INTRODUCTION:_____________________________________________________________ Gastrointestinal endoscopy has been attempted for over 200 years, but the introduction of semirigid gastroscopes

in the middle of the twentieth century marked the dawn of the modern endoscopic era. Since then, rapid advances in endoscopic technology have led to dramatic changes in the diagnosis and treatment of many digestive diseases. Innovative endoscopic devices and new endoscopic treatment modalities continue to expand the use of endoscopy in patient care.1

Upper endoscopy, also referred to as esophagogastroduodenoscopy is performed by passing a flexible endoscope through the mouth into the esophagus, stomach, bulb and second part of duodenum. It offers the best method of examining the upper GI mucosa. Flexible endoscopes provide either an optical image (transmitted over fiberoptic bundles) or an electronic video image (generated by a charge-coupled device in the tip of the endoscope). Operator controls permit deflection of the endoscope tip; fiberoptic bundles bring light to the tip of the endoscope; and working channels allow washing, suctioning, and the passage of instruments. Progressive changes in the diameter and stiffness of endoscopes have improved the ease and patient tolerance of endoscopy.1

Endoscopy has emerged in recent years as a prominent diagnostic tool in evaluating and diagnosing various gastrointestinal diseases. History of UGI Endoscopy dates back to 1868 when Kussmaul designed first rigid UGI endoscope, followed by semi flexible endoscope by Rudolf Schindler in 1932 and first flexible fiber optic gastro scope in 1957 by Hirschowirtz. Upper GI endoscopy is done by inserting a flexible scope up to the 2nd part of the duodenum. Due to the many use of Upper GI endoscopy, the number and type of people (patient) who undergoes this procedure is steadily increasing and varied respectively. It was therefore the researchers aim to establish a clinical profile of patients who underwent Upper GI endoscopy in this institution for the year 2009.

Gastrointestinal Endoscopy, Chapter 285, Harrison's Principles of Internal Medicine 17th Edition.

GENERAL OBJECTIVE:_______________________________________________________

To determine the clinical profile of patients who underwent upper gastrointestinal endoscopy both admitted and out-patient in MCU-FDTMF hospital from January 1, 2009 to December 31, 2009.

SPECIFIC OBJECTIVES:______________________________________________________

1. To determine the Age Distribution of patients who underwent upper gastrointestinal endoscopy both admitted and out-patient from January 1, 2009 to December 31, 2009. 2. To determine the Sex Distribution of patients who underwent upper gastrointestinal endoscopy both admitted and out-patient from January 1, 2009 to December 31, 2009. 3. To determine the most common symptoms of patients who underwent upper gastrointestinal endoscopy December 31, 2009 4. To determine the top 3 most common diagnosis of patients who underwent upper gastrointestinal endoscopy both admitted and out-patient from January 1, 2009 to December 31, 2009 5. To determine the prevalence of therapeutic endoscopy procedure in both admitted and out-patient from January 1, 2009 to December 31, 2009 6. To determine the proportion of subjects who underwent upper gastrointestinal endoscopy with and without anesthesia assist in both admitted and out-patient from January 1, 2009 to December 31, 2009 both admitted and out-patient from January 1, 2009 to

SCOPE AND LIMITATION OF THE STUDY:_____________________________________

The study reviewed the chart of patients both admitted and out-patient who underwent upper GI endoscopy from January 1, 2009 to December 31, 2009. The study only included patient aged >18 years old who underwent Upper GI endoscopy for the first time.

SIGNIFICANCE OF THE STUDY:_______________________________________________

This study established the clinical profile of adult patients who underwent upper gastrointestinal endoscopy in both admitted and out-patient January 1, 2009 to December 31, 2009. It aimed to aid the clinician identify patients who might greatly benefit from an upper GI endoscopy. The study determined the top 3 most common diagnosis of patients who underwent upper GI endoscopy thereby developing clinical strategies to prevent such diseases and treat such.

REVIEW OF RELATED LITERATURE:_________________________________________

Endoscopy is one of the most commonly utilized diagnostic procedures in Gastroenterology. Upper Gastrointestinal Endoscopy is done by inserting a flexible scope up to the 2nd part of the duodenum. One of the indications of Upper Gastrointestinal Endoscopy is Upper Gastrointestinal Bleeding.

According to Yusof, the indications for Upper Gastrointestinal Endoscopy are the following: 1. Diagnostic evaluation for symptoms or signs suggestive of upper gastrointestinal disease (e.g. dyspepsia, dysphagia, non-cardiac chest pain, recurrent emesis); 2. Surveillance for

upper gastrointestinal cancer in high risk settings (Barrett esophagus, polyposis syndromes); 3. Biopsy for known or suggested upper gastrointestinal disease (e.g. malabsorption syndromes, neoplasms, infections); 4. Therapeutic intervention (e.g. retrieval of foreign bodies, control of hemorrhage, dilatation or stenting stricture, ablation of neoplasms, gastrostomy placement, others).

The great diagnostic value of performing Upper GI endoscopy cannot be overly emphasized. The number of diseases who maybe accurately diagnosed with Upper GI endoscopy greatly aids a clinician properly manage patients. The study of Canilang 2007, upper GI bleeding secondary to Peptic Ulcer disease was accurately diagnosed using Upper GI endoscopy with most of the patient belonging to the 50-70 year old age group. Several studies have also identified Upper GI endoscopy as an adequate diagnostic tool to diagnose masses involving the upper GI tract.

The demographic profile of the study group indicates that male, 51-70 years of age group constitutes the most number of patients with upper gastrointestinal bleeding. More than one risk factor is identified in the majority of cases. According to Rodrigues MD, out of the 120 patients, most of the patients belonged to an age group of more than 50 years. Layton et. al. identified several risk factors in his study. This includes NSAIDS intake, smoking, stressful events, alcohol intake, and even advance age.

On the study of Barclay et. al., he compared the activity of bleeding in patients treated previously with proton pump inhibitors versus without premedication. He found out that there was less active bleeding on the omeprazole group. Although higher rate of active bleeding without premedications and was noted to be at 33%. This study showed that most of the sites identified were not actively bleeding. This indicates that the site has spontaneously resolved with the normal homeostatic mechanism. Predisposing factors on the activity of bleeding includes previous history of bleeding diathesis and liver disease, of which the clotting factor synthesis is impaired.

On the study of Canilang, he determined that the most common cause of Upper Gastrointestinal Bleeding diagnosed endoscopically in MCU-FDTMF hospital is Peptic ulcer disease belonging to the 51-70 years age group. Most common are males with signs and symptoms of anemia and upper abdominal pain. On Endoscopy, majority of the site identified is not actively bleeding and primarily located on the lower third of the esophagus and antrum. Most commonly utilized treatment is 2-4 weeks regimen with proton pump inhibitors or H2 blockers for peptic ulcer disease and band ligation for variceal bleeding.

RESEARCH DESIGN AND METHODOLOGY:____________________________________

Research Design: This is a descriptive/retrospective study.

The Setting: This study was conducted at MCU-FDTMF Hospital.

Subject Selections: This study involved Medical and endoscopy records from January 1, 2009 to December 31, 2009. Patients who underwent Upper Gastrointestinal Endoscopy were included.

Inclusion Criteria: 1. Patients more than 18 years old who underwent upper GI endoscopy for the first time from January 1, 2009 to December 31, 2009 2. Patients who were admitted and seen as out-patient in the Endoscopy Unit of the Department of Medicine from January 1, 2009 to December 31, 2009.

Exclusion Criteria: 1. All patients who underwent Upper Gastrointestinal endoscopy for the second time. Methodology: Charts and medical records of the included subjects were reviewed and analyzed. The research tool used to investigate was a tally sheet with the following variables: 1. Age 2. Sex 3. Chief Complaint 4. Diagnosis 5. Patient Category 6. Anesthesia Assist 7. Therapeutic Procedure

Data was collected, encoded and tallied in Microsoft Office Excel 2007 per month then summarized the annual data. Descriptive statistics were generated for all variables. For nominal data, frequencies and percentages were computed. And for numerical data, mean SD was generated.

RESULTS AND INTERPRATATION:____________________________________________ Table no.1 Age Distribution of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.
Age Less than 20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 TOTAL In Patient (%) 5 (2.3%) 23 (10.7%) 22 (10.3%) 37 (17.3%) 39 (18.3%) 39 (18.3%) 32 (14.9%) 17 (7.9%) 214 Out patient (%) 7 (2.4%) 43 (14.6%) 54 (18.3%) 57 (19.3%) 71 (24.1%) 31 (10.4%) 25 (8.5%) 7 (2.4%) 295 TOTAL 12 66 76 94 110 70 57 24 509 Percentage 2.4% 13% 15% 18.5% 21.6% 13.8% 11.2% 4.7% 100%

Figure no.1 Age Distribution of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.
30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 20 21-30 31-40 41-50 51-60 61-70 71-80 81-90

In Patient Out Patient

Interpretation: Table no. 1 showed the frequency and percentages of the different age group who underwent Upper gastrointestinal endoscopy in both admitted and out patient. This revealed that among the In-patients, the 51-60 and 61-70 year old age group both underwent the procedure the most. This was followed by the 41- 50 year old and 71-80 year old. While among the Out-

patients, the 51-60 year old age group predominated, followed by 41-50 year old and 31-40 year old bracket. In total, the most frequent age group who underwent the procedure in the year 2009 ranged from 51-60 years old. Figure no. 1 showed a bell-shape trend of patients who underwent the endoscopy. It peaked at the 3rd to 6th decade of life with their younger and older counterparts having the procedure done less.

Table no.2 Sex Distribution of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.
Sex Female Male Total In Patient (%) 90 (42%) 124 (58%) 214 Out patient (%) 167 (57%) 128 (43%) 295 Total 257 252 509 Percentage 50.5% 49.5% 100%

Figure no.2 Sex Distribution of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.

Out Patient

43% 57%

In patient

58% 42%

Male
Interpretation:

Female

Table no. 2 and Figure no. 2 showed the sex distribution of the patients who underwent upper gastrointestinal endoscopy which revealed that admitted male patients (58%) are more frequent than admitted female patients (42%). On the contrary, in the out patient setting females (57%) in are more frequent than the males (43%). In general, patients who underwent the procedure in the year 2009 belong to the female group with 50.5%.

Table no. 3 The most common symptom of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.
Symptoms Epigastric pain Reflux Symptoms UGIB Dysphagia/Foreign Body Sensation Dyspepsia Chest Pain Chemical Ingestion/ Caustic Injury Annual Examination Others TOTAL In Patient 99 22 57 9 15 1 1 9 1 214 Percentage 46.3% 10.3% 26.6% 4.2% 7% 0.5% 0.5% 4.2% 0.5% 100% Out patient 128 65 29 15 43 2 0 10 3 295 Percentage 43.4% 22% 9.8% 5.1% 14.6% 0.7% 0 3.4% 1% 100%

Figure no. 3 The most common symptom of patients who underwent Upper Gastrointestinal Endoscopy as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.

1% 1% 0% 4% 7% 4% 46% 27% 1% 0% 1% 3%

IN PATIENT
Epigastric pain Reflux Symptoms UGIB Dysphagia/Foreign Body Sensation Dyspepsia

Chest Pain OUT PATIENT Chemical Ingestion/ Caustic Injury Epigastric pain Annual Examination Reflux Symptoms Others

15% 10% 5% 10% 43%

UGIB Dysphagia/Foreign Body Sensation Dyspepsia Chest Pain Chemical Ingestion/ Caustic Injury Annual Examination

22%

Others

Interpretation:

Table no.4 Most Common Diagnosis of patients who underwent Upper Gastrointestinal Series as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009. Diagnosis In Patient (%) n=214 Negative Upper GI endoscopy Ulcers H.pylori Infection Reflux Esophagitis Hiatal Hernia Erosions Duodenitis Gastritis Esophageal Varices Portal Hypertensive Gastropathy Malignancy Obstruction/Mass/Polyps Candidal Infection 16 (7.5%) 87 (40.6%) 17 (7.9%) 32 (14.9%) 39 (18.2%) 48 (22.4%) 5(2.3%) 51(23.8%) 23(10.7%) 16 (7.5%) 8 (3.7%) 18 (8.4%) 3 (1.4%) Out patient (%) n=295 3 (1%) 66 (22.4%) 74 (25%) 106 (35.9%) 85 (28.8%) 70 (23.7%) 7 (2.4%) 97 (32.9%) 7 (2.4%) 12 (4.1%) 27 (9.2%) 21 (7.1%) 4 (1.4%) TOTAL n=509 19 153 91 138 124 118 12 148 30 28 35 39 7 3.7% 30.1% 17.9% 27.1% (24.4%) (23.2%) (2.4%) (29.1%) (5.9%) (5.5%) (6.9%) (7.7%) (1.4%) Percentage

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Figure no.4 Most Common Diagnosis of patients who underwent Upper Gastrointestinal Series as In patient and Out patient in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.

Candidal Infection Obstruction/Mass/Polyps Malignancy Portal Hypertensive Gastropathy Esophageal Varices Gastritis Duodenitis Erosions Hiatal Hernia Reflux Esophagitis H.pylori Infection Ulcers Negative Upper GI endoscopy 0 20 40 60 80 100 120

Out Patient In Patient

Interpretation:

Table no.5 Frequency of patients who underwent Upper Gastrointestinal Series as In patient and Out patient with anesthesia assist in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009. Anesthesia Assist With assist Without assist Total In Patient 36 178 214 Percentage 16.8% 83.2% 100% Out patient 9 286 295 Percentage 3% 97% 100%

Figure no.5 Frequency of patients who underwent Upper Gastrointestinal Series as In patient and Out patient with anesthesia assist in MCUFDTMF In Patient Hospital from 17% January 1, 2009 to December 31, 2009.

With assist

83%

Without assist
11

3% Out Patient

With assist Without assist

97%

Interpretation:

Table no.6 Frequency of patients who underwent Upper Gastrointestinal Series as In patient and Out patient with anesthesia assist in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009. Therapeutics With therapeutics Without therapeutics Total In Patient 24 190 214 Percentage 11% 89% 100% Out patient 7 288 295 Percentage 2% 98% 100%

Figure no.6 Frequency of patients who underwent Upper Gastrointestinal Series as In patient and Out patient with anesthesia assist in MCU-FDTMF Hospital from January 1, 2009 to December 31, 2009.

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With therapeutics

Without therapeutics

89%

98%

11% 2%
In Patient Out Patient

Interpretation:

DISCUSSION:_______________________________________________________________ The study showed that 509 patients underwent endoscopy for the year 2009. Where 42% (214) of which were admitted patients and 58% (295) were done on OPD basis. As shown in Table nos. 1 and 2 and Figure nos. 1 and 2, demographic profile of the study group indicates that 51-60 and 61-70 years age group (both 18.3%) constitutes the most number of admitted patients who underwent upper GI endoscopy and 58 % were males. On the other hand, 57% of the patients who underwent Upper GI endoscopy on OPD basis were females wherein the age group of 51- 60 year old predominated. According to Canilang M.D, 51-60 and 61-70 age group ( 22.22 % and 23.23 % respectively) constitutes the most number of patients who underwent Upper GI endoscopy from 2005 to 2007 and 57.88 % were males.

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The study group also showed in Table no. 3 and Figure no.3 that the most symptom/complaint of patients who underwent Upper GI endoscopy was epigastric pain for both admitted and out patients. This result was in concurrence to the study of Legrans M.D, which showed that 52.2% of patients diagnosed of dyspepsia who underwent endoscopy had epigastric pain as their chief complaint. Epigastric pain was closely followed by Upper GI bleeding as the most common sign necessitating Upper GI endoscopy. According to the study of Irfan Ahmed MD, 57.4% of adult patients who underwent upper GI endoscopy had upper GI bleeding as their main complaint. The top 3 most common diagnosis of patients who underwent Upper GI endoscopy in the OPD department were Reflux esophagitis 18.3%, Gastritis 16.7%, hiatal hernia 14.7% as shown in Table no. 4 and Figure no. 4. According to the study of Rezailashkajani et.al, of the 501 Iranian patients who underwent Upper GI endoscopy 50% had reflux esophagitis with 90% of those having grade A. The results were also in concurrence to the study of Boyce et.al, where he stated that reflux esophagitis was the most common form of Gastroesophageal Reflux disease diagnosed. He also stated that the most common symptom associated with Reflux esophagitis was epigastric discomfort/heart burn. This was consistent with the researchers data of epigastric pain as the most common complaint in our study group. Among various studies, Reflux esophagitis was noted to be highly associated with hiatal hernia 63-87%. According to the study of Muszy ski J et.al, frequency of gastritis was found to rise with age, particularly up to the 4th decade of life, being analogical in both sexes. Among those admitted, 24% (87) had a diagnosis of ulcer. Of the 87 patients, 59% (52 patients) were diagnosed to have Antral Ulcers, 24% had duodenal ulcers and 7% had ulcers in the body of the stomach. According to the study of Olokoba et.al, 59% of 40 patients who underwent Upper GI endoscopy were diagnosed to have Pepic Ulcer disease. According to Zhie et.al, the most common site of non-variceal bleeding on their hospital was in the antrum and first part of the duodenum which is in concurrent to the results of this study. The results of the study also showed in Table no 5 and Figure no.5 that 16.8% of the

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admitted who underwent endoscopy required anesthesia assistance in the form of IV sedation administered by an anesthesiologist. While majority of the admitted patients who underwent upper GI endoscopy only required local anesthesia. According to the study of Horiochi et.al and Nelson et.al, selected patients may be able to undergo endoscopic procedures without sedation. Small-diameter endoscopes (less than 6 mm) can improve the tolerability of upper endoscopy when sedation is not used. In general, topical anesthesia is used during unsedated endoscopy. Therapeutic intervention done endoscopically was noted to be low in Table no.6 and Figure no. 6. Among the admitted patients, only 11% had therapeutic intervention of which the most common was sclerotherapy. Only 2% of patients in the OPD category underwent therapeutic intervention.

CONCLUSION:_______________________________________________________________ A total number of 509 patients underwent endoscopy from January 2009-December 2009. Of the 509, 42% (n= 214) were admitted patients while 58% (n= 295) were done in the Out Patient Department. Amongst the admitted, 50.5 % (n=257) were females and 49.5 % (n=252) were males. 49.2% (n= 124) were males, while 65% (n= 167) of the patients who underwent endoscopy in the OPD were females. Age range of the subject is from 16 to 89 years old. The mean age of the study population was 26.75 (mean age) 12.17 (SD) for admitted patients and 36.87 (mean age) 23.5 (SD) for out patients. The top most common symptoms identified among admitted patients who underwent Upper GI endoscopy were epigastric pain 46.3%, Upper GI bleeding 26.6% and reflux symptoms 10.3% respectively. In the OPD setting, epigastric pain still predominated as the most common symptom with 43.4% closely followed by reflux symptoms with 22%. The study revealed that the most common diagnosis of admitted patients who underwent Upper GI endoscopy were Ulcers 24% (Antral 59%, Duodenal 24%, Body 7% ) closely followed

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by Reflux esophagitis with 8.8%. Reflux esophagitis was also discovered to be the most common diagnosis in the OPD setting with 18.3% followed by gastritis with 16.7%. Overall, Reflux Esophagitis predominates with a total incidence of 30% among all patients who underwent upper GI endoscopy. Sedation requiring anesthesia assistance was noted at 8.8% overall. Admitted patients who required sedation was 16.8% while only 3% from the Out patient department required sedation which showed that anesthesia assist is not required for upper GI endoscopy. Since most of the patients can tolerate the procedure well. Therapeutic intervention had an overall prevalence of 6.1%. Among admitted patients 11% underwent therapeutic intervention while only 2% were from the Out patient service

RECOMMENDATION:_________________________________________________________ 1. The researchers recommend a longer duration of study to further establish the clinical profile of patients who underwent upper GI endoscopy. 2. The researchers recommend that comparisons and association among the age group and most common diagnosis be made for the study to be of more use to clinicians. 3. The researchers recommend the use of statistical analysis to compare the clinical profile of the gathered data to identify the significant results which may be used as reference for future researchers. 4. The researchers recommend the use of the gathered data to compare and associate the symptoms of patient who underwent the procedure that had a positive endoscopic finding and negative endoscopic findings.

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