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Introduction: Not much is known of the yield of upper gastrointestinal endoscopy
(UGE) in relation to ethnic descent.
Aim: Study findings in UGE in
relation to the ethnicity.
Material & Methods: A prospectively collected dataset was
studied retrospectively. Presence five major endoscopic findings (Hiatal
hernia, peptic ulcer, oesophagitis, malignancy and gastritis) was studied. The
patients were divided in groups: Group 1 patients of Turkish descent, group 2
patients of Arabic descent, group 3 Asian descent, and group 4 patients of
Western descent.
Results: The data set comprised of 38205 consecutive UGE’s. The number of men
undergoing UGE was significantly higher in patients of group 2. Patients in
groups 1 and 2 significantly had more often no macroscopic abnormalities. All
phenotypes of reflux disease were significantly more often seen in patients of
group 4. Signs indicative of gastritis were significantly less often seen in
patients from group 4. Patients belonging to group 2 had significantly less
often peptic ulcer disease. Malignancies were significantly more often
diagnosed in patients in group 4 (group 1: 0.73%, group 2: 0.3%, group 3: 1%,
and group 4:3.1%).
INTRODUCTION
In
daily practice endoscopy of the upper gastro-intestinal (UGE) tract is applied
on a regular basis. Mostly the procedure is done because of upper abdominal
complaints (dyspepsia and reflux complaints). The overall yield of the
procedure is high [1].
It is
well-known that certain diseases or abnormalities occur more often in people of
a specific race or ethnic descent. For instance, sickle cell anemia is much
more often seen in patients of African descent compared with for instance the
Western population. People from African descent do not respond well to therapy
with ACE-inhibitors.
It
already was shown that yield of colonoscopy differs if ethnic descent of the
patient is taken into account [2].
There
are some data in the literature on the yield of UGE in different groups of
patients [3-5]. The ethnic descent of the patient could be of importance in the
beforehand chance of detecting abnormalities during UGE.
A study was done in a large
prospectively collected dataset of UGE’s in order to determine the yield of the
procedure in relation to the ethnic descent.
MATERIAL & METHODS
A
prospectively collected dataset of UGE’s covering more than 25 years was
studies retrospectively. All endoscopies were done in the Zaans Medical Center,
the community hospital of the Zaanstreek region in The Netherlands.
The
procedure was done with Olympus™ (with fiber optic endoscopes in
1992 and 1993, and from 1994-2013 video endoscopes) and Fujinon™ endoscopes
(since 2013).
The
most prevalent endoscopic diagnoses were evaluated. These were: insufficient
cardia closure or hiatal hernia; oesophagitis, nodular and/or erosive
gastritis, peptic ulcer disease; malignancy; and metaplastic epithelium in the
oesophagus (Barrett’s oesophagus).
In the course of time, patients
could undergo more than one
In the
Zaanstreek region the majority of inhabitants is authentic Dutch or of Western
descent. In addition, there are people originating from different countries.
There is a large population of Turkish descent (almost 11% of the total
population). In addition, people from Morocco, but also a smaller number of
refugees from the Middle East live in the Zaanstreek region. Also, people from
Asian descent (mostly Indonesia and Hong Kong) but also from Indian-Suriname
descent form a significant population.
In the
Netherlands the descent or place of birth of every person is registered. These
data are incorporated in the hospital registration system and retrieved if
necessary. In addition, people of a specific ethnicity born in the Netherlands
were identified by their family name.
To the
best of our knowledge the patients could be divided in four groups. Group 1
patients of Turkish descent, group 2 patients originating from Morocco,
Northern Africa and the Middle East (Arabic descent). Group 3 patients of Asian
descent and finally group 4 all patients of Western descent, including Italian
and Spanish people but also patients originating from Central or Eastern
Europe.
RESULTS
The
data set comprised of 38205 consecutive UGE’s. In patients of group 1 3825 procedures
were done in 2575 patients, in group 2 this was 1105 in 852 patients. In group
3, 647 in 504 patients, and finally in group 4, 32889 in 24420 patients.
Table 1
shows the gender in the different groups. The number of men undergoing UGE was
significantly higher in patients of group 2.
Table 2
shows the numbers of UGE’s in which abnormalities were diagnosed and the number
of procedures without macroscopic abnormalities. Patients in groups 1 and 2
significantly had more often no macroscopic abnormalities in oesophagus,
stomach and duodenum.
Table 3
shows the presence of the most prevalent findings in the four groups of
patients. All phenotypes of reflux disease (insufficient closure of the cardia,
hiatal hernia, oesophagitis and Barrett’s) were significantly more often seen
in patients of group 4. Signs indicative of gastritis were significantly less
often seen in patients from group 4, but significantly more often in patients
of groups 1 and 2. Patients belonging to group 2 had significantly less often
peptic ulcer disease.
Malignancies
were significantly more often diagnosed in patients in group 4 (group 1: 0.73%,
group 2: 0.3%, group 3: 1%, and group 4:3.6%) Table 4.
DISCUSSION
Despite
the fact that UGE is applied frequently in many countries as diagnostic and
therapeutic instrument, little is known about the yield in different races or
ethnicities of the patients.
The
present study reports the yield of UGE in relation to ethnicity or descent in a
large cohort of patients. There are several interesting observations.
A
procedure without any macroscopic abnormality was clearly significantly more
often seen in patients of Turkish and Arabic descent. Of course, it can be that
many of these patients had microscopic gastritis. The present study does not
give clues about the prevalence of H.pylori
infection in the different ethnic groups. It was not possible to retrieve
histological data. However, in the literature data on prevalence have been
reported. Mahamid M et al. studied the prevalence of H.pylori infection Jews and Arabs living in Israel [6]. They
detected no differences in outcomes of UGE or in presence of H.pylori. However, differences in H.
pylori genotypes among the ethnic groups occur [7]. H pylori appears to be associated with a reduced severity of reflux
in Indians [5]. Erosive or nodular gastritis is indicative of H.pylori infection [8]. In the present
study nodular and erosive gastritis was significantly less often diagnosed in
patients of Western descent (group 4). The condition was significantly more
often present in patients of Turkish and Arabic descent. Indirectly, this
suggests presence of active H.pylori
infection in these groups.
It is
clear that all phenotypes of reflux disease are significantly more often seen
in patients of Western descent. In an earlier, much smaller, study from the
Zaanstreek region in the Netherlands, it already was shown that reflux disease occurred significantly less
often in immigrants, 24% versus 55.5% (P < 0.0001) [9].
Hewett et al. found Barrett’s oesophagus to be
less prevalent in patients from the Indian subcontinent [4]. On the other hand,
Indians appeared to have a higher prevalence of Barrett’s oesophagus compared
with Chinese (P < 0.05) or Malays (P < 0.01). Hiatus hernia and erosive
esophagitis were both positively associated with Barrett’s metaplasia (P <
0.01) [10]. In the present study patients of Asian descent had the same low
prevalence of reflux disease compared with patients from Turkish or Arabic
descent.
Ulcers were significantly less often present in
patients of Arabic descent. Although it is generally known that peptic ulcer
disease has a high prevalence in cases of H.pylori infection, ulcers were significantly more often
seen in patients of groups 3 and 4. The reason for this is not obvious.
Possibly the use of NSAID’s in the Western population could be a factor.
However, there are differences in presentation of peptic ulcer if Turkish
people are compared with authentic Dutchmen. Turkish patients with peptic ulcer
disease are younger and mostly men. In addition, most of the ulcers in Turkish
patients are associated with H.pylori
infection [11]. There also are differences in the presence of ulcer disease and
reflux oesophagitis in men and women of Turkish descent. Men are significantly
more often H. pylori-positive and
Turkish men suffered more often from reflux oesophagitis (81% vs. 19%, P <
0.0001), hiatus hernia (58% vs. 42%, P < 0.0001) and peptic ulcer disease
(74% vs. 26%, P < 0.0001) [12]. [MOU1]
Malignancy was significantly more often diagnosed
in patients of Western descent. It already was shown that colorectal
malignancies are quite rare in patients of Turkish descent [13].
The same seems to be true for oesophageal and
proximal stomach cancer. Saumoy et al. described differences in race and
ethnicity with respect to non-cardia gastric cancer prevalence within the
United States [14].
A
possible shortcoming of the present study is that age was not calculated for
every patient. On the other hand, this was not possible. All endoscopic diagnoses were cumulated. In a
single patient it could be possible that during the first endoscopy only
erosive gastritis was seen while during a next endoscopy (many years later)
oesophagitis was diagnosed. What age of the patient should then be noted?
Another
point of criticism could be that upper GI-endoscopy is not easily available for
immigrants. This is not the case in the Netherlands. The health system is
accessible for every inhabitant. Medical
insurance is mandatory, even for refugees from the Middle East or other war
zones.
It can be concluded that there are differences in upper gastro-intestinal morbidity patterns if ethnicity is taken into account. It would be interesting to study what the reasons for these differences are. Is it dietary habits, or life style? Prevalence of H.pylori infection is a plausible explanation for differences in erosive of nodular gastritis and even peptic ulcer. Dietary habits and body mass index could be an explanation for the high prevalence of reflux disease in the Western population. It would be interesting to study whether immigrants adapt in their new environment and will develop more reflux. Identification of environmental factors responsible for this difference would be of value.
1. Loffeld
RJ, van der Putten AB (2003) The yield of UGIE: A study of a ten-year period in
the ‘Zaanstreek’. Neth J Med 61: 14-18.
2. Loffeld RJ, Liberov B, Dekkers PEP (2019) Yield of endoscopy of the lower digestive tract in relation to ethnic descent. J Gastrointestinal Oncology 40: 641-644.
3. Jinjuvadia R, Jinjuvadia K, Liangpunsukal S (2013) Racial disparities in gastrointestinal cancer-related mortality in the U.S. population. Dig Dis Sci 58: 236-243.
4. Hewett R, Chhaya V, Chan D, Kang JY, Poullis A (2015) Differences in intestinal metaplasia in Barrett’s esophagus patients in an ethnically diverse south London population. Indian J Gastroenterol 34: 399-403.
5. Rajendra S, Ackroyd R, Robertson IK, Ho JJ, Karim N, et al. (2007) Helicobacter pylori, ethnicity and the gastroesophageal reflux disease spectrum: A study from the East. Helicobacter 12: 177-183.
6. Mahamid M, Mari A, Khoury T, Bragazzi NL, Ghantous M (2019) Endoscopic and histological findings among Israeli populations infected with Helicobacter pylori: Does ethnicity matter? Isr Med Assoc J 5: 339-344.
7. Dabiri H, Maleknejad P, Yamaoka Y, Feizabadi MM, Jafari F, et al. (2009) Distribution of Helicobacter pylori cagA, cagE, oipA and vacA in different major ethnic groups in Teheran, Iran. J Gastroenterol Hepatol 24: 1380-1386.
8. Loffeld RJ (1999) Diagnostic value of endoscopic signs of gastritis: With special emphasis to nodular antritis. Neth J Med 54: 96-100.
9. Loffeld RJ, van der Putten AB (2004) Prevalence of gastroesophageal reflux disease in immigrants living in the Zaanstreek region in the Netherlands. Dis Esophagus 17: 87-90.
10. Rajendra S, Kutty K, Karim N (2004) Ethnic differences in the prevalence of endoscopic esophagitis and Barrett’s esophagus: The long and short of it all. Dig Dis Sci 49: 237-242.
11. Loffeld RJ, van der Putten AB (2001) The occurrence of a duodenal or gastric ulcer in two different populations living in the same region: A cross-sectional endoscopical study in consecutive patients. Neth J Med 59: 209-212.
12. Wegman
AI, Loffeld RJ (2009) Gastroscopy in immigrants of Turkish descent. J
Gastroenterol Hepatol 24: 1187-1190.
14. Saumoy
M, Schneider Y, Shen N, Kahaleh M, Sharaiha RZ (2018) Cost effectiveness of
gastric cancer screening according to race and ethnicity. Gastroenterology 155:
648-660.
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Table 1 -
Table 2
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Table 3
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Table 4
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