Rectal bleeding in adults over 20 years: Endoscopic investigations and results in current hospital practices in Yaoundé, Cameroon

doi:10.4236/ojgas.2013.36051

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Open Journal of Gastroenterology, 2013, 3, 298-302 OJGas

http://dx.doi.org/10.4236/ojgas.2013.36051 Published Online October 2013 (http://www.scirp.org/journal/ojgas/)

Rectal bleeding in adults over 20 y ears: Endoscopic

investigations and results in current hospital

practices in Yaoundé, Cameroon

Firmin Ankouane Andoulo1, Dominique Noah Noah2*, Roger Djapa1, Michele Tagni Sartre3,

Elie Claude Ndjitoyap Ndam4, Kathleen Ngu Blacket1

1CHU Yaounde, Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of

Yaounde I, Yaounde, Cameroon

2Yaounde Central Hospital, Department of Internal Medicine, Faculty of Medicine and Pharmaceuticals Sciences, University of

Douala, Douala, Cameroon

3La Cathédrale Medical Centre, Yaounde, Cameroon

4Yaounde General Hospital, Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, Uni-

versity of Yaounde I, Yaounde, Cameroon

Email: *[email protected]

Received 25 July 2013; revised 29 August 2013; accepted 12 September 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

ABSTRACT

Introduction: In order to identify the modes of inves-

tigation and the results of the assessment of rectal

bleeding in the Cameroonian adult, we retrospective-

ly analysed the records of 287 patients aged above 20

years diagnosed with rectal bleeding with the aim to

know the prescription patterns according to age, the

diagnostic performance of tests and the results. Me-

thodology: Between the 1st of January 2009 and the

30th of June 2010, we examined patients at the Uni-

versity Teaching Hospital and the “La Cathédrale”

Medical Centre in Yaounde. Age, sex, endoscopic

tests and results were evaluated. Results: 287 proto-

cols met our selection criteria, sex ratio (M/F) 2.4/1,

median age 46 years interquartile range [36 , 55 ]. N o r-

mal tests were 57 (19.2%). Main lesions: haemorrhoids

(42.4% CI95 36.7 - 48.3), colorectal cancer (10.8%

CI95 7.5 - 14.9), anal fissure (8.8% CI95 5.8 - 12.6)

and colorectal polyps (8.4% CI95 5.5 - 12.2). The pre-

valence of significant lesions (polyps and cancer) re-

corded 7% for those under age 40. 20.5% in those

were between 40 - 50 years, and 28.9% for those over

50 years. For anoscopies, 44.4% were under 40 years,

39.3% of cases of sigmoidoscopy affected those be-

tween 40 - 50 years and colonoscopy affected 54% of

those over 50 years. For the diagnostic yield, 26.2%

had a significant lesion for flexible sigmoidoscopy and

only 16.7% and 1.6% for colonoscopy and anoscopy

respectively. Conclusion: The study shows that ano-

scopy and sigmoidoscopy are the main initial tests

conducted in Cameroon in the assessment of rectal

bleeding in adults of less than 50 years and they are

quite sufficient. Haemorrhoids and colorectal cancer

are the main pathologies.

Keywords: Rectal Bleeding; Colon Polyps; Colorectal

Cancer; Sigmoidoscopy; Colonoscopy; Cameroon

Cancer

1. INTRODUCTION

Rectal bleeding accounts for 20% of gastrointestinal

bleeding. It is equal to the most common detection mode

for lower gastrointestinal bleeding especially in the eld-

erly [1]. Several studies have been conducted in order to

know what mode of investigation is appropriate depend-

ing on the age of the patients, the risk of colorectal can-

cer and the clinical presentation mode [2-4]. Even though

colonoscopy is unanimously recommended for patients

aged 50 and above in the assessment of rectal bleeding

[5], there seem to be no consensus guidelines on how to

deal with rectal bleeding in young patients under the age

of 50 [1,3,6,7].

In sub-Saharan Africa and more specifically Camer-

oon, few studies have focused on the topic and there is

no consensus [1,8,9].

We sought to know, through a retrospective study,

which investigation modes existed in our context and the

*Corresponding author.

OPEN ACCESS

F. A. Andoulo et al. / Open Journal of Gastroenterology 3 (2013) 298-302 299

results found while reviewing cases of the rectal bleeding

following the patients’ ages, especially in the diagnosis

of significant lesions such as colorectal polyps and colo-

rectal cancer.

2. MATERIALS AND METHODS

We conducted a retrospective study on the medical his-

tory of all patients aged 20 and above who had carried

out an endoscopic assessment for rectal bleeding in

Yaounde, Cameroon, from 1st January 2009 to 30th June

2010. These were patients of the University Teaching

Hospital (CHU) Yaounde and La Cathédrale Medical

Centre Yaoundé (CMC). Investigative tests used were

anoscopy, flexible sigmoidoscopy and colonoscopy.

The tests which were excluded were colonoscopies

with poor preparation, sigmoidoscopies with poor prepa-

ration, protocols indicating the diagnosis of a rectal tu-

mor palpable on rectal examination, the examination of

patients below 20 years and incomplete file protocols for

the analysis of variables. Only one test was administered

per patient during the study.

Variables recorded were as follows: demographic cha-

racteristics (age, gender), the types of tests required (ano-

scopy, flexible sigmoidoscopy, colonoscopy) and test re-

sults (normal or presence of a colorectal lesion).

Data was entered and analyzed using the French ver-

sion of Epi Info 6.04 software and Excel 2007. For quan-

titative variables, the means, standard deviations, medi-

ans and interquartile ranges (IQR) were calculated. Pro-

portions were set for qualitative variables together with

their confidence intervals at 95% (95% CI).

To examine the relationship between two discrete

variables, we used the Pearson’s χ2 test using the Yates’

correction and Fisher’s exact test for reduced samples,

for an accepted significance level of 5%.

3. RESULTS

3.1. Sample Population (Table 1)

During the study period, a total of 312 protocols for en-

doscopic tests carried out in adult patients in rectal blee-

ding records were analysed. Two hundred and ninety-

seven (95.2%) protocols sampled met our inclusion cri-

teria. Of all the patients, 100 (33.7%) were under 40

years, 83 (27.9%) were between 40 and 50 years and 114

(38.4%) were above 50 years of age. In terms of gender,

there were 209 (70.4%) men and 88 (29.6%) women

with an M/F sex ratio of 2:4. The average age was 46

years IQR [36 years, 55 years] and the modal age was 55

years.

As for the tests conducted, 124 (41.7%) tests were

anoscopies, 84 (28.3%) were flexible sigmoidoscopies

and 89 (30%) took colonoscopy tests. Of these tests, 55

(44.4%) anoscopies concerned patients under 40 years,

33 (39.3%) flexible sigmoidoscopies involved patients

aged between 40 - 50 years and 48 (54%) colonoscopies

were done on patients over 50 years.

3.2. Results of Endoscopies in the Assessment of

Rectal Bleeding in the Cameroonian Adult

(Table 2)

The results were normal in 57 (19.2%) tests. The pre-

dominant lesions were haemorrhoids with 126 cases

(42.4%, 95% CI: 36.7 to 48.3), followed by colorectal

cancer, 32 cases (10.8%, 95% CI 7.5 to 14, 9), anal fis-

sures recorded 26 cases (8.8%, 95% CI 5.8 to 12.6) and

colorectal polyps 25 cases (8.4%, 95% CI 5.5 to 12.2).

Exceptionally, colitis recorded 12 cases (4.0%, 95% CI

2.1 to 7.0), colonic diverticula 11 cases (3.7%, 95% CI

1.1 to 6.5), rectal ulcers 6 cases (2%, 95% CI: 0.7 - 4.3)

and rectal varices 1 case (0.3%, 95% CI: 0.0 - 1.9).

3.3. The Prevalence of Significant Lesions

According to the Ages of Patients with

Rectal Bleeding (Table 3)

In patients below 40 years, 7 (7%) significant lesions

were found (including 3 (3%) colorectal cancers and 4

Table 1. Distribution of tests according to age groups in the

assessment of rectal bleeding in Cameroonian adults.

Anoscopies

(n = 124)

Sigmoidoscopy

(n = 84)

Colonoscopies

(n = 89)

Total

(n = 297)

Workforce by age, n (%)

˂40 years old100 (33.7)55 (44.4) 22 (26.2) 23 (25.8)

40 - 50 years83 (27.9)32 (25.8) 33 (39.3) 18 (20.2)

>50 years 114 (38.4)37 (29.8) 29 (34.5) 48 (54)

Table 2. Prevalence of colorectal lesions found in reports on

rectal bleeding by endoscopy in Cameroonian adults (n = 297).

Results Employees (Percentage) Confidence

interval 95%

Angiodysplasia 1 0.3 0.0 - 1.9

Cancer 32 10.8 7.5 to 14.9

Colitis 12 4.0 2.1 to 7.0

Diverticulum 11 3.7 1.1 to 6.5

Anal fissure 26 8.8 5.8 to 12.6

Haemorrhoids 126 42.4 36.7 to 48.3

Colonic polyps 25 8.4 5.5 to 12.2

Solitary rectal ulcer6 2.0 0.7 - 4.3

Rectal varices 1 0.3 0.0 - 1.9

Normal 57 19.2 14.9 - 24.1

F. A. Andoulo et al. / Open Journal of Gastroenterology 3 (2013) 298-302

300

polyps (4%) colorectal polyps) in patients aged between

40 - 50 years, 17 (20.5%) significant lesions were found

(including 10 (12.0%) colorectal cancers and 7 (8.4%)

colorectal polyps) and in patients over 50 years, 33

(28.9%) significant lesions were found (including 19

(16.7%) colorectal cancers and 14 (12.3%) colorectal

polyps). In the univariate analysis, significant lesions

commoner in patients aged above 50 years (Relative

Risk: 2.21, 95% CI: 1.38 to 3.53, p = 0.0007).

3.4. Contribution of Endoscopy in the Diagnosis

of Significant Lesions in Adult Patients with

Rectal Bleeding (Table 4)

Significant lesions were detected in 33 (16.7%) patients

(17 (19.1%) colorectal cancers and 16 (17.8%) colorectal

polyps) with rectal bleeding using colonoscopy. Flexible

sigmoidoscopy helped in detecting significant lesions in

22 (26.2%) patients (including 14 (16.7%) colorectal

cancers and 8 (9.5%) colorectal polyps). Finally, sig-

nificant lesions were detected by anoscopy in 2 (1.6%)

patients (including 1 (0.8%) colorectal cancers and 01

(0.8%) colorectal polyp). In the univariate analysis, the

diagnosis of significant lesions was strongly connected to

colonoscopy compared with other endoscopic tests (Re-

lative Risk: 3.21, 95% CI 2.02 to 5.11), p < 10−5).

4. DISCUSSION

Colonoscopy is considered the best endoscopic method

in assessing and managing rectal bleeding [4,10,11]. To-

day, there are no consensus guidelines on its formal in-

Table 3. Prevalence of significant lesions according to patients’

age groups reports on rectal lesions in the Cameroonian adult.

Age group

<40 years

(n = 100)

40 - 50 years

(n = 83)

>50 years

(n = 114)

Significant lesions, n (%) 7(7) 17 (20.5) 33 (28.9)

Colorectal cancer, n (%) 3 (3) 10 (12.0) 19 (16.7)

Colorectal polyps, n (%) 4 (4) 7 (8.4) 14 (12.3)

Table 4. Prevalence of significant lesions according to endo-

scopy in the assessment of rectal lesions in the Cameroonian

adult.

Endoscopic tests

Anoscopies

(n = 124)

Sigmoidoscopy

(n = 84)

Colonoscopies

(n = 89)

Significant lesions, n (%) 2 (1.6) 22 (26.2) 33 (37.1)

Colorectal cancer, n (%) 1 (0.8) 14 (16.7) 17 (19.1)

Colorectal polyps, n (%) 1 (0.8) 8 (9.5) 16 (17.8)

dication in patients under 40 years who suffer from rectal

bleeding [3,6,10]. Bhargava et al. [12] further argued

that the predominant lesions in rectal bleeding cases in

tropical countries and the tests conducted were different

from those reported in Western countries. The study’s

aim was to analyse test prescription practices in the

process of diagnosing rectal bleeding in the Cameroonian

adult, taking into account age, and to report the results of

these study, and most especially, significant lesions. We

observed that colonoscopy was the second review after

Anoscopy, prescribed in our community, especially in

patients over 50 years. In patients less than 40 years,

anoscopy was the first test used to investigate rectal

bleeding and in patients between 40 - 50 years, flexible

sigmoidoscopy was the first-line examination. Haemor-

rhoids (42.4%), colorectal cancer (10.8%), anal fissure

(8.8%) and colorectal polyps (8.4%) were the predomi-

nant lesions. Significant lesions, particularly colorectal

cancer were common in patients above 50 years.

The specificity of rectal bleeding in our country is

twofold. First, it is assumed in our context that haemor-

rhoidal disease cannot be treated by way of modern me

dicine, but only through traditional medicine. Also, when

people suspect that they may be suffering from amoebic

colitis caused by rectal bleeding they resort to self-me-

dication using metronidazole and this is common prac-

tice among the population. This explains why patients

arrive too late at the hospital and in fewer numbers. This

peculiarity may have had an impact on our results, espe-

cially in the prevalence of colorectal cancer. The alarm

symptoms that we did not identify in this work could be

the reasons that led our patients to consult. This is a ret-

rospective study and we could have excluded patients

with alarm symptoms so as to avoid selection bias. How-

ever, the study as far as we know is the first in our coun-

try. It provides an overview of the medical prescriptions

in case of rectal bleeding. The legal framework for pre-

scribing examinations is not observed in Cameroon.

Thus, the traditional practitioner, paramedics, general

practitioners and other specialists besides gastroentero-

logist may prescribe an investigation test.

The incidence of rectal bleeding increases with age

and corresponds with an increasing frequency of gastro-

intestinal diseases and this is specific to each region. In

our study, it was observed that patients above 50 years

(38.4%) and those under 40 years (33.7%) were the most

affected. We did not find any justification for this. On

the contrary, comorbidity and some medications such as

NSAIDs and anticoagulants are known to account for the

lower gastrointestinal bleeding in the elderly. The main

lesions found in our study were different, apart from hae-

morrhoids, from those reported in some tropical coun-

tries [8,9,12]. Rather, they were similar to those reported

by Mbengué et al. [1] in Dakar, Senegal. Djibril et al. [8]

F. A. Andoulo et al. / Open Journal of Gastroenterology 3 (2013) 298-302 301

in Lome, Togo limited their study to subjects aged be-

tween 24 - 45 years; individuals aged 50 and above were

excluded. These subjects are known to be most affected

by colorectal cancer [13] cancer which could explain the

low prevalence (5.88%) of colorectal cancer in this series

compared to ours. Also, Assi et al. [9] in Abidjan, Côte

d’Ivoire, reported a prevalence of colorectal cancer of

5.53% among adult subjects with rectal bleeding using

colonoscopy as a diagnostic test. The difference com-

pared to our series would be based on the type of diag-

nostic tests. It is important to note the high prevalence of

colorectal cancer in our study and in that of Mbengué et

al. [1] of 10.8% and 11.9% respectively. Changes in our

eating habits have been observed in recent years, initially

predominantly vegetarian and meat-rich today may

partly explain these results.

The prevalence of significant lesions in patients 40 -

50 years and in patients over 50 years was high, whereas

in patients below 40 years, it was low. These results are

consistent with those contained in the literature and es-

pecially those in the work of Lewis et al. [6] who re-

ported similar results in a series of patients under 50

years with rectal bleeding. During the study and that of

Lewis et al. [6] the warning signs which are changing

bowel habits, iron deficiency anaemia and weight loss,

these signs are known to have a high positive predictive

value [14-16] in diagnosing colorectal cancer in a patient

with signs of rectal bleeding which were not mentioned.

The diverticular bleeding is a common cause of rectal

bleeding in the West [17]. In sub-Saharan Africa, diver-

ticular disease is a rare disease [18] and diverticular

bleeding is rarely described [19]. The 3.7% prevalence

rate is therefore in accordance with these arguments.

Bleeding from rectal ulcer seemed relatively frequent

compared to the literature [20,21]. Lin et al. [21] have

identified comorbid conditions associated with this dis-

ease including diabetes, bed-rest, renal failure, hypogly-

caemia albumin, cerebrovascular accidents, respiratory

failure and atherosclerosis. None of these factors was re-

ported in our series. Their cause is not mechanical.

The diagnostic value for significant lesions, particu-

larly colorectal cancer was higher with flexible sigmoi-

doscopy (26.2%) for lesions of the distal segment of the

colon. This is not a new observation [11,22,23]. We

noted that 65.5% of flexible sigmoidoscopy was per-

formed in patients less than 50 years. This test is consid-

ered sufficient in the assessment of rectal bleeding with-

out alarming symptoms in patients less than 50 years by

some authors which is due to the preferential localization

of significant lesions in the distal colon in this age group

on the one hand [2-4,11,24], but also due to a low preva-

lence of significant lesions, particularly colorectal cancer

in this age group [6,16,25,26]. Marderstein et al. [10] in

a study of simple rectal bleeding emphasised that the

diagnostic yield of colonoscopy was low in indicating

this. The authors added that flexible sigmoidoscopy was

sufficient to exclude significant injury if other formal

indicators for colonoscopy were not associated. We drew

three arguments from the findings in relation to our study:

1) that flexible sigmoidoscopy was sufficient in the as-

sessment of our patients under 50 years, 2) that the per-

formance of this test was high and 3) that our patients

probably had warning signs associated with rectal bleed-

ing to explain the high frequency of significant lesions in

the age group of those below 50 years (27.5%). Late ar-

rival to the hospital as already mentioned is a contribut-

ing factor.

Colonoscopy in the assessment of rectal bleeding

without warning signs has a low yield according to some

authors [10,14,23] and is costly for a patient who has no

health insurance. In Cameroon, the price of a colono-

scopy is three times that of sigmoidoscopy. Colonoscopy

was the second examination prescribed in our study

(30%), especially in patients over 50 years. It is recom-

mended by most published guidelines and EPAGE II

criteria (available at http://www.epage.ch) in screening

for colorectal cancer in patients at high risk of colorectal

cancer [27] and in subjects aged above 50 years. Risk

factors for colorectal cancer and alarm symptoms were

not identified in this study. However, the contribution of

colonoscopy was instrumental in the diagnosis of sig-

nificant lesions. Late arrivals at hospitals explain this

result.

5. CONCLUSION

The absence of a legal framework and a consensus on the

follow-up of rectal bleeding on the one hand and the tra-

ditional methods of individuals in the face of rectal blee-

ding on the other hand are major obstacles in assisting

the patient. However, the requirements of investigative

tests do not really deviate from what is recommended in

several publications in the existing literature. Test results

need to be reported taking into account the characteris-

tics of rectal bleeding and its associated warning signs.

The high cost of testing and the lack of health coverage

oblige one to adopt a systematic approach focusing on

anoscopy and sigmoidoscopy such as initial tests for young

patients with no warning signs and colonoscopy for eld-

erly patients or those at the risk of colorectal cancer.

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