Upper gastrointestinal endoscopic findings in chronic kidney disease

Omnia S Shabka; Ghada M Al Ghazaly; Mahmoud F Selim; Khalid M Zaghloul

doi:10.4103/tmj.tmj_7_17

ORIGINAL ARTICLE

Year : 2017 | Volume : 45 | Issue : 2 | Page : 64-67

Upper gastrointestinal endoscopic findings in chronic kidney disease

Omnia S Shabka M.B.B.CH. , Ghada M Al Ghazaly, Mahmoud F Selim, Khalid M Zaghloul
Department of Internal Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission	25-Jan-2017
Date of Acceptance	24-May-2017
Date of Web Publication	13-Oct-2017

Correspondence Address:
Omnia S Shabka
Department of Internal Medicine, Faculty of Medicine, Tanta University, Al-Mamoun Street Al-Mahalla ALkobra, Gharbiya, 31951
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/tmj.tmj_7_17

Abstract

Background
The most common, nonrenal, chronic disorders in patients with end-stage renal disease are gastrointestinal disorders, necessitating the need to understand the accompanying gastrointestinal disorders.
End-stage renal disease includes such as those receiving renal replacement therapy. Some gastrointestinal conditions are due to uremia or due to the effects of renal replacement therapy or underlying disease or medications.
Aim
This study aimed to detect upper endoscopic findings in patients with chronic kidney disease.
Patients and methods
Thirty patients with end-stage renal disease complaining of gastrointestinal manifestation were recruited from the Internal Medicine Department of Tanta University Hospital in the period from October 2014 to March 2015. All patients in this study were subjected to upper gastrointestinal endoscopy after routine laboratory and radiological evaluation.
Results
Most patients had upper gastrointestinal bleeding [24 (80%) patients]. Reflux esophagitis was detected in five (16.7%) patients, esophageal erosion in two (6.7%) patients, esophageal ulcer in three (10%) patients, pyloric ulcer in five (16.7%) patients, antral gastritis in 11 (36.7%) patients, gastric ulcer in seven (23.3%) patients, duodenitis in 13 (43.3%) patients, duodenal ulcer in 11 (36.7%) patients. The duodenum was the most common site of lesion with duodenal lesion detected in 24 (80%) patients.
Conclusion
Gastrointestinal affection is common in patients with chronic kidney disease, with upper gastrointestinal bleeding detected as the most common presenting symptom, duodenum as the most commonly affected site, and duodenitis was the most commonly detected lesion.

Keywords: chronic kidney disease, endoscopic findings, gastrointestinal bleeding

How to cite this article:
Shabka OS, Al Ghazaly GM, Selim MF, Zaghloul KM. Upper gastrointestinal endoscopic findings in chronic kidney disease. Tanta Med J 2017;45:64-7

How to cite this URL:
Shabka OS, Al Ghazaly GM, Selim MF, Zaghloul KM. Upper gastrointestinal endoscopic findings in chronic kidney disease. Tanta Med J [serial online] 2017 [cited 2023 Mar 25];45:64-7. Available from: http://www.tdj.eg.net/text.asp?2017/45/2/64/216691

Introduction

Gastrointestinal (GI) disorders are a common occurrence in the general population and can significantly impair quality of life [1].

Furthermore, GI symptoms are common among patients with end-stage renal disease (ESRD) [2] and occur in 32–85% of patients undergoing dialysis [3].

The prevalence of these disorders is generally similar in predialysis patients, patients on hemodialysis, and patients on peritoneal dialysis, but there is a trend toward increasing symptoms with increasing duration of renal failure [4].

The incidence of GI symptoms can largely be attributed to the underlying conditions, such as increased level of uremic toxin, the effect of dialysis, lifestyle change, or the medications required for treatment [4],[5].

The most common GI symptoms in patients with chronic kidney disease (CKD) include nausea, vomiting, abdominal pain, constipation, and diarrhea. Inflammatory bowel disease (IBS) also has a high prevalence in these patients, ranging from 11 to 33% [2].

The reasons for the high incidence of upper gastrointestinal bleeding (UGIB) among those with ESRD are not known. Furthermore, it is not known if dialysis-specific factors such as heparin exposure during hemodialysis and platelet dysfunction resulting from uremia may also increase the risk of UGIB [6].

Upper GI endoscopy has been used to investigate the etiology and prevalence of such lesions. Although results from studies that have used this technique are conflicting, it seems that the frequency of upper GI lesions in patients with CKD is greater than in the general population [7].

Aim

This study aimed to detect upper endoscopic findings in patients with CKD.

Patients and methods

This retrospective study was carried out on 30 patients with end-stage kidney disease, recruited from the Internal Medicine Department of Tanta University Hospital in the period from October 2014 to March 2015. Patients were subjected to upper GI endoscopy for the evaluation of GI symptoms.

All participants provided informed written consent after full explanation of the benefits and risk and the study was approved by Tanta Faculty of Medicine Ethical Committee.

Inclusion criteria

Patients with CKD on hemodialysis or without hemodialysis were complaining of upper GI symptoms.

Exclusion criteria

Patients with chronic liver disease.

Methods

All participants in this study were subjected to: thorough history taking, full clinical examination, laboratory investigations in the form of kidney function tests (blood urea and serum creatinine and blood urea nitrogen),liver function tests, complete blood count, serum Ca⁺⁺ and PO₄, upper GI endoscopy using endoscope EPK i_5000 (Pentax, Tokyo, Japan).

Statistical analysis

The collected data were organized, tabulated, and statistically analyzed using statistical package for the social sciences software (SPSS, version 13; SPSS Inc., Chicago, Illinois, USA). Significance was adopted at P value less than 0.05 for interpretation of results of tests of significance.

Results

This study was carried out on 30 patients of which 16 (53.3%) of were men, 14 (46.75%) were women, their age ranging from 15 to 84 years with a mean age of 56.93±14.59 years. Twenty-three patients previously underwent dialysis, duration ranged from 0.17 to 13.0 years with a mean of 2.98±3.42 years ([Table 1]).

Table 1 Distribution of the studied cases according to demographic data (n=30)

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Seventy percent of studied cases had no history of previous endoscopy, and 30% of studied cases had a history of previous endoscopy. The associated symptoms were upper GI bleeding in 24 (80%) patients, epigastric pain in four (13.3%) patients, vomiting in one (3.3%) patient, epigastric pain and vomiting in one (3.3%) patient. Regarding endoscopic intervention, 10 (33.3%) patients underwent therapeutic endoscopic intervention, while 20 (66.7%) patients did not undergo therapeutic endoscopic intervention ([Table 2]).

Table 2 Distribution of cases according to symptoms,previous endoscopy and intervention

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Reflux esophagitis was detected in five (16.7%) patients, esophageal erosion in two (6.7%) patients, esophageal ulcer in three (10%) patients, pyloric ulcer in five (16.7%) patients, antral gastritis in 11 (36.7%) patients, gastric ulcer in seven (23.3%) patients, duodenitis in 13 (43.3%) patients, and duodenal ulcer in 11 (36.7%) patients ([Table 3]).

Table 3 Distribution of studied cases according to endoscopic findings

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Discussion

GI system is involved with several presentation conditions, such as uremic gastroenteritis, anorexia, nausea and vomiting, uremic fetor, peptic ulcer, GI bleeding, hepatitis, idiopathic ascites, and peritonitis [8].

The study showed that the main GI symptoms detected in patients studied were upper GI bleeding in 24 (80%) patients, epigastric pain in four (13.3%) patients, vomiting in one (3.3%) patient, and both epigastric pain and vomiting in one (3.3%) patient. This goes hand in hand with Huang et al. [9], who found that hematemesis and melena were detected in 52.9% of the patients studied. On the other hand, Sotoudehmanesh et al. [10] found that the main GI symptom detected was nausea in 12.6% of patients followed by heart burn in 8.7%, while no symptoms were detected in the majority of cases (73.8%). Also Nand et al. [11] showed that the main GI symptom in CKD patients under study was nausea in 96% of cases, followed by vomiting in 80%, with hematemesis detected only in 4% of patients, the difference in presentation of patients in different studies could be explained by the severity of lesions, availability of health services, and early seeking of medical advice from patients.

Upper endoscopic evaluation of patients involved in this study showed the following lesions; reflux esophagitis detected in five (16.7%) patients, esophageal erosions in two (6.7%) patients, esophageal ulcer in three (10%) patients, pyloric ulcer in five (16.7%) patients, antral gastritis in 11 (36.7%) patients, gastric ulcer in seven (23.3%) patients, duodenitis in 13 (43.3%) patients, and duodenal ulcer in 11 (36.7%) patients.

Duodenitis was detected as the most common lesion in this study (43.3%). This was not compatible with Bacci et al. [12] and Nand et al. [11] where duodenitis was detected in 32.8% of cases by Bacci et al. [12], and not detected at all by Nand et al. [11]. In both studies erosive gastritis was detected as the most common lesion. Sotoudehmaneshi et al. [10] detected duodenal erosion as the most common lesion in 32% of studied patients.

Antral gastritis was a common lesion in this study detected in 36.7% of enrolled patients and it comes as the second most commonly detected finding. This goes hand in hand with Bacci et al. [12] (77%), Nand et al. [11] (32%), Kawaguchi et al. [13] (27%), Bang et al. [14] (31%).Duodenal ulcer was also a common lesion in this study detected in 36.7% of patients as well as gastric ulcer (23.3%) and both were shown as the most common cause of GI bleeding in our patients. Huang et al. [9] detected duodenal ulcer and gastric ulcer as the important source of bleeding (22.5 and 37%, respectively). Also it was compatible with the findings of Khedmat et al. [15] and Chacaltana et al. [16], who showed peptic ulcer as a common source of bleeding detected in 16.1 and 24.1% of patients, respectively. On the other hand, as per the results of Sibinović-Raičević et al. [17] peptic ulcer was detected only in 2% of patients. Moriyama et al. [18] detected erosive gastritis as the most common source of GI bleeding detected in 58% of patients.

Important lesions detected in this study show no relation to age, duration of dialysis, or laboratory results with only ulcerative lesions showing male predominance, and this is same as the findings of Sotoudehmaneshi et al. [10], who showed that male patients were 2.24 times more likely to have important lesions; this may be due to the large number of men than women participating in this study, and may also be due to the effect of sex on gastric ulceration as it is more common in men.

Conclusion

GI diseases are common in chronic renal failure, and it is easily documentable with endoscopy. Some findings are more common than others, such as duodenitis, duodenal ulcer, gastritis, gastric and pyloric ulcer, and this indicates the necessity for endoscopic evolution of those patients in order to detect these lesions early and to properly manage them to prevent serious and fatal complications.

Recommendations

Endoscopy on patients with ESRD can help in early detection of commonly occurring GI lesions and proper management for prevention of serious complications.

Acknowledgements

The authors acknowledge all participants for their help during this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Jones R. Primary care research and clinical practice: gastroenterology. Postgrad Med J 2008; 84:454–458.
2.	Cano E, Neil K, Kang Y, Barnabas A, Eastwood B, Nelson R. Gastrointestinal symptoms in patients with end-stage renal disease undergoing treatment by hemodialysis or peritoneal dialysis. Am J Gastroenterol 2007; 102:1990–1997.
3.	Salamon K, Woods J, Paul E, Huggins C. Peritoneal dialysis patients have higher prevalence of gastrointestinal symptoms than hemodialysis patients. J Ren Nutr 2013; 23:114–118.
4.	Strid H, Simrén M, Johansson C, Svedlund J, Samuelsson O, Björnsson S. The prevalence of gastrointestinal symptoms in patients with chronic renal failure is increased and associated with impaired psychological general well-being. Nephrol Dial Transplant 2002; 17:1434–1439.
5.	Dong R, Guo ZY. Gastrointestinal symptoms in patients undergoing peritoneal dialysis: multivariate analysis of correlated factors. World J Gastroenterol 2010; 16:2812–2817.
6.	Daniel L, Adrian M, Bryan R, Stephen L, Donald S, Catherin O. Risk factors for upper gastrointestinal bleeding among ESRD patients. Kidney Int 2003; 64:1455–1461.
7.	Shirazian S, Radhakrishnan J. Gastrointestinal disorders and renal failure exploring the connection. Nat Rev Nephrol 2010; 6:480–492.
8.	Kasper L, Braunwald E, Fauci S, Hauser S, Longo D, Jameson L et al. Harrison principle of internal medicine. 16th ed. New York: McGraw Hill; 2005. pp. 1268–1312.
9.	Huang S, Song M, Kim O, Koh S, Yom S, Chang T et al. Decisive indicator for gastrointestinal workup in patients with non-dialysis chronic kidney disease. Int J Med Sci 2012; 9:634–641.
10.	Sotoudehmanesh R, Asgari A, Ansari R, Nouraie M. Endoscopic findings in end stage renal disease. Digestive Diseases Research Center, Tehran University of Medical Sciences. Endoscopy 2003; 35:502–505.
11.	Nand N, Malhotra P, Bala R. Evaluation of upper gastrointestinal symptoms and effect of different modalities of treatment in patients of chronic kidney disease. J Indian Acad Clin Med 2014; 15:182–187.
12.	Bacci R, Russo T, Carvalho D, Chehter Z, Jordao C, Fonseca L. Endoscopic alterations in a cohort of hemodialysis patients. Int J Gen Med 2014; 7:459–461.
13.	Kawaguchi Y, Tetsuya M, Kawana I, Yasuzaki H, Kokuho T, Toya Y et al. Gastroesophageal reflux disease in chronic renal failure patients, evaluation by endoscopic examination. Tokai J Exp Clin Med 2009; 34:80–83.
14.	Bang SC, Lee SY, Lee HY, Sung H, Park JH, Kim SH et al. Characteristics of nonvariceal upper gastrointestinal hemorrhage in patients with chronic kidney disease. World J Gastroenterol 2013; 43:7719–7725.
15.	Khedmat H, Amini M, Agah H, Lessan-Pazeshki M, Einollahi B, Pourfarziani V et al. Gastro-duodenal lesions and Helicobacter pylori infection in uremic patients and renal transplant recipients. Transplant Proc 2007; 39:1003–1007.
16.	Chacaltana A, Velarde H, Espinoza J. Endoscopic lesions in the upper digestive tract in patients with terminal chronic renal insufficiency. Rev Gastroenterol Peru 2007; 3:246–252.
17.	Sibinović-Raičević S, Nagorni A, Raičević R, Brzački V, Stojanović M. Endoscopic findings in the proximal part of the digestive tract in patients with chronic renal failure. Med Biol 2011; 13:84–89.
18.	Moriyama T, Matsumoto T, Hirakawa K, Ikeda H, Tsuruya K, Hiarkata H, Lida M. Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis. J Gastroenterol 2010; 45:515–522.