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Lower Gastrointestinal Tract Pathology in Saudis: Results of Endoscopic Biopsy Findings in 1,600 Patients

1987; King Faisal Specialist Hospital and Research Centre; Volume: 7; Issue: 4 Linguagem: Inglês

10.5144/0256-4947.1987.306

0975-4466

Abdelrahman E. Mohamed, Mohamed A. Al-Karawi, M A Hanid, Ismail Yasawy,

Gastrointestinal disorders and treatments

Original ArticlesLower Gastrointestinal Tract Pathology in Saudis: Results of Endoscopic Biopsy Findings in 1,600 Patients AbdelRahman El-Sheikh Mohamed, Dip Ven, MRCP, DTM & H Mohamed A. AL-Karawi, Facharzt Mohamed Anwar Hanid, and MD, MRCP Ismail YasawyMD AbdelRahman El-Sheikh Mohamed Senior Registrar, Department of Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia Search for more papers by this author , Mohamed A. AL-Karawi Head, Division of Gastroenterology, Department of Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia Search for more papers by this author , Mohamed Anwar Hanid Consultant Gastroenterologist, Department of Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia Search for more papers by this author , and Ismail Yasawy Registrar, Division of Gastroenterology, Department of Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia Search for more papers by this author Published Online:1 Oct 1987https://doi.org/10.5144/0256-4947.1987.306SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTBetween 1979 and 1985, 1,775 patients had sigmoidoscopy or colonoscopy in the Gastroenterology Unit of Riyadh Armed Forces Hospital, because of different gastrointestinal tract problems. Sixteen hundred of these patients were Saudis. This study shows the incidence of lower gastrointestinal tract pathology in Saudi patients, based on the histological findings from endoscopic biopsies of the colon. The most common pathological finding was infective causes (18.6%), of which Schistosoma mansoni infestation accounts for 9.31%. One hundred eleven Saudi patients (6.94%) had nonspecific colitis, 10 (0.6%) had tuberculosis, and 3 (0.19%) had amoebic colitis. Ulcerative colitis was diagnosed in 28 (1.75%), Crohn's disease in 3 (0.19%), and diverticular disease in 16 patients. There was a low incidence of adenomatous polyps (2.69%) and colorectal cancer (0.78%) compared to Western and Far Eastern countries, but similar to Middle Eastern countries.INTRODUCTIONThere areno previous reports on lower gastrointestinal tract pathology studying large numbers of Saudi patients. The aim of this study is to identify the incidence and pattern of lower gastrointestinal diseases in Saudis and to compare the findings with reports on lower gastrointestinal tract diseases from other Middle Eastern, Asian and Western countries.Due to genetic, dietary and other etiologic and epidemiologic factors, it was expected that the lower gastrointestinal tract diseases in Saudis would differ from other countries, especially Western and Far Eastern countries.MATERIALS AND METHODSBetween March 1979 and December 1985, 1,775 patients had sigmoidoscopic and colonoscopic examinations at the Gastroenterology Unit of Riyadh Armed Forces Hospital. These patients were referred from different departments within the hospital or from other hospitals in the Kingdom because of different gastrointestinal symptoms, including abdominal pain, dyspepsia, constipation, diarrhea, bleeding per rectum, and weight loss.Before the procedure, each patient was well prepared by using X-prep or Colyte solution. Rectal examination was done in every patient and, if indicated, proctoscopy was done. Patients were usually given intravenous diazepam and busco-pan, and examined with an Olympus fiberopticS1sigmoidoscope or LB3colonoscope, according to the clinical indication and as requested by the referring physician. Three to six biopsies for histological examination were taken from each patient who had a suspected lesion during examination. Usually 4-6 serial histological sections from each biopsy were studied.No biopsies were taken in some patients who had normal sigmoidoscopy or colonoscopy. The exceptions were patients who were clinically suspected of having schistosomiasis and in whom nodemonstrable lesion was obvious, from whom three rectal biopsies were taken.In patients who were suspected of having tuberculosis, aspirations from the lesions were taken for smears and culture for tubercle bacilli.Colonic polyps were completely excised whenever possible.RESULTSOf the 1,775 patients who had sigmoidoscopy or colonoscopy during the seven-year period, 1,310 had sigmoidoscopy, 131 had partial colonoscopy, and 334 patients had total colonoscopy (Table 1). Fifty-two of these patients had more than one examination, usually for follow-up as indicated in patients with infective or inflammatory bowel disease, polyps or malignancy. There were 1,242 males and 533 females whose ages ranged between 7 and 87 years (mean 39.5 years). Sixteen hundred patients were Saudis and 175 were non-Saudi nationals (Table 2).Table 1. Yearly number of patients and endoscopic procedures, March 1979 through December 1985.Table 1. Yearly number of patients and endoscopic procedures, March 1979 through December 1985.Table 2. Findings on non-Saudi national patients.Table 2. Findings on non-Saudi national patients.The pathologic diagnosis in these patients was based on the histologic findings from the endoscopic biopsies taken from the colon.The commonest finding was Schistosoma mansoniinfection in 149 Saudi patients (9.31%). Table 3 shows the infective and inflammatory diseases. The endoscopic findings in patients with schistosomiasis included patchy areas of inflammation with or without hemorrhagic or telangiectatic areas in the colonic mucosa. No obviouslesions were seen in 23 patients; however, rectal biopsy revealed Schistosoma mansoniova. These patients were suspected to have schistosomiasis as indicated by history or serological tests for schistosomiasis and in whom feces examination was negative. Single or multiple schistosomal polyps may also be found and these cannot be differentiated endoscopically from other benign polyps of the large bowel.Table 3. Infective and inflammatory large bowel disease.Table 3. Infective and inflammatory large bowel disease.One hundred thirty-five Saudi patients had nonspecific colitis or proctitis, the biopsies ofwhich showed infiltration of the mucosa by inflammatory cells but no evidence of Schistosoma ova, granuloma, crypt abscess, amoeba or malignancy. In only 54 of these patients were feces examination for parasites or culture done, and these were negative.Ten patients had tuberculosis of the colon in which histology showed typical granuloma, and in four of these acid-fast bacilli were seen. In the remaining six patients, acid-fast bacilli were seen in smears or cultures from biopsy specimens oraspirates from colonic lesions.Table 4 shows the polypoid and malignant diseases in 71 patients. Forty-three Saudi patients (2.69%) had adenomatous polyps, and of these 33 were males and 10 were females. Malignant lesions were found in 13 (0.78%) Saudi patients (7 males and 6 females). One patient who had a renal transplant had Kaposi's sarcoma and Schistosoma mansoni.Table 4. Polypoid and malignant diseases.Table 4. Polypoid and malignant diseases.Table 5 lists other different lesions in 1,390 patients.Table 5. Other findings.Table 5. Other findings.DISCUSSIONInfective disease of the colon is the most common pathologic finding in all Saudi patients (18.6%), of which Schistosoma mansoni infestation is the commonest disease in 9.31% of the Saudi patients studied. This finding was expected since schistosomiasis is endemic in Saudi Arabia, especially in the southwestern region.1 Fourteen patients with schistosomiasis were non-Saudi nationals who came from other countries where schistosomiasis is known to be endemic. One of them was an Egyptian whose biopsy showed adenocarcinoma of the rectum as well as Schistosoma mansoni. Schistosomiasis of the bowel can lead to the formation of single or multiple schistosomal polyps as found in five of our patients. Dimmette, et al,2 studied 98 Egyptian patients with carcinoma of the large bowel, and 17 of these had Schistosoma mansoniinfestation in which detailed histologic studies revealed no outstanding features to distinguish parasitic from non-parasitic groups. Chen, et al,3 from China reported that Schistosoma japonicuminfestation played an etiological role in bowel malignancy.Nonspecific colitis is the second commonest histological finding in this study (6.94%). This is probably due to infective agents in most patients. Ten patients (0.6%) had tuberculosis of the large bowel. Tuberculosis is one of the commonest infectious diseases in Saudi Arabia.4,5 Only three Saudi patients (0.19%) had amoebic colitis. Abu Al-Saud6 reported only 13 cases of Entamoeba histolyticafrom a total of 8,736 feces specimens.This study shows a low incidence of adenomatous polyps (2.69%) and colorectal cancer (0.78%) in Saudis compared with other published series from the West7,8 and Far East.9 Al-Nakib, et al,10 reported four polyps and ten cancers in Kuwaitis from a total number of 481 colonoscopies done during a period of 4½ years. Similar incidence has been reported from Iraq,11 Jordan,12,13 and Lebanon.14 The low incidence of colorectal cancer in Saudis is possibly due to the high-fiber diet and the frequent intake of laban (yogurt). Burkitt suggested that dietary fiber deficiency and consumption of refined sugar are of etiological importance in colon cancer incidence.15The incidence of ulcerative colitis (1.75%) and Crohn's disease (0.19%) in Saudis is similar tothose reported in Kuwaitis and other Arabs.16 Mokhtar, et al,17 have reported the first two cases of Crohn's disease in Saudis.Diverticular disease of the colon was diagnosed in 14 Saudi patients. Diverticular disease, especially if not multiple, might be missed during colonoscopy or sigmoidoscopy.Normal colonic biopsies were found in large numbers of patients and, in most of these, the colonoscopic appearances were normal. It is expected that some of these patients are normal or suffer from diseases such as irritable bowel syndrome or other alimentary tract diseases not related to the large bowel.Due to the recent and advanced medical services within the Kingdom of Saudi Arabia, it is expected that in the future there will be a substantial decrease in the incidence of infective diseases, including those affecting the large bowel.ARTICLE REFERENCES:1. Arfaa F. "Studies on schistosomiasis in Saudi Arabia" . Am J Trop Med Hyg. 1976; 25(2):295-8. Google Scholar2. Dimmette RM, Elwi AM, Sproat HF. "Relationship of schistosomiasis to polyposis and adenocarcinoma of large intestine" . Am J Clin Pathol. 1956; 26:266-76. Google Scholar3. Chen MC, Chuang CY, Chang PY, Hu JC. "Evolution of colorectal cancer in schistosomiasis" . Cancer. 1980; 46:1661-75. Google Scholar4. Shanks NJ, Khalifa I, Al-Kalai D. "Tuberculosis in Saudi Arabia" . Saudi Med J. 1983; 4(2):151-6. Google Scholar5. Froude JR, Kingston M. "Extrapulmonary tuberculosis in Saudi Arabia: a review of 162 cases" . King Faisal Specialist Hospital Med J. 1982; 2(2):85-95. Google Scholar6. Abu Al-Saud AS. "A survey of the pattern of parasitic infestation in Saudi Arabia" . Saudi Med J. 1983; 4(2):117-22. Google Scholar7. Fruhmorgen P, Laudage G, Matek W. "Ten years of colonoscopy" . Endoscopy. 1981; 13(4):162-8. Google Scholar8. Sivak MV, Sullivan BH, Rankin GB. "Colonoscopy: a report of 644 cases and review of the literature" . Am J Surg. 1974; 128(3):351-7. Google Scholar9. Coode PE, Chan KW, Chan YT. "Polyps and diverticula of the large intestine: a necropsy survey in Hong Kong" . Gut. 1985; 26(10):1045-8. Google Scholar10. Al-Nakib BA, Jacob GS, Liddawi HA, Bayoumi A. "Fiberoptic colonoscopy: a report of findings in 481 patients from Kuwait" . Dis Colon Rectum. 1983; 26(4):236-8. Google Scholar11. Al-Bahrani ZR, Al-Khateeb AK, Degayi O, Butrous GS. "Cancer of the colon and rectum in Iraq" . Am J Proctology Gastroenterol Colon Rectal Surg. 1980; 31(1):20-2. Google Scholar12. Dajani YF, Kamal MF. "Colorectal juvenile polyps: an epidemiological and histopathological study of 144 cases in Jordanians" . Histopathology. 1984; 8(5):765-79. Google Scholar13. Dajani YF, Zayid I, Malatjalian DA, Kamal MF. "Colorectal cancer in Jordan and Nova Scotia: a comparative epidemiologic and histopathologic study" . Cancer. 1980; 46(2):420-8. Google Scholar14. Saab G. "Lymphomas, cancer of the bladder, colon and prostate in Lebanon: an epidemiological challenge" . Int J Epidemiol. 1985; 14(2):338. Google Scholar15. Burkitt DP. "Large bowel carcinogenesis: an epidemiologic jigsaw puzzle [editorial]" . J Natl Cancer Inst. 1975; 54(1):3-6. Google Scholar16. Al-Nakib B, Radhakrishnan S, Jacob GS, et al.. "Inflammatory bowel disease in Kuwait" . Am J Gastroenterol. 1984; 79(3):191-4. Google Scholar17. Mokhtar A, Khan MA. "Crohn's disease in Saudi Arabians" . Saudi Med J. 1982; 3(4):270-4. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 7, Issue 4October 1987 Metrics History Accepted10 January 1987Published online1 October 1987 KeywordsGastrointestinal diseases—pathologyEndoscopyInformationCopyright © 1987, Annals of Saudi MedicinePDF download