- Email: [email protected]
Improving the detection rate of microscopic colitis by introducing a colonoscopy quality-assurance programme
Arab Journal of Gastroenterology 11 (2010) 223–226
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Gastroenterology in Arab Countries
Improving the detection rate of microscopic colitis by introducing a colonoscopy quality-assurance programme Ahmed Gado a,⇑, Basel Ebeid b, Aida Metwali c, Anthony Axon d a
Department of Medicine, Bolak Eldakror Hospital, Giza, Egypt Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Banysweef University, Banysweef, Egypt c Department of Public Health, National Research Center, Giza, Egypt d Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom b
a r t i c l e
i n f o
Article history: Received 21 May 2010 Accepted 7 September 2010
a b s t r a c t Background and study aim: Microscopic colitis (MC) is diagnosed when a patient with chronic watery non-bloody diarrhoea (CWND) has an endoscopically normal colon (ENC) but colonic biopsies (CBs) show unique inflammatory changes. A colonoscopy quality-assurance programme (CQAP) was instituted in 2003 in our institution. The aim of this study was to determine the effect of instituting a CQAP on the alertness of the endoscopist in detecting MC in patients with CWND and ENC. Patients and methods: Initial assessment was performed in 2003. A total of 10 patients with CWND had ENC; however, ileoscopy was not performed. CBs were obtained for further investigations in 40% of the patients. MC was diagnosed in 10% of the patients. A quality-improvement process was instituted which required both ileoscopy to be routinely performed and CB to be routinely obtained in all patients with CWND and ENC. A total of 41 patients for the period 2004–2009 were assessed retrospectively. Results: Ileoscopy was performed in 25% of patients in 2004, 57% in 2005, 67% in 2006, 67% in 2007 and 100% of patients in 2008 and 2009. Ileoscopy rates increased significantly (p < 0.001) from 53% of patients in 2004–2006 to 92% in 2007–2009. CBs were obtained in 50% of patients in 2004, 71% in 2005, 83% in 2006 and 100% of patients in 2007, 2008 and 2009. The number of patients in which CBs were obtained increased significantly (p < 0.001) from 71% of patients in 2004–2006 to 100% in 2007–2009. MC was diagnosed in 0% of patients in 2004, 14% in 2005, 33% in 2006, 50% in 2007, 50% in 2008 and 80% of patients in 2009. The frequency of diagnosing MC increased significantly (p < 0.001) from 18% of patients in 2004–2006 to 63% in 2007–2009. Conclusion: The implementation of a quality-assurance and improvement programme enhanced the quality of colonoscopy, increased the alertness of the endoscopist in detecting MC and improved the detection rate of MC. Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Microscopic colitis (MC) is diagnosed when a patient with chronic watery non-bloody diarrhoea (CWND) has an endoscopically normal colon (ENC) but colonic biopsies (CBs) show unique inflammatory changes characteristic of lymphocytic or collagenous colitis [1]. MC can be distributed throughout the colon or limited to the right colon [2]. A study showed that MC was limited to the right colon in 23% of patients [2]. MC is a disease with two subtypes of similar clinical but different histological features: lymphocytic colitis, which is characterised by pronounced colonic mucosal ⇑ Corresponding author. Address: Medical Department and GI Endoscopy Unit, Bolak Eldakror Hospital, Bolak Eldakror, Giza, Egypt. Tel.: +20 2 35837644; +20 2 0106809363 (mobile); fax: +20 2 27383040. E-mail address: [email protected] (A. Gado).
lymphocyte infiltration and collagenous colitis, which is characterised by increased sub-epithelial collagenous band thickness [3]. Although initially thought to be rare, more recent estimates have suggested that the yearly incidence of MC may be around 5.8/ 1,00,000 and the prevalence about 10–15.7/1,00,000 in Europe [4]. The reason for the increased recognition of MC in recent years is likely due to the increased awareness of its existence, and thus gastroenterologists routinely perform biopsy in patients with endoscopically normal-appearing colons. In two studies, published 5 years apart, it was shown that biopsy of normal colonic mucosa increased from 15% in 2000 to 78% in 2005 [5]. Bolak Eldakror Hospital is a secondary-care governmental hospital in Giza, Egypt. The gastrointestinal endoscopy unit was founded in 1999. The average colonoscopy volume is 28 procedures per year. A colonoscopy quality-assurance programme (CQAP) was instituted in 2003 [6–9]. Accordingly, the quality
1687-1979/$ - see front matter Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ajg.2010.09.002
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indicators developed by the American Society of Gastrointestinal Endoscopy and the British Society of Gastroenterology were implemented [10,11]. For easy application, quality indicators were identified for five major groups: patients, procedures, endoscopists, assistant staff and equipment. Process or outcome indicators were used in evaluating and monitoring the quality of endoscopic procedures, for example, quality indicators for patients with chronic diarrhoea are to perform ileoscopy during colonoscopy, to obtain biopsies from the rectum and to obtain CBs in any patient with chronic diarrhoea and ENC. It was reported that ileoscopic biopsy should be done in patients with macroscopically abnormal findings on the terminal ileum, including ulcers, apthous ulcers or erosions, nodular or erythematous mucosa and polypoid lesions [12]. However, all the patients showing clinically significant histopathology had ulcerative lesions macroscopically. Their histopathological findings provided important information for the diagnosis of Crohn’s disease, intestinal tuberculosis and Behcet intestine, and led to specific investigations or management [12]. The present study was undertaken to determine the effect of instituting a quality-assurance programme on the alertness of the endoscopist in detecting MC in patients with CWND and an ENC.
Out of these, 51% were women and 49% were men. Mean age was 41 years (range: 16–70 years). Mean duration of diarrhoea was 21 months (1–144). Fifty-one percent had more than six stools motions per day. In all patients, faeces were clearly loose or liquid.
Patients and methods Patients underwent colonoscopy by a gastroenterologist using a videocolonoscope (Olympus CF-230L/I). Biopsies were examined by two separate pathologists. Initial assessment of colonoscopy practice was performed in 2003. A total of 10 patients with CWND had an ENC in 2003, and ileoscopy was not performed. CBs were obtained for further investigations in 4 patients (40%) and MC was diagnosed in patient single patient. A quality-improvement process was instituted which required ileoscopy to be routinely performed, ileoscopic biopsy to be done with positive macroscopic findings and CBs to be routinely obtained in all patients with CWND and an ENC. Between 2004 and 2009, annual quality-assurance reports were transmitted to an independent experienced endoscopist with a particular interest in quality assurance for comment and advice. A total of 41 patients with chronic (more than 1 month) nonbloody diarrhoea of unexplained aetiology referred from outpatient clinic, medical department and other hospitals for the period 2004– 2009 were assessed retrospectively. All the patients had undergone full colonoscopy with no macroscopic abnormalities: four patients in 2004, seven in 2005, six in 2006, six in 2007, eight in 2008 and 10 patients in 2009. Ileoscopy was attempted in every patient in order to do ileoscopic biopsy if the patient had macroscopically abnormal findings on the terminal ileum. One colonic biopsy was obtained every 10 cm starting from the caecum. The CBs were immediately placed in three separate tubes with 10% formalin: proximal colon (caecum, ascending colon and transverse colon), distal colon (descending colon and sigmoid colon) and rectum. The Ileoscopy rates, the number of patients in which CBs were obtained for further investigation and the frequency of diagnosing MC were assessed over a period of 6 years. Statistical analysis: Data entry, tabulation and analysis were done using Statistical Package for the Social Sciences (SPSS) program for Window version 13. Descriptive data are presented as percentage and chi-square test was performed to detect the differences between two categorical groups.
Fig. 1. A case of lymphocytic colitis showing marked increase of lymphocytes within the lamina. Hx & E stain, 100.
Results A total of 41 patients were included in the study having undergone colonoscopy during 2004–2009 for non-bloody diarrhoea.
Fig. 2. A higher-power view of the previous case of lymphocytic colitis showing the lymphocytes invading the crypts. Hx & E stain, 200.
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A. Gado et al. / Arab Journal of Gastroenterology 11 (2010) 223–226
Laboratory investigation revealed no ova or cysts of parasitic origin in stools, and stools culture yielded no pathogens. All colonoscopies were deemed to be normal. Terminal ileum was intubated in 31
Fig. 3. A case of lymphocytic colitis showing early superficial collagenous deposition. Masson Trichrome stain, 100.
(76%) patients and it was macroscopically normal. CBs were obtained for further investigations in 36 (88%) patients. MC was diagnosed in 18 (44%) patients of whom 16 (89%) were lymphocytic colitis and two (11%) were collagenous colitis (Figs. 1–4). Mild colitis (non-specific colitis) was found in eight (20%) patients and normal histology was found in 10 (24%) patients. Ileoscopy was performed in one (25%) patient in 2004, four (57%) in 2005, four (67%) in 2006, four (67%) in 2007, eight (100%) in 2008 and 10 (100%) patients in 2009 (Fig. 5). Terminal ileum intubation rates increased significantly (p < 0.001) from 53% in 2004–2006 to 92% in 2007–2009 (Table 1). CBs were obtained in two (50%) patients in 2004, five (71%) in 2005, five (83%) in 2006, six (100%) in 2007, eight (100%) in 2008 and 10 (100%) patients in 2009 (Fig. 5). The number of patients in which CBs were obtained for further investigation increased significantly (p < 0.001) from 71% in 2004–2006 to 100% in 2007–2009 (Table 2).
Fig. 5. Terminal ileum intubation, tissue sampling of colon and microscopic colitis detection rates among studied years. Number of patients in which colonic biopsies were obtained for further investigation.
Table 1 The terminal ileum intubation rates among studied years. 2004–2006
2007–2009
Terminal ileum intubated, no. (%) Terminal ileum not intubated, no. (%)
9 (52.94%) 8 (47.06%)
22 (91.67%) 2 (8.33%)
Total
17 (100%)
24 (100%)
v2 = 8.1, P < 0.001, highly significant.
Table 2 The tissue sampling rates among studied years. 2004–2006
2007–2009
Biopsies were obtained, no. of patients (%) Biopsies were not obtained, no. of patients (%)
12 (70.59%) 5 (29.41%)
24 (100%) 0.0 (0.0%)
Total
17 (100%)
24 (100%)
v2 = 8.1, P < 0.001, highly significant.
Table 3 The microscopic colitis detection rates among studied years.
Fig. 4. A high-power view of a case of early collagenous colitis showing a superficial mucosal band of deposited collagen stained blue with Masson Trichrome stain, 200.
2004–2006
2007–2009
Microscopic colitis, no. (%) Other diagnosisa, no. (%)
3 (17.65%) 14 (82.35%)
15 (62.50%) 9 (37.50%)
Total
17 (100%)
24 (100%)
2
v = 8.1, P < 0.001, highly significant. a Normal: 10 (24%); mild colitis: 8 (20%); and no diagnosis because biopsies were not obtained: 5 (12%).
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A. Gado et al. / Arab Journal of Gastroenterology 11 (2010) 223–226
MC was diagnosed in 0 (0.0%) patients in 2004, one (14%) in 2005, two (33%) in 2006, three (50%) in 2007, four (50%) in 2008 and eight (80%) patients in 2009 (Fig. 5). The frequency of diagnosing MC increased significantly (p < 0.001) from 18% in 2004–2006 to 63% in 2007–2009 (Table 3).
The major drawbacks of our study are that the study involved a single centre, had a low volume of patients and that it is a retrospective study. Conflicts of interest The authors declared that there was no conflict of interest.
Discussion Acknowledgements The effectiveness of colonoscopy depends on the technical quality of the procedure [13]. The goal of maintaining and enhancing the quality of services should be addressed by a continuous process of measuring aspects of endoscopic performance [10]. Continuous quality improvement has been recommended by professional societies as a part of every colonoscopy programme [14]. MC, which is characterised by chronic watery diarrhoea with normal radiological and endoscopic appearances, is diagnosed only by histopathological examination [15,16]. All clinicians should have a higher index of suspicion for MC and, therefore, CBs should be obtained in all patients with diarrhoea who have a macroscopically normal colonoscopy [1]. A CQAP was instituted in 2003 in our institution. Ileoscopy was not routinely performed and CBs up until then were obtained for further investigations in only 40% of patients having CWND with an ENC. MC was diagnosed in 10% of patients. The qualityimprovement process required ileoscopy to be routinely performed, ileoscopic biopsy to be done with positive macroscopic findings and CBs to be routinely obtained in all patients with CWND and an ENC. The ileoscopy rate during colonoscopy depends on the experience and skill of endoscopists [12]. In our study terminal, ileum intubation rate was 76%, which is similar to that of other published studies (72–97%) [12]. Terminal ileum intubation rates improved consistently. Our rates increased significantly from 53% in 2004– 2006 to 92% in 2007–2009. Terminal ileum was normal in all patients excluding Crohn’s disease, intestinal tuberculosis and Behcet’s intestine. The alertness of the endoscopist in detecting MC increased. The number of patients in which CBs were obtained for further investigation increased significantly from 71% in 2004–2006 to 100% in 2007–2009. The detection rate of MC improved. The frequency of diagnosing MC increased significantly from 18% in 2004–2006 to 63% in 2007–2009. The implementation of a quality-assurance and improvement programme enhanced the quality of colonoscopy, increased the alertness of the endoscopist in detecting MC and improved the detection rate of MC.
The authors wish to thank Prof. Ali El-Hindawi, Cairo University and Prof. Maha Akl, Theodor Bilharz Research Institute for their contribution in the pathological examination. References [1] Butt SK. How are we in detecting microscopic colitis? Gut 2009;58(Suppl. 1):A92. [2] Thijs WJ, van Baarlen J, Kleibeuker JH, et al. Microscopic colitis: prevalence and distribution throughout the colon in patients with chronic diarrhoea. Neth J Med 2005;63(4):137–40. [3] Erdem L, Yildirim S, Akbayir N, et al. Prevalence of microscopic colitis in patients with diarrhea of unknown etiology in Turkey. World J Gastroenterol 2008;14(27):4319–23. [4] Fernandez Banares F, Salas A, Forne M, et al. Incidence of collagenous and lymphocytic colitis: a 5-year population-based study. Am J Gastroenterol 1999;94(2):418–23. [5] Al Malki A. Diagnosis and management of microscopic colitis. Saudi J Gastroenterol 2006;12(3):142–5. [6] Gado A. Quality assurance in Egypt. World Gastroenterol News (WGN) 2007;12(1):43. [7] Gado A, Ebeid B. Impact of a continuous quality improvement program on infection control of endoscopes. Int J Infect Control 2009;5:i1. [8] Gado A. Quality in endoscopy - is it applicable in developing countries? An Egyptian experience [homepage on the Internet], 2009 Feb.. [9] Gado A, Ebeid B, Axon A. High quality colonoscopy in a low volume unit; is it achievable? Arab J Gastroenterol 2010. doi:10.1016/j.ajg.2010.07.003. [10] Bjorkman DJ, Popp Jr JW. Measuring the quality of endoscopy. Gastrointest Endosc 2006;63(Suppl. 4):S1–2. [11] Quality and safety indicators for endoscopy [homepage on the Internet]. . [12] Jeong SH, Lee KJ, Kim YB, et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008;23(1):51–5. [13] Raymond JM, Tissot B, Dartigues JF, et al. Quality assessment of colonoscopy in usual practice in a French area: Aquitaine. In: Anonymous International society of technology assessment in health care. Meeting; 1993. p. 142. [14] Imperiali G, Minoli G, Meucci GM, et al. Effectiveness of a continuous quality improvement program on colonoscopy practice. Endoscopy 2007;39(4): 314–8. [15] Bohr J, Tysk C, Eriksson S, et al. Collagenous colitis: a retrospective study of clinical presentation and treatment in 163 patients. Gut 1996;39(96):846–51. [16] Pardi DS, Smyrk TC, Tremaine WJ, et al. Microscopic colitis: a review. Am J Gastroenterol 2002;97(4):794–802.
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Gastroenterology in Arab Countries
Improving the detection rate of microscopic colitis by introducing a colonoscopy quality-assurance programme Ahmed Gado a,⇑, Basel Ebeid b, Aida Metwali c, Anthony Axon d a
Department of Medicine, Bolak Eldakror Hospital, Giza, Egypt Department of Tropical Medicine and Infectious Diseases, Faculty of Medicine, Banysweef University, Banysweef, Egypt c Department of Public Health, National Research Center, Giza, Egypt d Department of Gastroenterology, The General Infirmary at Leeds, Leeds, United Kingdom b
a r t i c l e
i n f o
Article history: Received 21 May 2010 Accepted 7 September 2010
a b s t r a c t Background and study aim: Microscopic colitis (MC) is diagnosed when a patient with chronic watery non-bloody diarrhoea (CWND) has an endoscopically normal colon (ENC) but colonic biopsies (CBs) show unique inflammatory changes. A colonoscopy quality-assurance programme (CQAP) was instituted in 2003 in our institution. The aim of this study was to determine the effect of instituting a CQAP on the alertness of the endoscopist in detecting MC in patients with CWND and ENC. Patients and methods: Initial assessment was performed in 2003. A total of 10 patients with CWND had ENC; however, ileoscopy was not performed. CBs were obtained for further investigations in 40% of the patients. MC was diagnosed in 10% of the patients. A quality-improvement process was instituted which required both ileoscopy to be routinely performed and CB to be routinely obtained in all patients with CWND and ENC. A total of 41 patients for the period 2004–2009 were assessed retrospectively. Results: Ileoscopy was performed in 25% of patients in 2004, 57% in 2005, 67% in 2006, 67% in 2007 and 100% of patients in 2008 and 2009. Ileoscopy rates increased significantly (p < 0.001) from 53% of patients in 2004–2006 to 92% in 2007–2009. CBs were obtained in 50% of patients in 2004, 71% in 2005, 83% in 2006 and 100% of patients in 2007, 2008 and 2009. The number of patients in which CBs were obtained increased significantly (p < 0.001) from 71% of patients in 2004–2006 to 100% in 2007–2009. MC was diagnosed in 0% of patients in 2004, 14% in 2005, 33% in 2006, 50% in 2007, 50% in 2008 and 80% of patients in 2009. The frequency of diagnosing MC increased significantly (p < 0.001) from 18% of patients in 2004–2006 to 63% in 2007–2009. Conclusion: The implementation of a quality-assurance and improvement programme enhanced the quality of colonoscopy, increased the alertness of the endoscopist in detecting MC and improved the detection rate of MC. Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Microscopic colitis (MC) is diagnosed when a patient with chronic watery non-bloody diarrhoea (CWND) has an endoscopically normal colon (ENC) but colonic biopsies (CBs) show unique inflammatory changes characteristic of lymphocytic or collagenous colitis [1]. MC can be distributed throughout the colon or limited to the right colon [2]. A study showed that MC was limited to the right colon in 23% of patients [2]. MC is a disease with two subtypes of similar clinical but different histological features: lymphocytic colitis, which is characterised by pronounced colonic mucosal ⇑ Corresponding author. Address: Medical Department and GI Endoscopy Unit, Bolak Eldakror Hospital, Bolak Eldakror, Giza, Egypt. Tel.: +20 2 35837644; +20 2 0106809363 (mobile); fax: +20 2 27383040. E-mail address: [email protected] (A. Gado).
lymphocyte infiltration and collagenous colitis, which is characterised by increased sub-epithelial collagenous band thickness [3]. Although initially thought to be rare, more recent estimates have suggested that the yearly incidence of MC may be around 5.8/ 1,00,000 and the prevalence about 10–15.7/1,00,000 in Europe [4]. The reason for the increased recognition of MC in recent years is likely due to the increased awareness of its existence, and thus gastroenterologists routinely perform biopsy in patients with endoscopically normal-appearing colons. In two studies, published 5 years apart, it was shown that biopsy of normal colonic mucosa increased from 15% in 2000 to 78% in 2005 [5]. Bolak Eldakror Hospital is a secondary-care governmental hospital in Giza, Egypt. The gastrointestinal endoscopy unit was founded in 1999. The average colonoscopy volume is 28 procedures per year. A colonoscopy quality-assurance programme (CQAP) was instituted in 2003 [6–9]. Accordingly, the quality
1687-1979/$ - see front matter Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ajg.2010.09.002
224
A. Gado et al. / Arab Journal of Gastroenterology 11 (2010) 223–226
indicators developed by the American Society of Gastrointestinal Endoscopy and the British Society of Gastroenterology were implemented [10,11]. For easy application, quality indicators were identified for five major groups: patients, procedures, endoscopists, assistant staff and equipment. Process or outcome indicators were used in evaluating and monitoring the quality of endoscopic procedures, for example, quality indicators for patients with chronic diarrhoea are to perform ileoscopy during colonoscopy, to obtain biopsies from the rectum and to obtain CBs in any patient with chronic diarrhoea and ENC. It was reported that ileoscopic biopsy should be done in patients with macroscopically abnormal findings on the terminal ileum, including ulcers, apthous ulcers or erosions, nodular or erythematous mucosa and polypoid lesions [12]. However, all the patients showing clinically significant histopathology had ulcerative lesions macroscopically. Their histopathological findings provided important information for the diagnosis of Crohn’s disease, intestinal tuberculosis and Behcet intestine, and led to specific investigations or management [12]. The present study was undertaken to determine the effect of instituting a quality-assurance programme on the alertness of the endoscopist in detecting MC in patients with CWND and an ENC.
Out of these, 51% were women and 49% were men. Mean age was 41 years (range: 16–70 years). Mean duration of diarrhoea was 21 months (1–144). Fifty-one percent had more than six stools motions per day. In all patients, faeces were clearly loose or liquid.
Patients and methods Patients underwent colonoscopy by a gastroenterologist using a videocolonoscope (Olympus CF-230L/I). Biopsies were examined by two separate pathologists. Initial assessment of colonoscopy practice was performed in 2003. A total of 10 patients with CWND had an ENC in 2003, and ileoscopy was not performed. CBs were obtained for further investigations in 4 patients (40%) and MC was diagnosed in patient single patient. A quality-improvement process was instituted which required ileoscopy to be routinely performed, ileoscopic biopsy to be done with positive macroscopic findings and CBs to be routinely obtained in all patients with CWND and an ENC. Between 2004 and 2009, annual quality-assurance reports were transmitted to an independent experienced endoscopist with a particular interest in quality assurance for comment and advice. A total of 41 patients with chronic (more than 1 month) nonbloody diarrhoea of unexplained aetiology referred from outpatient clinic, medical department and other hospitals for the period 2004– 2009 were assessed retrospectively. All the patients had undergone full colonoscopy with no macroscopic abnormalities: four patients in 2004, seven in 2005, six in 2006, six in 2007, eight in 2008 and 10 patients in 2009. Ileoscopy was attempted in every patient in order to do ileoscopic biopsy if the patient had macroscopically abnormal findings on the terminal ileum. One colonic biopsy was obtained every 10 cm starting from the caecum. The CBs were immediately placed in three separate tubes with 10% formalin: proximal colon (caecum, ascending colon and transverse colon), distal colon (descending colon and sigmoid colon) and rectum. The Ileoscopy rates, the number of patients in which CBs were obtained for further investigation and the frequency of diagnosing MC were assessed over a period of 6 years. Statistical analysis: Data entry, tabulation and analysis were done using Statistical Package for the Social Sciences (SPSS) program for Window version 13. Descriptive data are presented as percentage and chi-square test was performed to detect the differences between two categorical groups.
Fig. 1. A case of lymphocytic colitis showing marked increase of lymphocytes within the lamina. Hx & E stain, 100.
Results A total of 41 patients were included in the study having undergone colonoscopy during 2004–2009 for non-bloody diarrhoea.
Fig. 2. A higher-power view of the previous case of lymphocytic colitis showing the lymphocytes invading the crypts. Hx & E stain, 200.
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Laboratory investigation revealed no ova or cysts of parasitic origin in stools, and stools culture yielded no pathogens. All colonoscopies were deemed to be normal. Terminal ileum was intubated in 31
Fig. 3. A case of lymphocytic colitis showing early superficial collagenous deposition. Masson Trichrome stain, 100.
(76%) patients and it was macroscopically normal. CBs were obtained for further investigations in 36 (88%) patients. MC was diagnosed in 18 (44%) patients of whom 16 (89%) were lymphocytic colitis and two (11%) were collagenous colitis (Figs. 1–4). Mild colitis (non-specific colitis) was found in eight (20%) patients and normal histology was found in 10 (24%) patients. Ileoscopy was performed in one (25%) patient in 2004, four (57%) in 2005, four (67%) in 2006, four (67%) in 2007, eight (100%) in 2008 and 10 (100%) patients in 2009 (Fig. 5). Terminal ileum intubation rates increased significantly (p < 0.001) from 53% in 2004–2006 to 92% in 2007–2009 (Table 1). CBs were obtained in two (50%) patients in 2004, five (71%) in 2005, five (83%) in 2006, six (100%) in 2007, eight (100%) in 2008 and 10 (100%) patients in 2009 (Fig. 5). The number of patients in which CBs were obtained for further investigation increased significantly (p < 0.001) from 71% in 2004–2006 to 100% in 2007–2009 (Table 2).
Fig. 5. Terminal ileum intubation, tissue sampling of colon and microscopic colitis detection rates among studied years. Number of patients in which colonic biopsies were obtained for further investigation.
Table 1 The terminal ileum intubation rates among studied years. 2004–2006
2007–2009
Terminal ileum intubated, no. (%) Terminal ileum not intubated, no. (%)
9 (52.94%) 8 (47.06%)
22 (91.67%) 2 (8.33%)
Total
17 (100%)
24 (100%)
v2 = 8.1, P < 0.001, highly significant.
Table 2 The tissue sampling rates among studied years. 2004–2006
2007–2009
Biopsies were obtained, no. of patients (%) Biopsies were not obtained, no. of patients (%)
12 (70.59%) 5 (29.41%)
24 (100%) 0.0 (0.0%)
Total
17 (100%)
24 (100%)
v2 = 8.1, P < 0.001, highly significant.
Table 3 The microscopic colitis detection rates among studied years.
Fig. 4. A high-power view of a case of early collagenous colitis showing a superficial mucosal band of deposited collagen stained blue with Masson Trichrome stain, 200.
2004–2006
2007–2009
Microscopic colitis, no. (%) Other diagnosisa, no. (%)
3 (17.65%) 14 (82.35%)
15 (62.50%) 9 (37.50%)
Total
17 (100%)
24 (100%)
2
v = 8.1, P < 0.001, highly significant. a Normal: 10 (24%); mild colitis: 8 (20%); and no diagnosis because biopsies were not obtained: 5 (12%).
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MC was diagnosed in 0 (0.0%) patients in 2004, one (14%) in 2005, two (33%) in 2006, three (50%) in 2007, four (50%) in 2008 and eight (80%) patients in 2009 (Fig. 5). The frequency of diagnosing MC increased significantly (p < 0.001) from 18% in 2004–2006 to 63% in 2007–2009 (Table 3).
The major drawbacks of our study are that the study involved a single centre, had a low volume of patients and that it is a retrospective study. Conflicts of interest The authors declared that there was no conflict of interest.
Discussion Acknowledgements The effectiveness of colonoscopy depends on the technical quality of the procedure [13]. The goal of maintaining and enhancing the quality of services should be addressed by a continuous process of measuring aspects of endoscopic performance [10]. Continuous quality improvement has been recommended by professional societies as a part of every colonoscopy programme [14]. MC, which is characterised by chronic watery diarrhoea with normal radiological and endoscopic appearances, is diagnosed only by histopathological examination [15,16]. All clinicians should have a higher index of suspicion for MC and, therefore, CBs should be obtained in all patients with diarrhoea who have a macroscopically normal colonoscopy [1]. A CQAP was instituted in 2003 in our institution. Ileoscopy was not routinely performed and CBs up until then were obtained for further investigations in only 40% of patients having CWND with an ENC. MC was diagnosed in 10% of patients. The qualityimprovement process required ileoscopy to be routinely performed, ileoscopic biopsy to be done with positive macroscopic findings and CBs to be routinely obtained in all patients with CWND and an ENC. The ileoscopy rate during colonoscopy depends on the experience and skill of endoscopists [12]. In our study terminal, ileum intubation rate was 76%, which is similar to that of other published studies (72–97%) [12]. Terminal ileum intubation rates improved consistently. Our rates increased significantly from 53% in 2004– 2006 to 92% in 2007–2009. Terminal ileum was normal in all patients excluding Crohn’s disease, intestinal tuberculosis and Behcet’s intestine. The alertness of the endoscopist in detecting MC increased. The number of patients in which CBs were obtained for further investigation increased significantly from 71% in 2004–2006 to 100% in 2007–2009. The detection rate of MC improved. The frequency of diagnosing MC increased significantly from 18% in 2004–2006 to 63% in 2007–2009. The implementation of a quality-assurance and improvement programme enhanced the quality of colonoscopy, increased the alertness of the endoscopist in detecting MC and improved the detection rate of MC.
The authors wish to thank Prof. Ali El-Hindawi, Cairo University and Prof. Maha Akl, Theodor Bilharz Research Institute for their contribution in the pathological examination. References [1] Butt SK. How are we in detecting microscopic colitis? Gut 2009;58(Suppl. 1):A92. [2] Thijs WJ, van Baarlen J, Kleibeuker JH, et al. Microscopic colitis: prevalence and distribution throughout the colon in patients with chronic diarrhoea. Neth J Med 2005;63(4):137–40. [3] Erdem L, Yildirim S, Akbayir N, et al. Prevalence of microscopic colitis in patients with diarrhea of unknown etiology in Turkey. World J Gastroenterol 2008;14(27):4319–23. [4] Fernandez Banares F, Salas A, Forne M, et al. Incidence of collagenous and lymphocytic colitis: a 5-year population-based study. Am J Gastroenterol 1999;94(2):418–23. [5] Al Malki A. Diagnosis and management of microscopic colitis. Saudi J Gastroenterol 2006;12(3):142–5. [6] Gado A. Quality assurance in Egypt. World Gastroenterol News (WGN) 2007;12(1):43. [7] Gado A, Ebeid B. Impact of a continuous quality improvement program on infection control of endoscopes. Int J Infect Control 2009;5:i1. [8] Gado A. Quality in endoscopy - is it applicable in developing countries? An Egyptian experience [homepage on the Internet], 2009 Feb.