RESULTS

A total of 3287 UGIE's were performed over the 11 year period of the study. Table 1 illustrates some background characteristics of the study population. The mean age of the participants was 45 years (SD=18.4). Around 38.7% of study participants were less than 40 years old, followed by 34.8% of participants who were in the age group 40 to 59 years old. The majority of study participants were Saudi 86.1%, compared to 13.9% who were non-Saudi. Only 5.8% of study subjects reported tobacco use. Male participants constituted 61.1%, of the study participants while those females were 38.9%.

Table 1: Age distribution, nationality and Tobacco use among study participants


According to Table 2, the commonest indications for endoscopy among study participants were UGI bleeding (23.3%), with a significant difference between males and females (p-value =0.000), (29.2%) and (14.3%) respectively. Epigastric pain was the second indication (15.7%) also with a significant difference between male and female patients (p-value=0.000). Acid Peptic Disease (APD) was the third indication for UGIE (14.4%), followed by Dyspepsia (7.5%) and regular follow-up (6.5%). Other causes were Reflux Oesophagitis (5.5%), Dysphagia (4.3%), Abdominal pain (3.8%), Pers. Nausea/Vomiting(3.6%) and Anemia (3.2%).

Table 2: Causes of referral of the studied patients to the upper endoscopy unit according gender


Table 3 presents results on findings of upper GI endoscopy among the studied patients according to gender and age groups. The table suggests that endoscopic diagnoses revealed normal findings in 21.3% of patients. Normal findings for females were (31.0%) significantly higher than for male patients (15.5%), p-value = 0.000. Normal findings also differ significantly according to age groups (p-value =0.000), and show a decreasing trend with increase in patient's age. Table 3 further confirmed that pattern of endoscopic diagnoses shows the persistence of three common diseases; Oesoph Varices (15.2%), Gastritis(14.0%) and Oesophagitis(10%). Oesoph. Varices was significantly higher among males than females, and also significantly different among the three different age groups (p-value =0.0000). Gastritis increases with increase in age but with no significant differences between the different three age groups and gender. Regarding the other findings, Duodenal Ulcer was diagnosed in (9%) of the patients and was significantly higher in males than females. Gastric Ulcer disease was diagnosed in only (3.7%) of the patients.

Click here for Table 3: Findings of upper endoscopy among the studied patients according to gender and age groups

The results of logistic regression analyses for potential risk factors of three common endoscopic findings are shown in Table 4. The analysis revealed that gender, and patient's age was associated with a significantly high risk of Oesoph. Varices (OR=3.43 and 1.95 respectively and P-value< 0.001 for all). The table also suggested that the most important independent predictors of Gastritis were patients' age, smoking status and NSAID use (OR = 1.36, 12.8, 2.786 and 4.284 respectively, p-value< 0.05 for all coefficients). None of the variables mentioned in the table were a significant predictor of Oesophagitis (p-value>0.05 for all).

Click here for Table 4: Logistic Regression Analyses for potential risk factors of common UGI findings among the study patients

DISCUSSION

Gastrointestinal (GI) diseases are sources for substantial morbidity and mortality in developing as well as in developed countries [22]. Gastrointestinal disorders are among the common causes of visiting health care facilities in Saudi Arabia [10-13]. These types of diseases affect patients' quality of life; cause a significant reduction in work productivity and increased economic burden [23&24].

This is the first study that has dealt with UGI E in Gizan region. Previously published work on UGI endoscopy in Gizan investigated Barrett's oesophagus and oesophageal cancer [25]. The present study attempted to study the common indications and findings of upper endoscopy in patients in Gizan patients presenting to King Fahd Central Hospital. A total of 3287 UGI endoscopy were performed over the 11 year period of the study. The results of the study suggested that UGI bleeding was the indication for UGIE in the vast majority of our patients. Such a high proportion has not been reported before by the studies conducted in KSA [26, 27], while a similar trend can be observed from other West African and East African studies [28-29]. From this study, the next most common indication for UGI is Epigastric pain, which is also different from studies conducted in other parts of KSA[26, 27].

The differences in the commonest indication may be due to differences in the terminologies used. Epigastric pain is localized to the region of the upper abdomen. It is a common symptom of gastroesophageal reflux disease (GERD) or heartburn. On the other hand Acid Peptic Disease (APD) was reported as the third indication for undergoing UGIE. APD is a collective term used to include many conditions such as gastro-esophageal reflux disease (GERD), gastritis, gastric ulcer, duodenal ulcer, esophageal ulcer and Zollinger Ellison Syndrome (ZES). Other common reasons for UGIE among our patients were Dyspepsia, Reflux Oesophagitis, dyspepsia GERD symptoms, recurrent vomiting and anemia. Only 1.6% of our patients underwent UGIE for Malignancy. Although Dyspepsia is less encountered in our studies, it accounts for 15-77.5% of indications for UGIE in Saudi Arabia and other studies elsewhere [26, 30-34].

This study documented three common diseases reported by upper endoscopy procedures which are; OesophVarices, Gastritis and Oesophagitis. The results suggest that esophageal disease is common in Jazan region. Other studies in Saudi Arabia indicate the low prevalence of such diseases [12,26]. The finding that the prevalence of esophageal varices in Gizan differs from other parts of Saudi Arabia [26] draws question whether it is linked to schistosomiasis, which may be the underlying cause of esophageal varices in the region, during the study time. Similar prevalence was reported in Sudan in which schistosomiasis is prevalent [35]. Suliman et al, 2010 attributed the increase of esophageal disorders to the changes in life style and nutritional habits in Saudi Arabia[33].

Gastritis is a well known heterogeneous pathological condition that is responsible for the incidence of many gastrointestinal diseases. Literature suggests that the prevalence of gastritis among adults in the Western world is estimated at 62%[36]. In the present study, Gastritis was the commonest pathology reported in our patients with prevalence of 14%, which is similar to other studies in Saudi and other Arabian countries [12,26, 35]. The difference between our results and western countries' prevalence regarding Gastritis may be attributed to life style and alcohol use, which is not prevalent in Saudi Arabia.

In the present study normal endoscopy was reported more commonly in females (31.2%) as compared to males (15.3%) showing that more females suffer from gastrointestinal symptoms in our setup. Although the rate of normal endoscopy is similar to other Saudi studies conducted during the past 20 years [10-12], it calls for more in-depth investigation, when compared to more recent Saudi and regional studies [26&35].

In this article an effort was made to document the reasons for and outcome of upper gastrointestinal endoscopy in Gizan region for the first time. The limitations of this study are that subjects were studied in a single hospital only. In addition, the fact that the study was based on a retrospective study design may not allow for proper causal inferences and study variables were limited to what was available in patients' files.

CONCLUSION

In conclusion the results of the study suggested that UGIE bleeding was the main indication for UGIE in the vast majority of our patients. In addition to that three common diseases; Oesophageal Varices, Gastritis and Oesophagitis were the main findings of the UGIE among the study population. Preventive measures should be adopted to cope with the situation and to prevent complications of esophageal and gastritis diseases among the Jazan population.

Abbreviations:

KSA	Kingdom of Saudi Arabia
UGIE	Upper gastrointestinal endoscopy
GI	Gastrointestinal
EGD	Oesophagogastroduodenoscopy
KFCH	King Fahad Central Hospital
APD	Acid Peptic Disease
Oesoph	Oesophageal
SD	Standard Deviation
HG	Hypertensive gastropathy
GERD	Gastro-esophageal reflux disease
ZES	Zollinger Ellison Syndrome
CI	Confidence Interval
SPSS	Statistical Package for Social Sciences
NSAIDS	Nonsteroidal anti-inflammatory drugs
GE. J.	Gastroesophageal Junction

Acknowledgement:
I would like to thank the nursing and medical staff of the endoscopic unit of the King Fahad Central Hospital, Jazan Region KSA.

REFERENCES

1. Cotton PB, Hawes RH, Barkun A, et al. Excellence in endoscopy: toward practical metrics. GastrointestEndosc 2006; 63:286.
2. Bjorkman DJ, Popp JW Jr. Measuring the quality of endoscopy. GastrointestEndosc 2006; 63:S1.
3. Silvis SE, Nebel O, Rogers G, et al. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976; 235:928.
4. Geraci G, Pisello F, Modica G, et al. Complications of elective esophago-gastro-duodenoscopy (EGDS). Personal experience and literature review]. G Chir 2009; 30:502.
5. Wolfsen HC, Hemminger LL, Achem SR, et al. Complications of endoscopy of the upper gastrointestinal tract: a single-center experience. Mayo ClinProc 2004; 79:1264.
6. American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. GastrointestEndosc 2000; 52: 831-7.
7. Cappell, M. S., &Friedel, D. The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. Medical Clinics of North America, 2002; 86(6), 1165-1216.
8. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. GastrointestEndosc 2012; 76:1087.
9. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. GastrointestEndosc 2006; 63:570.
10. Ayoola EA, Al-Rashed RS, Al-Mofleh IA, Al- Faleh FZ, Laajam M. Diagnostic yield of upper gastrointestinal endoscopy in relation to age and gender: a study of 10112 Saudi patients. Hepatogastroenterology 1996; 43: 409-15.
11. Satti MB, Twum-Danso K, Al-Freihi HM, Ibrahim EM, Al-Gindan Y, Al-Quorain A, et al. Helicobacter pylori-associated upper gastrointestinal disease in Saudi Arabia: a pathologic evaluation of 298 endoscopicbiopsies from 201 consecutive patients. Am J Gastroenterol 1990; 85: 527-34. 13.
12. Al-Quorain A, Satti MB, Al-Hamdan A, Al-Gassab G, Al-Freihi H, Al-Gindan Y. Pattern of upper gastrointestinal disease in the eastern province of Saudi Arabia: endoscopic evaluation of 2982 patients. Trop Geogr Med 1991; 43: 203-8.
13. Al-ShehriAM, Al-Knawy B, Al-Jaber K. Use of a simple questionnaire developed by the American College of gastroenterology to determine prevalence of GERD among a community-based population in Saudi Arabia. Saudi J Gastroenterology 2003; 9: 49.
14. Cooper GS. Indications and contraindications for upper gastrointestinal endoscopy. GastrointestEndoscClin N Am 1994; 4: 439-454
15. Taye M, Kassa E, Mengesha B, Gemechu T, Tsega E Upper gastrointestinal endoscopy: a review of 10,000 cases. Ethiop Med J 2004; 42: 97-107 [PMID: 16895026].
16. Olokoba AB, Olokoba LB, Jimoh AA, Salawu FK, Danburam A, Ehalaiye BF. Upper gastrointestinal tract endoscopy indications in northern Nigeria. J Coll Physicians Surg Pak 2009; 19: 327-328.
17. Tedesco FJ, Endoscopy in the evaluation of patients with upper gastrointestinal symptoms: indications, expectations, and interpretation. J.Clin. Gastro enterol. 1980; 3 (suppl 2): 67-71. 7.
18. Health and public committee, American College of Physicians, Philadelphia, Pennsylvania., Clinical competence in diagnostic OGD. Annals of internal Medicine 1987; 937-939. 8.
19. The working party of the clinical services committee of the British Society of gastro enterology. Provision of GI endoscopy and relevant services for district general hospital, Gut 1991; 32: 95-100.
20. Standards of Practice Committee, Zuckerman MJ, Shen B, et al. Informed consent for GI endoscopy. GastrointestEndosc 2007; 66:213.
21. Plumeri PA. Informed consent for gastrointestinal endoscopy in the '90s and beyond. GastrointestEndosc 1994; 40:379.
22. Peery, A. F., Dellon, E. S., Lund, J., Crockett, S. D., McGowan, C. E., Bulsiewicz, W. J., &Shaheen, N. J. (2012). Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology, 143(5), 1179-1187.?
23. Kaji M, Fujiwara Y, Shiba M, et al. Prevalence of overlaps between GERD, FD and IBS and impact on health-related quality of life. Journal of Gastroenterology and Hepatology 2010; 25(6):1151-1156.
24. Barkun A, Leontiadis G. Systematic Review of the Symptom Burden, Quality of Life Impairment and
Costs Associated with Peptic Ulcer Disease. The American Journal of Medicine 2010; 123(4): 358-366.
25. Gadour, M. O., &Ayoola, E. A. (1998). Barrett's oesophagus and oesophageal cancer in Saudi
Arabia. Tropical gastroenterology: official journal of the Digestive Diseases Foundation, 20(3), 111-115.
26. Al-Romaih, W. R., & Al-Shehri, A. M. (2006). Appropriateness of upper gastrointestinal endoscopy referrals from primary health care. Annals of Saudi medicine, 26(3), 224.?
27. Azzam, N. A., Almadi, M. A., Alamar, H. H., Almalki, L. A., Alrashedi, R. N., Alghamdi, R. S., & Al-hamoudi, W. Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study. World journal of gastroenterology: WJG, 2015; 21(2), 637.
28. Khurram M, Kharr HT, Hassan Z, Umar M, Javed S, Asghar T, et al. A 12years audit of
upper gastrointestinal endoscopic procedures. J Coll Physician Surg Pak 2003 Jun;13(6):321-314.
29. Taye M, Kassa E, Mengesha B, Gemechu T, Tsega. Upper gastrointestinal endoscopy: a review of 10,000 cases. Ethiop Med J.2004;42(2):97-107.
30. Jones RH, Lydeard SE, Hobbs FD, Kenkre JE, Williams EI, Jones SJ, et al. Dyspepsia in England and Scotland. Gut. 1990;31:401-5.
31. Knill-Jones RP. Geographical differences in the prevalence of dyspepsia. Scand J Gastroenterol Suppl.1991;182:17-24.
32. Talley NJ, Silverstein MD, Agreus L, Nyren O, Sonnenberg A, Holtmann G. AGA technical review: Evaluation of dyspepsia. American Gastroenterological Association. Gastroenterology. 1998;114:582-95.
33. Al-Humayed, S. M., Mohamed-Elbagir, A. K., Al-Wabel, A. A., & Argobi, Y. A. The changing pattern of upper gastro-intestinal lesions in southern Saudi Arabia: an endoscopic study. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association, 2010; 16(1), 35.
34. Zagari, R. M., Law, G. R., Fuccio, L., Cennamo, V., Gilthorpe, M. S., Forman, D., & Bazzoli, F. Epidemiology of functional dyspepsia and subgroups in the Italian general population: an endoscopic study. Gastroenterology 2010; ,138(4),
35. Elhadi, A. A., Mirghani, H. O., Merghani, T. H., Mohammed, O. S., & Eltoum, H. A Pattern of Endoscopic Findings of Upper Gastrointestinal Tract in Omdurman Teaching Hospital, Sudan. Sudan Journal of Medical Sciences, 2014; 9(2), 71-74.
36. R. J. L. F. Loffeld, B. Liberov, and P. E. P. Dekkers, "The changing prevalence of upper gastrointestinal endoscopic diagnoses: a single-centre study," The Netherlands Journal of Medicine, vol. 70, no. 5, pp. 222-226, 2012.