Endoscopy indications in patients with chronic kidney diseases: A single-center experience in Libya

Elmukhtar Habas; Mohamed Tabib; Amnna Rayani; Ali Elhrash; Abdel-Naser Elzouki

doi:10.4103/LJMS.LJMS_6_17

ORIGINAL ARTICLE

Year : 2017 | Volume : 1 | Issue : 1 | Page : 9-12

Endoscopy indications in patients with chronic kidney diseases: A single-center experience in Libya

Elmukhtar Habas¹, Mohamed Tabib¹, Amnna Rayani², Ali Elhrash³, Abdel-Naser Elzouki⁴
¹ Department of Medicine, Tripoli Central Hospital, Tripoli University, Tripoli, Libya
² Tripoli Pediatric Hospital, Tripoli University, Tripoli, Libya
³ Zawia Dialysis Center, Zawia, Libya
⁴ Department of Medicine, HMC, Qatar

Date of Web Publication

5-Jun-2017

Correspondence Address:
Elmukhtar Habas
Department of Medicine, Tripoli Central Hospital, Tripoli
Libya

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_6_17

Abstract

Background and Aim: Gastrointestinal (GI) symptoms are common in patients with chronic kidney disease (CKD), and upper GI endoscopy is a diagnostic tool for GI manifestations in this group of patients, but it is not always indicated. The aim of this study was to investigate the necessity of upper GI endoscopy in CKD and end-stage renal disease (ESRD) on regular hemodialysis patients presented to emergency department (ED) with upper GI symptoms. Materials and Methods: Totally 90 CKD patients presented to ED with acute upper GI symptoms to at Tripoli Central Hospital were enrolled in this study. They were 43 females (87.8%) and 47 males (52.2%), age mean (48.9 ± 0.13). They were divided into three groups. Group A: Patients had upper GI endoscopy at presentation and after 3 days. Group B: Patients refused endoscopy at presentation, but they agreed to do it after 3 days of admission. Group C: Patients refused endoscopy at presentation and after 3 days. At ED, patients had clinical assessment, laboratory tests, and abdominal ultrasound before endoscopy. Results: Hematemesis and vomiting were the most common symptoms. Endoscopy findings at presentation in Group A were erosive gastritis in 19 patients (60.3%), erosive esophagitis in 3 patients (10%), superficial esophagitis in 7 patients (23.3%), and duodenal ulcer in 1 patient (3.3%). Repeated endoscopy after 3 days of admission revealed normal mucosal findings in 24 patients (80%) and remarkable improvement of mucosa in the rest of patients. Group B patients (30 patients) had 3 days of proton pump inhibitor therapy at medical ward and/or medical intensive care unit. Endoscopy findings after 3 days of admission revealed normal results in 29 patients (96.7%) and superficial gastritis in 1 patient (3.3%). Conclusion: Urgent endoscopy is not always needed in CKD and ESRD on hemodialysis patients with acute upper GI symptoms who presented to ED. Most of these symptoms can be managed medically, and urgent endoscopy should be deserved to patients with severe GI complications.

Keywords: Chronic kidney disease, end-stage renal disease, endoscopy, gastrointestinal symptoms

How to cite this article:
Habas E, Tabib M, Rayani A, Elhrash A, Elzouki AN. Endoscopy indications in patients with chronic kidney diseases: A single-center experience in Libya. Libyan J Med Sci 2017;1:9-12

How to cite this URL:
Habas E, Tabib M, Rayani A, Elhrash A, Elzouki AN. Endoscopy indications in patients with chronic kidney diseases: A single-center experience in Libya. Libyan J Med Sci [serial online] 2017 [cited 2023 Mar 28];1:9-12. Available from: https://www.ljmsonline.com/text.asp?2017/1/1/9/207559

Introduction

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) cause many organ complications including gastrointestinal (GI) tract (GIT).^{[1],[2],[3],[4]} CKD and ESRD affect whole GIT parts leading to multiple different lesions. GIT lesions in those patients lead occasionally to serious different clinical symptoms. GIT involvement in CKD-ESRD diseases manifests as uremic anorexia, gastroenteritis, nausea, vomiting, uremic fetor, idiopathic ascites, peptic ulcer disease, GIT bleeding, viral hepatitis, and peritonitis.^[5] Most of the presenting symptoms in uremic patients can be related to the underlying pathological processes.^[6] The pathophysiology of the symptoms and the endoscopic findings in CKD-uremic patients are well explored by many previous studies.

Helicobacter pylori is one of the inhabitants in most normal population, but it is mostly not harmful. In CKD patients, immunity is usually suppressed. This impairment of immune system function in CKD patients has led to investigator to postulate that H. pylori has a significant role in increasing risks for both gastritis and peptic ulcer; however, the role of H. pylori infection as a cause of gastric lesions in CKD patients had been unproven.^[7] Furthermore, it has been reported that hyperacidity, hypergastrinemia, H. pylori infection, and mucosal cytoprotection have not major role in uremic gastroduodenal lesions.^[8]

Endoscopy to CKD patients is important to discover and to follow as well to treat different gastroduodenal and colonic illnesses, and prevention of GIT complications that might be contraindications to kidney transplantation in CKD and ESRD patients before renal transplantation.^[9]

Although studies regarding benefits of proton pump inhibitors, antacids, and hemodialysis in CKD patients, GIT presenting symptoms have been conducted, but up to our knowledge, the necessity of upper GIT endoscopy in every CKD-ESRD patient has not been evaluated. Therefore, the present study was planned to assess whether upper GIT endoscopy is needed or not in every CKD-ESRD patient presents with upper GI symptoms to emergency department (ED).

Materials and Methods

Study population and setting

The study population comprises 90 patients with Stage V CKD or ESRD on hemodialysis who were presented with GIT symptoms to the ED and were admitted to the medical wards or intensive care unit (ICU) at Tripoli Central Hospital. All patients were informed of the objective of the study by attending nephrologists. The protocol of this study was conducted in accordance with the Helsinki Declaration.^[10] Patients were divided into three groups according whether endoscopy was conducted or not. Group A: Patients accepted to perform upper GIT endoscopy at presentation and after 3 days of admission. Group B: Patients refused to have upper GIT endoscopy at presentation but agreed to do it after 3 days of admission. Group C: Patients refused to do upper GIT endoscopy at presentation and after 3 days of admission.

Clinical assessment and other variables

Each patient was examined at presentation and daily clinical followed up till they were discharged. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MBP), and pulse rate were recorded since admission at closed and regular interval. MBP was calculated by MBP = DBP + 1/3 (SBP − DBP). Other clinical variables of each patient on the day of the endoscopy were verified from the medical records. The variables included age, gender, and GI symptoms at presentation. Complete blood count, kidney function tests, liver function tests, prothrombin time/international normalized ratio, chest X-ray, and abdominal ultrasound were carried out before upper endoscopy performed. Uremic patients who had symptoms and/or signs of encephalopathy such as seizures, muscular irritability, or altered level of consciousness did not perform upper GIT endoscopy and were excluded from the study.

Endoscopic examination

Upper GIT endoscopy was conducted using a forward-viewing endoscope (Olympus, Tokyo, Japan) after insertion of an intravenous cannula for injection buscopan and diazepam or propofol infusion, when required. The mucosal lesions were classified according to the “minimal standard terminology” established by the World Organization of Digestive Endoscopy (OMED).^[11] After an overnight fast, patients were prepared by topical anesthesia with 8% lidocaine solution sprayed in the mouth cavity and then swallowed by the patient to anesthetize the pharynx and esophagus. After insertion of an intravenous cannula, injections of buscopan and diazepam or propofol infusion were given when required. Under endoscopy, the patients were assessed for the presence and the location of reflux esophagitis, gastric ulcer, gastric erosion, duodenal ulcer, duodenal erosion, cancer, and other types of lesions. Reflux esophagitis was diagnosed when at least one or more areas of reddish mucosa or mucosal defects were seen at the esophagocardial junction.^[12] Consequently, esophagitis greater than grade M in modified Los Angeles classification for reflux esophagitis was regarded to be a positive clinical sign of reflux esophagitis.^[13] An ulcer was defined as an area of mucosal break with obvious whitish exudates that was >5 mm at its largest measurement point.^[14] The size of each ulcer was determined relative to biopsy forceps. Ulcers clearly larger than the size of the opened forceps were regarded to be >5 mm in size. Other mucosal breaks with reddened areas in the stomach or in the duodenum were judged to be erosions. In principal, biopsy specimens were not obtained from the mucosal lesions, with the exception of lesions suspected of being malignant tumor.

Statistical analysis

All data were arranged in Excel sheet of Microsoft office Version 13. Data analysis was done using Statistical Package for the Social and Science, version 19 (SPSS Inc., Chicago III, USA) for window. Paired t-test analysis was used and P< 0.05 was considered statistically significant.

Results

The cohort comprises 90 patients with CKD; they were 43 females (87.8%) and 47 males (52.2%). Their mean age ± standard error of mean (SEM) was 48.9 ± 1.40 years (range, 23–74). Hematemesis with or without melena was the most common presenting GI symptom that necessitates hospital admission. The presenting clinical features of the patients are shown in [Table 1]. The mean ± SEM of hemoglobin level at presentation was 8.3 ± 0.13 while at discharge, it was 10.3 ± 0.1 g/dl with P= 0.002. The mean ± SEM of pulse rate, SBP, DBP, and MBP was not different significantly. The mean blood pressure readings at presentation were: SBP 122 ± 2.1 mmHg (range, 90–160), DBP 77 ± 1.1 mmHg (range, 60–100), and MBP 92 ± 1.3 mmHg (range, 70–120), and mean pulse rate was 94 ± 1.5 beat/min (range, 70–120).

Table 1: Presenting clinical features of the 90 patients with chronic kidney disease or end.stage renal disease at presentation

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Group A consisted of thirty patients. They were 14 males (46.7%) and 16 females (53.3%) with mean ± SEM age of 51.3 ± 2.3 years (range, 23–73). They had upper GIT endoscopy twice. Their mean hemoglobin level at presentation was 8.2 ± 0.2 g/dl (range, 6–12), mean blood pressure readings at presentation were: SBP 99 ± 1.4 (range, 90–110 mmHg), DBP 69 ± 1.0 (range, 60–80 mmHg), and MBP 79 ± 1.0 (range, 70–90 mmHg), and mean pulse rate was 109 ± 1.0 beat/min (range, 100–120). Endoscopy findings at presentation were erosive gastritis in 19 patients (60.3%), erosive esophagitis (Grade II–III) in 3 patients (10%), superficial esophagitis (Grade I) in 7 patients (23.3%), and duodenal ulcer in 1 patient (3.3%). Repeated endoscopy after 3 days of admission revealed normal mucosal findings in 24 patients (80%) and remarkable improvement of mucosa in the rest of patients.

Group B patients (thirty patients) refused endoscopy at presentation, but they agreed to perform endoscopy after 3 days of proton pump inhibitor therapy at the medical ward and/or medical ICU. They were 14 males (46.7%) and 16 females (53.3%) with mean age of 46.4 ± 2.3 years (range, 27–74). They were anemic with mean hemoglobin of 7.7 ± 0.19 g/dl (range, 6–9.5), mean SBP was 129 ± 1.8 mmHg (range, 115–150), DBP was 77 ± 1.6 mmHg (range, 60–90), MBP was 94 ± 1.5 mmHg (range, 78–110), and pulse rate was 85 ± 1.6 mmHg (range, 80–98). Endoscopy findings after 3 days of admission revealed normal endoscopic finding in 29 patients (96.7%) and superficial gastritis in 1 patient (3.3%).

The third group (Group C) of patients included 30 patients who refused to perform endoscopy at presentation and also after 3 days of hospital admission. They had equal gender distribution with mean age of 49 ± 2.3 years (range, 26–71). Their mean hemoglobin level at presentation was 8.4 ± 0.2 g/dl (range, 6.4–11.5), SBP was 139 ± 2.4 mmHg (range, 120–160), DBP 85 ± 1.5 mmHg (range, 72–100), MBP 103 ± 1.7 mmHg (range, 88–120), and pulse rate was 72 ± 1.5 beat/min (range, 70–98).

Discussion

GIT complications in CKD and ESRD on hemodialysis patients have multifactorial causes and most if not all these complications are improved after starting dialysis. Even the nature of GIT CKD-ESRD-related complications as well as their distribution is altered significantly with intensive hemodialysis.^[15] In this study, hematemesis and vomiting were the most common complaints at presentation followed by melena and epigastric pain. This was reported by other previous studies and was associated with progressive stage of CKD (i.e., Stage IV and Stage V).^[16],[17]

Antral gastritis, pangastritis, and duodenitis were the most common endoscopic findings reported by Bansal et al.^[18] Our study results revealed that superficial gastritis and gastric erosions were most frequent endoscopic findings in Group A at presentation and were mostly improved with 3-day therapy of proton pump inhibitors (as reported in Group A and Group B). These findings are in agreement with other studies in CKD patients complained of dyspepsia or presented with other upper GIT symptoms as vomiting or epigastric pain.^[19]

Our results showed improvement of patients' presenting complaints after 3 days of symptomatic treatment with proton pump inhibitors, antacids and antiemetic drugs, and hemodialysis. Hemoglobin levels and endoscopic findings in Group A were also improved with same therapy as gastric erosions healed and no abnormal findings reported in 80% of patients in this group. More than 80% of patients in Group B had normal endoscopic findings in esophagus, stomach, duodenum, and jejunum after 3 days of medical therapy. This is may suggest that medical therapy with proton pump inhibitors combined with antacids and antiemetic as well as hemodialysis is helping in controlling most of upper GIT symptoms and endoscopic lesions at the proximal GIT in patients with CKD-ESRD. Patients in Group C declined the endoscopy but have also received proton pump inhibitors and other supportive treatment in addition to hemodialysis like the other two groups, and their symptoms and clinical findings improved dramatically.

The clinical findings in the three groups at presentation did not show significant difference. Hemoglobin improved in the three groups, without statistical significant difference between the groups. This could be explained by the different time of presentations or some patients had overhydration or hematemesis.

Gastritis, duodenitis, and esophagitis are common endoscopic lesions in CKD and ESRD patients. Upper GIT endoscopy in CKD-ESRD patients presented with vomiting, mild hematemesis, and nonmassive melena is not usually indicated while the present study and most of previous studies' findings reported that endoscopy findings and symptoms improve with medical treatment and hemodialysis in most of CKD-ESRD patients.

Conclusion

Urgent upper GIT endoscopy is not always necessary to be conducted in every CKD and ESRD on hemodialysis unless patients have severe symptoms or highly suggestive aggressive lesion that cause massive hematemesis and/or melena or severe anemia and/or shock.

Acknowledgment

Authors would like to acknowledge the help of the doctors and nurses in Medical Department, Tripoli Central Hospital, for their patience, support, and help to complete this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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