Assessment of Gastrointestinal Endoscopy in Al-Salam Teaching Hospital in Mosul City

Background: Gastrointestinal (GI) endoscopy has now been part of conventional medical practice for over thirty years following the development of useable flexible fibreoptic endoscopes in the early 1970’s. Aim: The study aim is to assess the gastrointestinal endoscopy outcomes and risk factors associated it'sin Al-Salam Teaching Hospital, Mosul City. Methodology: The samples purposively collected from the patients who referred for gastrointestinal endoscopies unit in Al-Salam Teaching Hospital in Mosul City for period from (20/1/2013) to (20/3/2013). The study sampled consist of (64) participants, (32) males and (32) females, (28.1%) their ages ranged between (46 – 55) years. The data were arranged for gender, age, locality, and the outcomes of the procedure. Results: Sixty four gastrointestinal procedure were performed. Of those who had positive endoscopic finding s; gastritis (18.8%), duodenitis (12.5%), and esophagitis, gastric ulcer (7.8%).The study also found that highest percentage of the sample were married, primary educational level, housewife, and urban region. Over two third of study patient's habitual status were NSAIDs followed one third of study patients were smoker. Conclusion: The study showed highest percentage endoscopic finding sited in stomach and esophagus. Recommendation: The study recommended availability of endoscopic facilities at all hospitals in country and make it accessible to all population and thus enables earlier diagnosis of digestive tract diseases. Providing comprehensive care for the patient when undergoing endoscopic procedures, which are in the nature of the case more important and technically complex and this care is provided through the training of nurses trained specifically for endoscopy.


INTRODUCTION:
Gastrointestinal (GI) endoscopy has now been part of conventional medical practice for over thirty years following the development of useable flexible fibreoptic endoscopes in the early 1970's (1) .The endoscopy of Gastrointestinal tract is a safe and easily carried out procedure of both high diagnostic and valuable therapeutic benefits with relatively low incidence of morbidity and low cost. (2)The international literature contains some evidence regarding endoscopic diagnosis performed at the primary care levelfor example, in the United States and the United Kingdom, where the majority of procedures were done at the initiative of physicians in the public sector, but not as part of an integrated population-wide program (3,4) .The inappropriate rate is higher in outpatients and in endoscopic units of non-academic hospitals (5,6) .Endoscopic examination is important is evaluating and managing upper and lower gastrointestinal problems.Digestive disorders are extremely common in the general population (7) .Endoscopy uses a tube and a fiber-optic system (endoscope) for observing the inside of a hollow organ or cavity and consent form is signed for any endoscopic procedure (8) .Esophagogastroduodenoscopy (EGD) affords an excellent view of mucosal surfaces of the esophagus, stomach, and proximal duodenum.While colonoscopy allows examination of the entire colon and rectum and frequently the terminal ileum (9) .The goals of high-quality endoscopyreceipt of an appropriately indicated procedure, a correct diagnosis, and appropriate careshould be achieved with minimal risk to the patient and take place in a wellequipped facility staffed by properly trained and competent endoscopists (10) .Standard diagnostic functions include inspection, biopsy, photography, and video recording.Diagnostic observations are made concerning focal benign or malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and extrinsic compression by contiguous structures.Common therapeutic endoscopic procedures include polypectomy, dilation of strictures, stent placement, and removal of foreign bodies, gastrostomy, and treatment of GI bleeding with injection banding, coagulation, sclerotherapy, and endoscopic therapy of intestinal metaplasia (9) .The study aim is to assess the gastrointestinal endoscopy outcomes in Al-Salam Teaching Hospital, Mosul City.

METHODOLOGY
A descriptive study was used to achieve the objectives of the present study for the period of (20/1/2013) to (20/3/2013).A purposive sample consisted of (64) participants, where, (32) males and (32) females with ages ranged between (46 -55) years.The study was carried out in the endoscopic unit at Al -Salam Teaching Hospital, Mosul city.The subject of the study was consisted from the patients with a wide range of complaints, such as epigastric pain, dyspepsia, indigestion, heartburn, vomiting, hematemesis, dysphagia, and swallowed foreign bodies were accepted for gastrointestinal endoscopy.Informed consents were taken from the patients or their sponsors.The endoscopy was performed as an outpatient procedure.Data are prepared, organized and entered into a computer file; statistical package for the social science (SPSS, version 15) is used for data analysis.Data are analyzed through the application of two approaches.This approach is employed through: Frequency distribution and Percentage.This table shows that the study sample percentage of habitual data for smoking, alcoholism and NSAIDs (25%), (1.6%) and (60.9%) respectively.Table 3 shows the percentage of organs to be examined by endoscopic findings.The highest percentage of patients had stomach disorder (43.75%) while (25%) of the patients had esophagus disorders and duodenal disorders (18.75%).This table shows the highest percentage of endoscopic outcome examination in gastritis (18.8%) followed duodenitis (12.5%) and esophagitis, gastric ulcer (7.8%).Table 5 indicates that there is a significant relation between smoking and GIT endoscopy at P < 0.05.Table 6 indicates that there is no significant relation between NSAIDs and GIT endoscopy at P < 0.05.

DISCUSSION:
Mosul is a second large city in Iraq with varying environmental regions and the inhabitants belong to wide ethnic diversities with different cultures and social habits.The population is experiencing rapid modernization and extra stress imposed by desertification, displacement, tribal conflicts and war.In this study males and female were equal (32%).In this study The mean age was (36) year with (28.1%) of the patients being under 60 year; similar or close results were reported from Turkey, Saudi Arabia, and Pakistan where the majority of patients were under (60) year (11,12) .In Western studies the mean age was >60 year and those above (60) year made (50 -70%) of the total (13,14) .Inflammation of the fore gut was the commonest pathology found (39.06%) i.e.gastritis (18.8%), duodenitis (12.5%) and esophagitis (7.8%).The prevalence of other disease (26.6%%) and gastric ulcer (7.8%) may add to this.In a similar society chronic gastritis was found in (25.8%) of cases in Kenya (15) and (36.9%) in Sudan (16) .In a study that included patients from four countries on three continents (Japan, China, Tanzania, and the Dominican Republic), Aoki et al. reported gastritis prevalence rates ranging from (23.5%) to (96.5%) (17) .The prevalence of esophagitis found in our study is quite similar to that reported by Du in China (18) , who found a rate of (20.8%) among ( 2231) patients.This in turn was higher than the (15.8%) also reported in China by Tseng (19) and the (12%) reported by Kim in a major study conducted in South Korea with (25,536) subjects (20) and by Chen in Taiwan (12%) (21) .A Swedish endoscopy study of peptic ulcer (22) in a random sample of (1001) persons from two communities found a relatively low prevalence (4.1%).However, other non-population-level studies involving series of patients spontaneously presenting in hospitals found higher prevalence's: (7%) in Finland (23) , (15%) in the United States (Alaska) (24) , (17.2%) in China (25) and (31.8%) in Poland (26) .Possible underlying causes may be ingestion of hot meals, Helicobacter pylori infection, consumption of alcohol and smoking and non-steroidal antiinflammatory drugs.Risk factors associated with diseases of the gastrointestinal tract in this study generally coincide with those reported by other authors.A selection of published articles on studies in Europe, Asia, and the Americas shows that H. pylori infection is the main predictor of peptic ulcer disease, followed by smoking (25) , although some authors do not consider the latter an independent predictor but rather a synergistic co-factor with H. pylori infection (27) .Other risk factors associated with peptic ulcer found in the literature are: male sex, advanced age (18) , prior history of ulcer, use of aspirin or other NSAIDs (28) and being divorced.Alcohol consumption is reported as a risk factor in some studies (18) and as a protective factor in others.Drugs such as aspirin and other NSAIDs are considered predictors of significant risk for gastric ulcer (25) , but this study was not able to show that association.Without a doubt, H. pylori infection is the main predictor of gastritis (29) , just as hiatal hernia, male sex, smoking, drinking alcohol, and overweight-obesity are for esophagitis (21) .

CONCLUSION:
One quarter of the study sample their age ranging from (46 -55) years.While, height percentage in married status, primary educational level, housewives, and urban residence.Over two third of studies sample taking NSAIDs followed one third of studies patient's smoker.The study showed high percentage of endoscopic finding site in stomach and colon.Highest percentage with outcome endoscopic examination in other disease followed gastritis and duodenitis.

RECOMMENDATION:
1. Availability of endoscopic facilities at all hospitals in country and make it accessible to all population and thus enables earlier diagnosis of digestive tract diseases.2. Expansion of the service with endoscopic, more relevant accessories and training supplement diagnosis and facilitate therapeutic measures.3. Standard guidelines should be utilized to improve or maintain standards of endoscopic services in ensuring cost-benefit and quality assurance.4. Providing comprehensive care for the patient when undergoing endoscopic procedures, which are in the nature of the case more important and technically complex and this care is provided through the training of nurses trained specifically for endoscopy.