Carcinoma of the Large Bowel: The disease as seen at the Kenyatta National Hospital over A 5 - Year Period 1969- 1973

Abstract

Carcinoma of the large bowel is uncommon in East Africa. Infective intestinal pathology is common , The symptoms of large bowel cancer often simulate those of infective intestinal disease. When opportunity to undertake this study occurred, therefore, it was predicted that when cancer of colon and rectum does occur, there is a "doctor's" delay in the diagnosis. It was undertaken therefore: (i) To establish whether such a delay, in fact occurs,and if so to suggest means whereby it might be reduced. (ii) To correlate such a delay in diagnosis to operability of tumour at the time of diagnosis. (iii) To study the acceptability of a permanent colostomy if and when opportunity arose. 49 patients with carcinoma of colon and rectum were treated at the Kenyatta National Hospital between 1969 and 1973. Of these 31 were male and 18 female. The youngest was 16 and the oldest about 75 years old. Their average age was about 45 years , The average age of patients with carcinoma of colon and rectum in Europe and North America is about 65 years. There is thus a shift to the left in this study. The duration of symptoms at the time of diagnosis was approximately three times that reported from North America and Western Europe. The tumours were resectable in only 38.8 per cent of the patients. This compares unfavourably with a resectability rate of 94.2 per cent reported from the United States of America (Frankliri, et al. 1968). It is suggested that the delay in diagnosis was, at least in part , responsible for the poorer prognosis of patients treated at the Kenyatta National Hospital. Indeed, the delay in diagnosis at the Vanderbilt Hospital in 1925 was comparable to that found at the Kenyatta National Hospital today. The duration of symptoms at the former Hospital fell from 11.5 months in 1925 to 5.5. months in 1968. The resctability rate improved from 50 percent to 94.2 percent in the same period (MacSwain et al , 1962, Franklin, et a1. 1968). The need for adequate evaluation of large bowel symptoms in this community is emphasized. Abdominal pain or discomfort, diarrhoea, blood in the stool and consti.pation are the commonest presenting symptoms. The 'Classical' symptom of morning diarrhoea wa s absent in this study. Weight loss, though frequently evident on clinical examination, is often not complained of Carcinoma of the rectum tends to be diagnosed earlier than that of the colon. Patients who present with acute intestinal obstruction give a shorter history of symptoms than other patients although this does not correlate with the curability of the disease. Indeed, the curability rate in the patients who presented with intestinal obstruction was lower than that of the rest of the group. Factors which may contribute to this are discussed. That most cancers of the large bowel can be diagnosed by simple investigative procedures - abdominal palpation, digital rectal examination and proctosigmoidoscopy - is clearly brought out in this study. Ten patients in this series were offered and accepted a permanent colostomy,5 as a palliative measure and 5 following a curative procedure. One patient refused a colostomy. The problems to be overcome by a patient with a permanent colostomy in this community are briefly discussed. The acceptability of an artificial anus appears to be related to the social environment, the education of the individual patient and the availability of appliances. In an environment of poverty, poor lay education, poor toilet facilities and great distances from urban centres the rehabilitation of a patient with a permanent colostomy is especially difficult. So that as a palliative procedure, it should be limited to those with complete obstruction in whom resection of tumour with end-to-end anastomosis or a by-pass procedure with rev establishment; of bowel continuity is impossible. Even in the presence of metastases and obstruction, extirpation of the tumour provides greater comfort to the patient.