Hemorrhoids/ Colonoscopy Audit

St Paul Colonoscopy Unit

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

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

3. Objective To I dentify common Clinical indications for Colonoscopy To Identify common C olonoscopy findings, and Diagnostic yield To Discuss on the Audit & Commonest finding To Figure out some Challenges To Make recommendations to I mprove C urrent Practice

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

5. Table 1: Demographic Profile of patients NUMBER PERCENTAGE GENDER MALE 31 56.3% FEMALE 24 43.6% AGE GROUPS * < 40 yrs were[ 18] * >= 40 yrs were [37] 0-9 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. Demographic Profile of Patients

7. Table 2: indications for colonoscopy 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. indications for colonoscopy

9. Table 3: COLONOSCOPIC FINDINGS 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% 2 ULCER [RECTAL & CECAL] 2 3.50% 2 IBS 1 1.75% 1 TAENIASIS 1 1.75% 1

10. COLONOSCOPIC FINDINGS 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. COLONOSCOPIC FINDINGS VS SEX

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

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

14. Discussion #1

15. Discussion #2 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. Discussion #2 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. Discussion #2 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 : : 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.

18. Discussion #2

19. Discussion #2

20. Discussion #3 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 RATE PROCTOSCOPY 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. Discussion #4 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 10-19 20-29 3 2 1 30-39 40-49 3 2 1 50-59 7 3 2 60-69 2 70-79 3 1 80-89 1

22. Discussion #4 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. Discussion #4 WHO Country Profile; 2014

24. Discussion #5 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.

25. Discussion #6

26. Discussion #7 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. Discussion 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. HAEMORRHOIDS/Piles 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. HAEMORRHOIDS/Piles 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. HAEMORRHOIDS/Piles Potential Sites 3 o’clock 7 o’clock 11 o’clock

31. HAEMORRHOIDS/Piles Below dentate line Varicosities of veins draining I nferior 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. HAEMORRHOIDS/Piles While no widely used classification system of external hemorrhoids exists, I nternal hemorrhoids are graded according to the degree to which they prolapse from the anal canal:

33. HAEMORRHOIDS/Piles The development of symptomatic hemorrhoids has been associated with Advancing age, D iarrhea , Prolonged sitting , Straining , C hronic constipation , Trauma Lack of Fiber rich diet

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

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

36. HAEMORRHOIDS/Piles

37. HAEMORRHOIDS/Piles Current View of Pathogenesis Shearing forces acting on anus Caudal displacement of anal cushions and mucosal trauma Fragmentation of supporting structures Loss of elasticity of anal cushions Loss of retraction of anal cushions

38. HAEMORRHOIDS/Piles 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. HAEMORRHOIDS/Piles 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??

40. HAEMORRHOIDS/Piles Symptoms Approximately 40 percent of individuals with hemorrhoids are asymptomatic. Symptomatic patients usually seek treatment for H ematochezia , P ain associated with a thrombosed hemorrhoid, P erianal pruritus, or F ecal soilage.

41. HAEMORRHOIDS/Piles 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 A nal S phincter Check for any mass/tenderness Anoscopic Exam/ Anal Manometry if hx of incontinence . Internal Hemorrhoids generally aren’t palpable. Proctoscopy/ Flexible Sigmoidoscopy

42. HAEMORRHOIDS/Piles

43. HAEMORRHOIDS/Piles Treatment Options Conservative dietary and Lifestyle modification Non Operative/Office procedures Operative Hemorrhoidectomy

44. HAEMORRHOIDS/Piles 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”

45. HAEMORRHOIDS/Piles 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%.

46. HAEMORRHOIDS/Piles 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

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

48. HAEMORRHOIDS/Piles

49. HAEMORRHOIDS/Piles

50. HAEMORRHOIDS/Piles

51. HAEMORRHOIDS/Piles 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

52. HAEMORRHOIDS/Piles Operative Hemorrhoidectomy Milligan-Morgan Hemorrhoidectomy [OPEN] Ferguson’s Hemorrhoidectomy [CLOSED]

53. HAEMORRHOIDS/Piles Operative Hemorrhoidectomy Harmonic Scalpel Stapler Hemorrhoidopexy

54. HAEMORRHOIDS/Piles 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

55. Challenges in the month November 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.

56. Recommendations Appropriate instructions for the patients. Appropriate patient screening. Complete D ata 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

57. Appendix Colonoscopy Audit.xlsx Sample Report

58. Appendix