SHORT COMMUNICATION
Flexible Sigmoidoscopic Findings in Patients with Fresh Rectal Bleeding Abu Bakar Hafeez Bhatti and M. Saeed Quraishy
ABSTRACT Flexible sigmoidoscopy can diagnose majority of pathologies in patients with rectal bleeding and is less demanding than colonoscopy. Frequency of different findings in patients with rectal bleeding on flexible sigmoidoscopy was considered. Out of a total of 215 patients, 133 (61.9%) were males and 82 (38.1%) were females. The most common findings were hemorrhoids in 49 patients (22.8%) and polyps in 37 (17.2%) patients. The mean duration of bleeding was 57.4 + 51.8 months. Seventeen (7.1%) were found to have malignancy on sigmoidoscopic biopsy. Flexible sigmoidoscopy was able to determine the cause of bleeding in majority of patients with rectal bleeding. Key words:
Flexible sigmoidoscopy. Hemorrhoids. Rectal bleeding. Polyp.
Fresh rectal bleeding usually signifies bleeding from lower gastrointestinal (GI) tract from sites distal to the ligament of Treitz. The causes of lower GI bleeding can be anatomic (diverticulosis), vascular (angiodysplasia, ischemic), inflammatory (infectious, idiopathic, radiationinduced) or neoplastic. A difference has been noticed between the West and the subcontinent in the frequency of different findings in patients with rectal bleeding. In the West, diverticulosis and polyps are the most common findings, while in India non-specific, enteric and tuberculous ulcers are the leading cause of rectal bleeding. In Pakistan, a recently conducted study determined the most common cause of rectal bleeding to be proctosigmoiditis.1 Limited data has been published regarding flexible sigmoidoscopic findings in patients with rectal bleeding in Pakistan. This study was done to determine frequencies of different findings on flexible sigmoidoscopy in patients with rectal bleeding. The study was carried out in Endoscopy Suite of Surgical Unit IV, Civil Hospital Karachi, from August 2009 to February 2010. A total of 215 patients underwent flexible sigmoidoscopy. All patients above the age of 12 years with complaints of rectal bleeding were included in the study. Patients with suspected peritonitis or diverticulitis were excluded. Patients with bleeding and/or clotting disorders and patients with evidence of upper GI bleeding e.g. hemetemesis or melena were also excluded to reduce bias. Surgical Unit IV, Dow University of Health Sciences and Civil Hospital, Karachi. Correspondence: Dr. Abu Bakar Hafeez Bhatti, A-391, Block - 15, Gulistan-e-Jauhar, Karachi. E-mail:
[email protected] Received December 21, 2010; accepted July 25, 2011
A total of 215 patients underwent flexible sigmoidoscopy. Male to female ratio was 1.6:1, i.e 133 males and 82 females. Age ranged from 13-90 years with mean age at presentation 41.79 ± 18.43 years. Frequency of different findings on flexible sigmoidoscopy is shown in Table I. The most common findings were hemorrhoids in 49 (22.8%) and polyps in 37 (17.2%) patients. Flexible sigmoidoscopy failed to determine any cause of bleeding in 46 (21.4%) patients. The range of duration of symptoms was from 1 month to 20 years. The mean duration of rectal bleeding at presentation was 57.4 + 51.8 months. The longest duration of symptoms at presentation was noticed in patients with polyps and hemorrhoids. Biopsy of suspicious lesions showed that 17 (7.1%) out of a total of 215 patients had malignancy. On histopathology, all these patients were found to have rectal adenocarcinoma. Ten out of these 17 patients had a poylpoid growth, while the rest had flat lesions in the rectum. Various studies have shown that hemorrhoids are the most common cause of lower GI bleeding. Hemorrhoids have also been shown to co-exist with other pathologies of rectal bleeding including malignancy. It has also been shown that sigmoidoscopy can diagnose majority of these pathologies.2,3 This emphasizes the importance of sigmoidoscopy in patients who present with a simple condition like hemorrhoids. The present study yielded similar results with hemorrhoids being the most comm on finding on flexible sigmoidoscopy in 49 (22.8%) out of 215 patients (Table I). However, no associated pathologies were found. Diverticuli are a common cause of lower GI bleeding.2-4 In the present study, diverticuli were identified as the cause of lower GI bleeding in only 5 (2.3%) of 215
Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (9): 577-578
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Abu Bakar Hafeez Bhatti and M. Saeed Quraishy
1.7% malignancy in their study on flexible sigmoidoscopic findings in patients with rectal bleeding.7 Another study in UK reported the incidence of cancer in patients with rectal bleeding to be around 4%.8 While, Papagigoriadis et al. from UK reported an incidence of cancer in 8.8% of patients undergoing flexible sigmoidoscopy.4 In this study, 17 (7.1%) of the total 215 patients were found to have malignancy on biopsy. Interestingly though, all patients had rectal adenocarcinoma and no malignancy was found in splenic flexure, descending and sigmoid colon.
Table I: Frequency of different findings on flexible sigmoidoscopy. Finding
Frequency
Percentage
Hemorrhoids
49
22.8%
Normal
46
21.4%
Polyps
37
17.2%
Growth
24
11.1%
Ulcer
20
9.3%
Proctitis
14
6.5%
Colitis
14
6.5%
Diverticulum
5
2.3%
Angiodysplasia
3
1.4%
Hemangioma
3
1.4%
Total
215
100%
It was concluded that flexible sigmoidoscopy is an effective procedure to determine the cause of lower GI bleeding in majority of the patients. Most patients who present with rectal bleeding have hemorrhoids or polyps as the cause of their bleeding. During sigmoidoscopy, malignancy should be kept in mind.
patients. Factors such as high fiber diet have been associated with low risk of diverticulosis in our population. Since diverticulosis is a disease of old age so the presence of relatively small number of patients above the age of 65 years in the present study could have affected the results.
REFERENCES
The proportion of patients with polyps was markedly different from the study by Zia et al.1 possibly due to difference in ethnicity and life style of the study populations. However, it was consistent with some of the studies performed in the West.3,4 The histological findings in these patients were hamartoma in 29 cases and adenoma in 8 cases. Angiodysplasia is a common lesion of the GI tract and although most are right sided, up to 30% of these lesions can involve the left side of the colon.5 In the present study, 3 (1.39%) patients had angiodysplasia as the cause of rectal bleeding. An interesting finding in this study was the presence of hemangiomas in 3 patients. Colonic hemangiomas are not very common and this aspect of the study needs thorough research. Colorectal cancer incidence was negligible before 1900s. The incidence of colorectal cancer has been on a rise following economic development and industrialization. Currently, colorectal cancer is the third leading cause of cancer deaths in both males and females in the United States.6 Different frequencies of colorectal cancer have been reported in literature from different parts of the world. Choi et al. reported an incidence of l l l l l
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Journal of the College of Physicians and Surgeons Pakistan 2011, Vol. 21 (9): 577-578
