "wounds in the stomach." Only 3% of respondents had heard of Helicobacter pylori (Hp). Respondents varied in their management of dyspepsia, with frequent eating (39.1%), doing nothing (23.9%), and taking Western medicine (20%) being the most common strategies. The diagnosis of "peptic ulcer disease" was made by a health worker in 64.3% of cases, and 27% of cases were self-diagnosed. Notably, 70.3% of diagnoses at formal health centers were based on clinical symptoms alone and only 22.7% of respondents received treatment according to Ugandan Ministry of Health guidelines. Among the 12 health care workers surveyed, 10 cited epigastric pain as a common symptom of "ulcer," although only two reported having heard of Hp. Only two out of 12 clinics had the capability to prescribe the triple therapy as treatment for presumed Hp. Conclusion: There is a high incidence of dyspepsia in Eastern Uganda, and current management strategies are poor and inconsistent, and may contribute to antibiotic resistance. Further studies are needed to investigate the causes of dyspepsia to guide appropriate management.
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Background: The correct diagnosis of functional gastrointestinal disorders (FGIDs) is quite a challenge. The overlaps between syndromes can complicate the interpretation of clinical data. Summary: The incidence of functional digestive disorders and irritable bowel syndrome are still underestimated with the currently applied diagnostic tools, and the management of the seemingly elusive disease is not satisfactory. For this reason, the "Rome" criteria were created to provide a better understanding and classification of FGIDs. Key Messages: Rome diagnostic criteria and recommendations should be used in the design and performance of clinical studies in the field of functional dyspepsia and irritable bowel syndrome.
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Surgery is the mainstay of achieving cure in gastrointestinal cancers. While health expenditure per capita (HEpC) has increased from 41 USin1995to97US in 1995 to 97 US in sub-Saharan Africa (SSA) in 2014, it remains well below the world HEpC of 1061 USortheEuropeanunionHEpCof3612US or the European union HEpC of 3612 US in 2014. Cancer appears to be a low public health priority in SSA, and this may in part be attributable to the burden of communicable disease such as Human Immunodeficiency Virus, malaria and tuberculosis. However, by 2030, the incidence of gastrointestinal cancers is set to increase by 73% in SSA compared to 59% worldwide. Over 90% of all GI cancers in SSA present late and the peak incidences occur about a decade earlier than in the West. The younger age at presentation could be the result of yet undefined molecular and biological differences, and environmental factors. For the few who present early, lack of infrastructure and expertise lead to poor therapeutic options and inevitable poorer outcomes. This chapter will give an overview of oesophageal, liver, gastric, and colorectal cancers pathways in sub-Saharan Africa.
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Dyspepsia is a common presenting complaint of various upper gastrointestinal disorders. The symptoms of causes of dyspepsia often overlap and this makes etiological diagnosis difficult. Endoscopy is the ideal procedure for identifying organic diseases of the foregut. Helicobacter pylori infection is associated with various upper gastrointestinal pathologies. A cross-sectional study was conducted to determine endoscopic findings and H. pylori status in two hundred and eight consecutive dyspeptic adult patients between June 2009 and April 2010 at Kilimanjaro Christian medical Centre, a referral and teaching hospital in northern Tanzania. The most commonly identified endoscopic findings were gastritis (61.10%), Gastroesophageal reflux disease (GERD) (57%), and Peptic ulcer disease (PUD) (24.1%). Gastric cancer was identified in 6.7 % of patients and all of them were aged 40 years and above (p=0.00). H. pylori infection was detected in 65% (n=130) of patients. H. pylori infection was present in 57% (n=24) of patients who were tested within six months after eradication therapy. Gastritis and duodenal ulcer were statistically significantly associated with H. pylori (p<0.001). No association was found between GERD and H. pylori infection (p>0.05). Gastritis, GERD, and PUD are the leading causes of dyspepsia. H. pylori infection is present in significant proportion of dyspeptic patients. Patients with Gastritis and PUD should undergo empirical eradication therapy if a confirmatory test is not available. Patients with dyspepsia who are over 40 years of age should undergo Endoscopy (EGD) for initial work up. Study on antimicrobial susceptibility pattern of H. pylori is recommended to guide choices for evidence based treatment option.
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Gastric cancer screening is common in countries with high prevalence rates of gastric cancer. However, data supporting the effectiveness of gastric cancer screening are lacking. Thus, the aim of this review was to examine the current evidence on gastric cancer screening. Herein, we reviewed radiographic and endoscopic tests as methods of gastric cancer screening. Previous cohort studies and case-control studies have demonstrated reduced gastric cancer mortality in study populations that had undergone gastric cancer screening with radiographic tests. Recently, a case-control study in Japan reported a 30% reduction in gastric cancer mortality when screening was undertaken via endoscopy. Also, endoscopic screening for gastric cancer exhibited higher sensitivity and specificity than radiographic screening. Moreover, most cost-effectiveness analyses on the best strategy for detecting early gastric cancer have generally concluded that endoscopy is more cost-effective than radiographic testing. Although data on the impact of endoscopy screening programs on gastric cancer mortality are limited, recent study results suggest that gastric cancer screening by endoscopy in average-risk populations performs better than radiography screening. Further evaluation of the impact of these screening methods should take into account cost and any associated reduction in gastric cancer mortality.
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It has been proposed that patients with dyspepsia can be classified into symptom groupings that may represent different pathophysiological entities, however, it remains to be shown that distinct symptom subgroups exist. To estimate the prevalence of dyspepsia (defined as upper abdominal pain) and dyspepsia subgroups, an age-and sex-stratified random sample of Olmsted County, Minnesota, residents, aged 30–64 years, were mailed a valid self-report questionnaire, 82% responded (n = 835). Subgroups were as follows, those with symptoms suggestive of peptic ulceration (ulcerlike dyspepsia), those with gastric stasis (dysmotilitylike dyspepsia), those with gastroesophageal reflux (refluxlike dyspepsia), and the remainder (unspecified dyspepsia). Ulcerlike dyspepsia was the commonest subgroup (prevalence, 16.0/100, 95% confidence interval, 13.4–18.5), but 43% of subjects with dyspepsia could be classified into more than one subgroup. Nearly one third of dyspeptics also had irritable bowel symptoms, but these were not confined to any particular dyspepsia subgroup. Although dyspepsia is very common in the community and the majority have ulcerlike symptoms, there is such overlap among the dyspepsia subgroups that a classification based on symptoms alone in uninvestigated patients may not be useful.
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Background: There is a paucity of published data regarding upper gastrointestinal diseases in Ugandans with upper gastrointestinal symptoms referred for endoscopy. Objectives: To study the presenting complaints, pathology and Helicobacter pylori prevalence among patients with upper gastrointestinal symptoms in South-Western Uganda. Methods: Patients presenting with upper gastrointestinal symptoms underwent upper endoscopy and a urease test for Helicobacter Pylori, all suspicious lesions were biopsied for histopathology review as appropriate. Results: The most common presenting complaints were epigastric pain (51.6%), dysphagia (13.6%) and odynophagia (7.1%). The most common endoscopy finding was gastritis (40.2%), followed by normal examination (15.2%), oesophageal cancer (13.6%), gastric ulcer (7.6%) and gastric cancer (7.1%). Patients older than 40 years (n=110) had significant findings including gastritis (50.9%), oesophageal cancer (22.7%) and gastric cancer (11.8%). However in younger patients, with the age range of 18-40 years (n=74), most examinations were normal (92.9%). Of the 176 patients able to undergo Helicobacter pylori testing 75.6% were positive. Helicobacter pylori infection was associated with statistically significant increase in gastritis, oesophageal cancer, gastric ulcer, gastric cancer, and duodenal ulcers (p-values< 0.05). Conclusion: Gastritis, ulcerative disease, and upper gastrointestinal malignancies are common in South-Western Ugandans and are associated with a high prevalence of Helicobacter pylori.
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Objective: Dyspepsia is a common disorder originating from the upper gastrointestinal tract, and is the most common indication for gastrointestinal endoscopy. Even though, functional dyspepsia (non-ulcer dyspepsia) is not life –threatening, it has profound clinical and economic effects, and influences the quality of life of sufferers. Data is scanty on functional dyspepsia from Nigeria. This study aims to determine the prevalence of functional dyspepsia in Yola, Nigeria. Methods: This was a cross-sectional study carried out at the Gastroenterology unit of Federal Medical Centre, Yola from December, 2006 to October, 2010. Patients with dyspepsia who had upper gastrointestinal endoscopy as part of their work-up were recruited. Their biodata, history and duration of dyspepsia were noted on a proforma. The spectrum of endoscopic findings was also noted. Results: A total of 441 patients underwent upper gastrointestinal endoscopy out of which 299 patients had dyspepsia. One hundred and thirteen (37.8%) were males while 186 (62.2%) were females, giving a male to female ratio of 1:1.6. The age range was from 18 to 97 years with a mean of 47.6 ± 9.4 years. Clinically significant endoscopic findings were seen in 94.0% while functional dyspepsia was seen in 18 patients (6.0%).