The document summarizes a gastroenterology audit conducted at SPHMMC in November 2018. 57 colonoscopies were performed and data was collected on patient demographics, indications for procedures, findings, and challenges. The most common indications were ruling out colorectal cancer (26.3%) and lower GI bleeding (14%). The most common findings were normal (28%), hemorrhoids (22.8%), and colorectal carcinoma (14%). Opportunities for improvement included standardizing report formats, assessing bowel prep quality, and monitoring key performance indicators like adenoma detection rates.

1. Beka Aberra [R2]
SPHMMC Gastroenterology Attachment
Moderator: Yemiserach Chane, MD, Internist/Gastroenterologist
December, 2018

2.  Objectives
 Audit
 Discussion
 Hemorrhoids in Brief
 Challenges of the Unit
 Recommendations
 Appendix

3.  To Identify common Clinical indications for Colonoscopy
 To Identify common Colonoscopy findings, and Diagnostic yield
 To Discuss on the Audit & Commonest finding
 To Figure out some Challenges
 To Make recommendations to Improve Current Practice

4. Data resources
 Colonoscopy Report Papers from November 1- 30 or
 From [Tikemt 22 -Hidar 21]
 In the Month of November 57Colonoscopies were done.
 Colonoscopy Audit.xlsx

5. NUMBER PERCENTAGE
GENDER MALE 31 56.3%
FEMALE 24 43.6%
AGE GROUPS
* < 40 yrs were[18]
* >= 40 yrs were [37]
0-9 0 0%
10-19 1 1.8%
20-29 12 21.8%
30-39 5 9%
40-49 10 18.3%
50-59 15 27.3%
60-69 5 9%
70-79 6 11%
80-89 1 1.8%
 Patients were Aged between [18-85 years] with Mean Age 46.42 Years;
56.3% Males and 43.6% Females

6. 0%
5%
10%
15%
20%
25%
30%
0
2
4
6
8
10
12
14
16
0-9 [10-19] [20-29] [30-39] [40-49] [50-59] [60-69] [70-79] [80-89]
AGE GROUPS
Chart Title
NUMBER PERCENTAGE

7. INDICATIONS NUMBER PERCENTAGE
R/o CRC 15 26.30%
LOWER GI BLEEDING 8 14%
CHRONIC DIARRHEA 7 12.30%
UNSPECIFIED INDICATIONS 7 12.30%
CONSTIPATION 6 10.60%
R/o IBD 4 7%
RECTAL MASS 4 7%
ABDOMINAL PAIN 2 3.50%
SCREENING 2 3.50%
ALTERED BOWEL HABITS 1 1.75%
ANEMIA 1 1.75%
The Commonest Indications
being Rule Out CRC [26.3%]
followed by LGIB [14%].

8. 0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
0
2
4
6
8
10
12
14
16
Chart Title
NUMBER PERCENTAGE

9. DIAGNOSIS NUMBER PERCENTAGE MALE FEMALE
NORMAL 16 28% 10 6
HEMORROIDS 13 22.80% 8 5
COLORECTAL CARCINOMA 8 14% 7 1
POLYP 7 12.20% 6 1
INFLAMMATORY BOWEL DISEASE 5 9% 1 4
NONSPECIFIC ILEITIS/COLITIS 2 3.50% 1 1
DIVERTICULOSIS 2 3.50% 0 2
ULCER [RECTAL & CECAL] 2 3.50% 0 2
IBS 1 1.75% 0 1
TAENIASIS 1 1.75% 0 1

10. 0%
5%
10%
15%
20%
25%
30%
0
2
4
6
8
10
12
14
16
18
Normal Hemorroids Colorectal Cancer Polyps IBD Nonspecific
Ileitis/Colitis
Ulcer
[Rectal/Cecal]
Diverticulosis IBS Taeniasis
Chart Title
Frequency Percent
Diagnostic yield is about 72% for colonoscopy of the
Total Indications [57]; Normal Findings were [16].
 53 % for CRC [15 R/o CRC Indications; 8 Findings]
 62.5% for Hemorrhoids [8 LGIB Indication; 5H/3P]

11. 0
2
4
6
8
10
12
14
16
18
Chart Title
NUMBER MALE FEMALE

12. FINDINGS NORMAL HEMORRHOIDS CRC POLYPS IBD NONSPECIFIC
ILEITIS/
COLITIS
DIVERTICUL
OSIS
ULCER
[RECTAL/
CECAL]
IBS TAENIASI
S
AGE
GROUPS
0-9 0
0 0 0 0 0 0 0 0 0
10-19 0
0 0 0 0 0 0 0 0 1
20-29 3 2 2 1 3 0 0 0 1 0
30-39 0
2 0 0 0 0 1 2 0 0
40-49 3
2 2 1 1 0 1 0 0 0
50-59 7 1 3 2 0 2 0 0 0 0
60-69 0
3 0 2 0 0 0 0 0 0
70-79 3
2 1 0 0 0 0 0 0 0
80-89 0
0 0 1 0 0 0 0 0 0

13.  Completion of Endoscopy Reports in Similar Format
 Assessment of Bowel Prep Quality
 Caecal Intubation Rate
 Polyp Detection Rate
 Adenoma Detection Rate
 Polyp Retrieval Rate
 Colonoscopy Withdrawal Time
 Rectal Retro-Flexion rate
 Safe Sedation Practice
 Assessment of Patient Comfort Score
 Immediate Adverse Event Rate

14. 0
5
10
15
20
25
30
35
40
Complete Incomplete
Count of COMPLETENESS

15. 0
5
10
15
20
25
30
35
Poor Not Prepared Not Adequate Good Fair Excellent Dirty
Count of PREPARATION
Many Endoscopist describe the quality of
bowel preparations in global terms like
Excellent, Good, Fair or Poor.
Usually, these terms are used to describe
the overall quality of bowel preparation.
 Although these terms are widespread,
it is not always clear what exactly is
meant by these terms and there may
be important differences in how these
terms are being interpreted and used.

16.  Insufficient mucosal visualization during colonoscopy can result in relevant lesions
being missed. This has been shown in studies on colorectal cancer screening programs,
where the adenoma detection rate is directly related to the quality of bowel
preparation.
 It has been suggested that the fact that Colonoscopic surveillance does not prevent
right-sided cancers is caused by the often worse quality of cleansing of the right side of
the colon.
 Poor bowel preparation can also result in difficult progression, an increased risk of
complications, prolonged procedure duration and an increase in the amount of
sedatives and analgesics required.
 The Aronchick scale. This scale grades the adequacy of cleansing of colonic segments
or the entire colon, using semi-quantitative descriptors:
Excellent/Good/Fair/Poor/Inadequate
 The Ottowa bowel preparation scale is another tool to assess adequacy of colonic
cleansing; Dividing in 3 Segments; Excellent/Good/Fair/Poor/Inadequate

17.  The Boston Bowel Preparation Scale, is a scoring system, that has an excellent
intra- and interobserver reliability, and is proven to be related to endoscopy
outcome. The colon is divided in three segments: The right side (including cecum
and ascending colon), the transverse colon (including the flexures) and the left
sided colon, which includes the descending colon, sigmoid and rectum.
 For all three sections cleansing is assessed as follows:
0: Unprepared colon segment with mucosa not seen because of solid stool that
cannot be cleared.
1: Portion of mucosa of the colon segment seen, but other areas of the colon not well
seen because of staining, residual stool, and/or opaque liquid.
2: Minor amount of residual staining, small fragments of stool and/or opaque liquid,
but mucosa of colon segment seen well.
3: Entire mucosa of colon segment seen well with no residual staining, small
fragments of stool or opaque liquid.

20.  Caecal Intubation Rate i.e. the proportion of patients in whom there was
insertion of the colonoscope tip into caecal caput; reflecting a complete
examination.
PROCEDURE NUMBER PERCENTAGE CAECAL
INTUBATION
RATEPROCTOSCOPY 2 3.5%
COLONOSCOPY 7 12.3%
PANCOLONOSCOPY 42 73.7% 84.2%
ILEOCOLONOSCOPY 6 10.5%
 Activities that Were Done
 Colonoscopic biopsy----26
 Removal of Polyp by Cold forceps and Cold snare----5

21.  Polyp Detection Rate Calculation Method: # of colonoscopy cases with at least one
polyp was biopsied or removed/Total # of screening colonoscopies.
 Polyps 7/57 [12.3%] vs CRC 8/57 [14%]
FINDINGS NORMAL CRC POLYPS
AGE GROUPS
* < 40 yrs were[2/1]
* >= 40 yrs were [6/6]
***Above Age of 40 yrs Fecal
Occult Blood testing +
DRE/Endoscopic Exams may
be necessary
0-9 0
0 0
10-19 0
0 0
20-29 3 2 1
30-39 0
0 0
40-49 3
2 1
50-59 7 3 2
60-69 0
0 2
70-79 3
1 0
80-89 0
0 1

22.  A retrospective analysis of 640 patients who underwent 681 Colonoscopic
examinations between March 1984 and April 1996 was undertaken. The major
indications were rectal bleeding (32.8%), change in bowel habit (24.7%),
abdominal pain (20.1%), abnormal barium enema (9.8%) and iron deficiency
anemia (4.8%).
 Total colonoscopy was performed in 79.3% of cases. The Colonoscopic finding was
normal in 49.8% of patients. Most of the lesions were benign.
 Polyps and carcinoma were found in 9.2% and 7% of patients respectively. 91.3%
of the lesions were located distal to the splenic flexure and of the remaining
proximal lesions, polyps and carcinoma accounted for only 2.2%. Rectal bleeding
produced the highest diagnostic yield (70%) followed by iron deficiency anemia
(61.3%), change in bowel habit (48.1%) and abnormal barium enema (47.6%).
Lower yields were found in patients with abdominal mass (33.3%), follow up
colonoscopy (28.6%) and abdominal pain (26.9%).
 Colonoscopy in the investigation of colonic diseases by Endale Kassa; EAMJ 1996

23. WHO Country Profile; 2014

24.  Conclusion: Hyoscine is used in clinical practice to decrease spasms in the colon during
colonoscopy in an effort to improve polyp or adenoma detection. However, this study
shows that hyoscine given before the procedure or at time of caecal intubation does not
improve polyp or adenoma detection.

26.  Adverse Events Rate Calculation method:
Each regional program will be responsible for determining the tracking measure
that is feasible given ITs infrastructure and clerical support.
Hospital separations data and transfusion records can be utilized to develop an
adverse event monitoring system.

27. The most common determined colonoscopy clinical
indication was to rule out CRC and diagnostic yield was
for Hemorrhoids followed by Colorectal Ca and Polyps.

28. Engorgement of the Hemorrhoidal
Venous Plexuses with redundancy of
their coverings
 Haemorrhoids
Haima = Blood
Rhoos = Flowing
 Piles
 Pila = Ball/Swelling in anal canal
which may/may not bleed

29. Internal hemorrhoidal plexus
 In submucosa
 Drain in superior rectal vein
 Communicate with external
plexus
 Site of communication
between portal and systemic
veins
 Veins at 3, 7 and 11 o’clock
position are large
External hemorrhoidal plexus
 Lies outside muscular coat of
anal canal
 Communicate freely with internal
plexus

30. Potential Sites
3 o’clock
7 o’clock
11 o’clock

31. Below dentate line
 Varicosities of veins
draining
 Inferior rectal artery
 Lined by
squamous epithelium
Painful
 Prone to thrombosis if
vein ruptures
(Thrombosed pile)
Above dentate line
 Varicosities of veins
draining
 Superior rectal artery
 Lined by
columnar epithelium
Pain insensitive
 May prolapse outside
anal canal
(Prolapsed hemorrhoid)

32. While no widely used
classification system of
external hemorrhoids
exists,
 Internal hemorrhoids
are graded according
to the degree to which
they prolapse from the
anal canal:

33.  The development of symptomatic hemorrhoids has been associated
with
 Advancing age,
 Diarrhea,
 Prolonged sitting,
 Straining,
 Chronic constipation,
 Trauma
 Lack of Fiber rich diet

34.  Secondary Causes
 Local: Anorectal deformity. Hypotonic Sphincter
 Abdominal: Ascites
 Pelvic: Gravid Uterus/ Ovarian-Uterine Neoplasms
 Portal Hypertension
 Neurological: Paraplegia/Multiple Sclerosis

35.  Pathogenesis Various Theories
1. Portal Hypertension and varicose veins
2. Upright posture of human beings
3. Erosion and weakening of wall of veins due to infections 2o to trauma
4. Hard fecal matter obstructing venous return
5. Raised anal canal resting pressure
6. Hyperplasia of Corpus Cavernosum Recti

37.  Current View of Pathogenesis
1. Shearing forces acting on anus
2. Caudal displacement of anal cushions and mucosal trauma
3. Fragmentation of supporting structures
4. Loss of elasticity of anal cushions
5. Loss of retraction of anal cushions

38.  Anal Cushions are hemorrhoidal venous plexuses together with some
arteriovenous anastomoses surrounded by smooth muscle, elastic and fibrous
tissue in the sub epithelial space both above and below dentate line.
 Shield anal canal/ sphincter during evacuation
 Complete the closure of the anal canal
 Contribute 15% of anal canal’s pressure
 Congest during Valsalva maneuver/ Increased intra abdominal pressure
 Their increase in size is the starting point of hemorrhoids

39.  EPIDEMIOLOGY — The true prevalence of hemorrhoids is uncertain as anorectal
discomfort is often attributed to symptomatic hemorrhoids.
 In a large, cross-sectional survey conducted in the United States, the self-reported
prevalence of symptomatic hemorrhoids was 4.4 percent.
 The prevalence was equal in both sexes, peaked between the ages of 45 and 65,
and declined thereafter.
 Development of symptoms prior to 20 years was unusual.
 ? Caucasians > Afro-Caribbeans
 Local Data??

42.  Symptoms Approximately 40 percent of
individuals with hemorrhoids are
asymptomatic.
 Symptomatic patients usually seek treatment
for
 Hematochezia,
 Pain associated with a thrombosed
hemorrhoid,
 Perianal pruritus, or
 Fecal soilage.

43.  Physical Exam
 Left Lateral decubitus positioning
 Check for any rashes/condylomata/eczema
 Any Abscess/fissures/fistulae
 Check Resting tone of anal canal; Voluntary contractions of External Anal
Sphincter
 Check for any mass/tenderness
 Anoscopic Exam/ Anal Manometry if hx of incontinence.
 Internal Hemorrhoids generally aren’t palpable.
 Proctoscopy/ Flexible Sigmoidoscopy

45. Treatment Options
Conservative dietary and Lifestyle
modification
Non Operative/Office procedures
Operative Hemorrhoidectomy

46.  Conservative dietary and Lifestyle modification
 Minimizing Straining and Preventing Constipation
 Drinking Fluids
 High Fiber diets
 Use of Fiber Supplements
 Stool Softeners
 Exercise “Kegels”
 Local Hygiene
 Go as soon as you feel the urge. If you wait to pass a
bowel movement and the urge goes away, your stool
could become dry and be harder to pass.
“You don’t defecate in the
Library; So You Shouldn’t read in
the bathroom”

47. Conservative dietary and Lifestyle modification
If Prolapses, Gently push back into anal canal
Use Moist or Wet toilet paper instead of dry toilet paper
Topical Treatments including
Pads, Ointments, Creams, Gels, Lotions, Suppositories
Calcium dobesilate 0.25% ; Anhydrous Lignocaine 3%;
Hydrocortisone acetate 0.25%, Zn 5%.

48. Conservative dietary and
Lifestyle modification
Sitz bath
 Sitz mean to sit
 Used in treatment of Gr. IV
hemorrhoids
 Duration:15-20 minutes
Cold water is used
 Draw heat out of sore piles
 Reduce blood flow in them
 Reduce pressure inside swollen
piles
Post operative
Warm water is used
 Dilatation of blood
vessels
 Allow blood to pass
through swollen piles
more quickly
 Relaxes muscles so ease
anal sphincter tone

49. Non Operative/Office procedures
Sclerotherapy
Band Ligation
Infra-red coagulation
Cryosurgery
Manual dilatation of anus
Sphicterotomy [Lateral]
Bicap Electrocoagulation
Haemorrhoidolysis

53. Operative Hemorrhoidectomy
 Mainly driven by impact of symptoms on quality of life
 3rd and 4th degree piles
 2nd degree not cured by conservative means
 Fibrosed hemorrhoid
 Interno-external hemorrhoid
 Bleeding sufficient to cause anemia
 Soiling
 Ulceration, thrombosis, gangrene

54. Operative Hemorrhoidectomy
 Milligan-Morgan Hemorrhoidectomy [OPEN]
 Ferguson’s Hemorrhoidectomy [CLOSED]

55. Operative Hemorrhoidectomy
 Harmonic Scalpel
 Stapler Hemorrhoidopexy

56. Complications of Surgery
 Early Complications
 Post Operative Pain/2-3 Wks.
 Wound Infection
 Post Op Bleeding
 Swelling of Skin Bridges
 Short term incontinence
 Difficult Urination
 Late Complications
 Anal Stenosis
 Anal Fissure
 Fecal Impaction
 Mild Incontinence
 Sub mucous abscess
 Delayed Bleeding
 Skin tags
 Recurrence

57.  Scope Problems
 Screening the patients Diagnostic yield was only 72 %.
 Different Colonoscopic reporting formats used
 Many Incomplete data fillings; Mostly Duration of procedure.
 Lack of Standard Grading of Bowel Preparation [BBPS].
 Lack of Imaging of Findings.
 Less therapeutic activities done; Mostly Diagnostic.
 No strict follow-up of patients post colonoscopy for complication detection.

58.  Appropriate instructions for the patients.
 Appropriate patient screening.
 Complete Data Filling.
 Standardized report format for all.
 Have PEG Laxative/Mg Citrate available for bowel preparation.
 Have follow-up forms for early complication detection.
 Have patient comfort levels assessed post procedure.
 Have consent forms acquisition on report format.
 Have BMI measurement on report format
 Further study into local prevalence of hemorrhoids and determinants of
possible increase in incidence??
 Have Complete Colonoscopy Audit

59. Colonoscopy Audit.xlsx
Sample Report

60. 0 2 4 6 8 10 12 14
Dr. Eskinder
Dr. Fisshea
Dr. Geda
Dr. Hailemicheal
Dr. Hana
Dr. Miftah
Dr. Paoulos
Dr. Yemisrach
Count of PERFORMED