Trends in upper gastrointestinal diagnosis over four decades in Lusaka, Zambia: a retrospective analysis of endoscopic findings

Abstract

Background and aims: There a shortage of robust information about profiles of gastrointestinal disease in sub-Saharan Africa. The endoscopy unit of the University Teaching Hospital in Lusaka has been running without interruption since 1977 and this 38-year record is largely intact. We report an analysis of endoscopic findings over this period.

Methods: Written endoscopy records from 29th September 1977 to 16th December 2014 were recovered, computerised, coded by two experienced endoscopists and analysed. Temporal trends were analysed using tables, graphs, and unconditional logistic regression, with age, sex of patient, decade, and endoscopist as independent variables to adjust for inter-observer variation.

Results: Sixteen thousand nine hundred fifty-three records were identified and analysed. Diagnosis of gastric ulcer rose by 22 %, and that of duodenal ulcer fell by 14 % per decade. Endoscopically diagnosed oesophageal cancer increased by 32 % per decade, but gastric cancer rose only in patients under 60 years of age (21 % per decade). Oesophageal varices were the commonest finding in patients presenting with haematemesis, increasing by 14 % per decade in that patient group. Two HIV-related diagnoses, oesophageal candidiasis and Kaposi's sarcoma, rose from almost zero to very high levels in the 1990s but fell substantially after 2005 when anti-retroviral therapy became widely available.

Conclusions: This useful dataset suggests that there are important trends in some endoscopic findings over four decades. These trends are not explained by inter-observer variation. Reasons for the divergent trends in incidence of peptic ulceration and apparent trends in diagnosis of upper gastrointestinal cancers merit further exploration.

Fig. 1

Contributions of individual endoscopists over the period 1977–2014. Only those endoscopists who contributed over 500 procedures are shown, except where they were the only doctors performing endoscopy at that time. The other 23 doctors are not shown, for clarity, but contributed 2656 records to the total. The bars at the bottom indicate the equipment in use over the whole period, beginning with non-immersible endoscopes (a) from 1977 to 1991, then immersible fibre-optic Olympus endoscopes (b) from 1991 to 2003, then fibre-optic Pentax endoscopes with camera viewing system (c) from 2003 to 2010, and lastly Pentax high-definition video endscopes (d) from 2010 to date

Fig. 2

HIV-related disorders over time: oesophageal candidiasis and Kaposi’s sarcoma are shown. The first publication defining the emergence of AIDS in Zambia was published in 1984 [24], and antiretroviral treatment became available at scale through public health facilities in 2005

Fig. 3

Gastric ulcer (GU) and duodenal ulcer (DU) diagnosis as percentage of peptic ulcer diagnoses over time

Fig. 4

Giant oesophageal ulcers of HIV