Rectal bleeding and implications for surgical care in Nepal

Abstract

Background Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world’s population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries (LIC) such as Nepal. The aim of this study is to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. Methods A countrywide survey utilizing the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool was administered from May 25th to June 12th 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding, and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged over 18 were included in this analysis. Results A total of 1350 households and 2,695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1,941 individuals 18 years and older stated they had experienced rectal bleeding (2.0%, 95% CI 1.4% to 2.7%), with a mean age of 45.5 (SD 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Healthcare was sought in 18 participants with current rectal bleeding, with 2 major procedures performed, one an operation for an anal fistula. For those who sought healthcare but did not receive surgical care, reasons included no need (4), not available (6), fear/no trust (5) and no money for healthcare (1). For those with current rectal bleeding who did not seek healthcare, reasons included no need (1), not available (2), fear/no trust (6) and no money for healthcare (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% CI 0.8% to 1.8%). Conclusion The Nepal healthcare system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a healthcare professional, and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in LIC is crucial to avoid emergency surgeries, advanced stage malignancies or fatalities from treatable conditions.

Directions for surgical capacity developments in Nepal: a population‐based assessment

“…A large populationbased survey was conducted in 2014 inventorising basic demographic properties and perceived unmet needs and disabilities of the populations of Nepal, Rwanda and Sierra Leone. Various cross-sections based on this data set were described and published before [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31], mainly focusing on Nepal. The aim was to evaluate the unmet surgical needs and perceived disabilities of the people of Nepal.…”