Colonoscopy is a procedure that involves the placement of a flexible tube with a fibre optic camera on its tip, through the rectum, in order to visualize the colon [1] . It is a key investigation required for diagnosis of several disease conditions involving the lower gastrointestinal tract [2] . Lower GI symptoms requiring colonoscopy include GI bleeding, chronic constipation, recurrent abdominal pain, chronic diarrhoea and mucoid stools among others [3] . Colonoscopy is the gold standard for screening and diagnosis of colorectal cancer [4] . Other benign lesions that are commonly encountered at colonoscopy include: polyps, colorectal adenomas, inflammatory bowel disease and other forms of colitis, as well as internal hemorrhoids and diverticulosis [5] [6] . The procedure also gives room for minimally invasive therapeutic modalities like polypectomy [5] . Advances in colonoscopy have greatly improved clinical practices in modern gastroenterology [7] .

In many African countries, colonoscopy services can only be accessed in a few health facilities [6] [8] [9] and many patients are treated empirically while others are referred to urban centres where the service can be accessed [10] . This is attributed to few trained health personnel to handle these procedures, lack of equipment and inadequate infrastructure [11] [12] .

In low- and middle-income countries, the prevalence of colorectal cancer has been reportedly low compared to developed countries. This is attributed to the limited access to colorectal disease screening services especially colonoscopy [13] . A study was done in Ethiopia, Kenya, Malawi and Zambia to evaluate the gastrointestinal endoscopy capacity by interviewing digestive healthcare professions in various health facilities and it was discovered that endoscopy capacity is severely limited in sub-Saharan Africa despite the high burden of gastrointestinal diseases in this region [14] .

In Uganda, there is limited local research to guide policy and programming for CRC prevention. This prompted a stakeholders engagement workshop in Kampala in March 2024 where limited CRC screening was reported as a major barrier to CRC diagnosis [15] .

Therefore, this study aimed at describing the various indications and findings at colonoscopy at Divine Mercy Hospital in South Western Uganda.

Majority of our patients were males with a male to female ratio of 1.7:1. This was consistent with studies done in south western Nigeria [3] and Zanzibar [16] where the male to female ratios were 3.5:1 and 1.2: 1 respectively. However, the explanation for this male predominance remains uncertain.

The mean age of our patients was 54.1 (±18.7) years. The youngest patient was 8years while the oldest patient was 91years. Colonoscopy was done in only 5 patients below 18years of age. In a large study that was conducted on 1858 patients, Naseer et al., reported a mean age of 51.7 (±18.5) years [1] which was quite similar to our study. However, in Ethiopia, Gudissa et al., reported a mean age of 43.5 years (SD = 15.67) with age range of 15 - 84 years [17] . The wide age range in our study could perhaps explain this variation in the mean age.

Lower Gastrointestinal bleeding (LGIB) is a threatening symptom that makes patients and their caretakers worried hence the need to seek medical services at the nearest health facility. In this study, LGIB was the most common indication for colonoscopy and this was also reported by Obonna et al., in Nigeria [3] . However, a study done by Qu et al., in Zanzibar, LGIB was the third most common indication after chronic diarrhea and abdominal pain [16] . Anorectal pain and chronic constipation were among the other indications for colonoscopy. One patient, who was a 27 years old male, had rectal prolapse as the indication for colonoscopy but the colonoscopy report revealed normal findings. Similarly, a 32 years old male had anal warts but his colon had normal findings. We were unable to establish his serostatus from the available data.

The most common benign finding at colonoscopy was presence of hemorrhoids which accounted for the largest portion of patients with LGIB. Other benign lesions identified at colonoscopy were colitis, inflammatory bowel disease, polyps, anal fissures and diverticulosis among others. Ismaila and Misauno also found hemorrhoids in 58.1% of the patients that were done colonoscopy and the other benign lesions were quite similar to the ones reported in our study [18] . This similarity could be explained by the fact that these studies were done in African countries whose communities share similar socio-economic status, environmental factors and health seeking behaviors. This study did not establish any causal factors for these findings.

Forty-nine patients had malignant lower GI conditions confirmed at histology and of these, 14 (28.6%) were below 50years of age. The CDC recommends that adults aged 45 to 75 years should be screened for colorectal cancer [19] . Although colorectal cancer (CRC) is more common in patients above 50 years of age, there are rising cases of early onset colorectal cancer among patients below 50 years and this may be partly attributed to lifestyle changes, obesity and dietary habits [20] [21] . Several studies have reported advanced age as a risk factor to colorectal cancer and these patients usually present with hematochezia and anemia [16] [22] [23] . Although males had a significantly higher predominancy among patients who had colonoscopy (63.5%), those with confirmed malignancy were almost in equal proportions without gender predilection. Male gender has been reported as a risk factor for CRC in some studies [20] . The histopathological diagnosis was predominantly adenocarcinoma, with varying degrees of differentiation. Other studies in literature have also reported adenocarcinomas as the most common histological diagnosis among patients with colorectal cancers [24] - [26] .

A number of patients (30.8%) had normal colonoscopy findings. This finding resonates well with some studies done in Nigeria that found normal colonoscopy findings in 24% [3] and 20.9% [18] . This was mainly observed among patients who presented with lower abdominal pains for which colonoscopy was requested by the attending doctor but it is presumed that the abdominal pain could have been due to other causes.

In South Western Uganda, the most common indication for colonoscopy was lower GI bleeding. Hemorrhoids, colitis and inflammatory bowel disease were the main benign findings at colonoscopy. Several patients also had lower GI malignancies and these were predominantly adenocarcinomas. This study highlights the importance of colonoscopy in diagnosing and managing lower GI conditions in a resource-limited setting.

Patients with lower GI symptoms should undergo colonoscopy to obtain a clear diagnosis that in turn helps the health worker to institute a proper plan of management.

This was a retrospective study that mainly looked at colonoscopy reports which had limited variables that would be extracted for statistical analysis, thus indepth analysis could not be done to establish the possible risk factors for these colonoscopy findings.

We had some missing histology results, this may be attributed to some patients who may prefer to go with their samples to be processed by their primary healthcare physician, thus the hospital lacks record of such histological results.

We acknowledge the support and guidance from the Faculty of Medicine at Mbarara University of Science and Technology as well as the theatre team and administration at Divine Mercy Hospital.