Keywords
endoscopy - gastroenterology -
Helicobacter pylori
- community - outcomes
Introduction
Healthcare expenditure in India is unaffordable for the majority of the patients.[1] Due to an increase in the cost of medical care combined with absence or inadequate
medical insurance coverage, patients cannot afford to be sick.[2] As per the World Health Organization (WHO) in 2016, the out-of-pocket expenses for
health in India is 65% versus 20% across the world. The poor people in India pay more
to avail of hospitalization in public health centers.[3] Patients cannot afford to pay for their medications or are not being reached by
public health facilities.[4] Patients in remote areas do not have access to standard medical care with the issues
related to cost of medical care, transportation, health literacy, lack of healthcare
insurance—all preventing healthcare access in a timely manner. In today's world, traveling
toward the disease and treating it is essential.[5] The healthcare system in India still struggles with rural doctor shortages.[6] Meanwhile, functional gastrointestinal (GI) disorders and liver diseases are increasing
in rural India.[7]
[8] Irregular and unhealthy food habits, bad lifestyle habits, poor sanitation all contribute
to an increase in GI ailments. To overcome the various barriers, and treat these patients,
we conducted medical camps at two community centers utilizing a mobile endoscopic
unit. The impact of new aspects of this modern endoscopy service, its outcomes, and
its challenges are discussed.
Methods
This was a retrospective analysis of prospectively collected data of patients who
presented with predominantly upper GI symptoms at two community health centers from
January 2020 to October 2020. It is an audit of endoscopy findings in a community
set up using a Mobile Endoscopy Unit (MEU). This study was conducted in accordance
with Good Clinical Practice and in a manner to conform with the Helsinki Declaration
of 1975, as revised in 2013 concerning human rights. This study was approved by the
Institutional Ethics Committee (IEC/OA-38/20) and a waiver of informed consent was
obtained.
Mobile Endoscopy Unit
A senior gastroenterologist with the help of a senior endoscopy technician designed
a mobile medical unit by providing innovative solutions to render a bus into a custom-made
endoscopy unit. The doctors within a MEU can obtain clinical history, examine patients
(ergonomically designed examination table), and perform basic diagnostic endoscopic
procedures. MEU has one endoscopic suite that meets standards of care for the operating
room and two consultation rooms. MEU is fully air-conditioned with requisite power
and water on board. It has an in-built generator and can also connect to nearby building
infrastructure for power. It has wheelchair lifts for patients with special needs.
MEU is integrated with all Medical Gas Systems (O2, air, and vacuum), endoscopy equipment storage cabinet, HEPA filtration system, patient
monitors, and pharmacy kart (essential medicines). MEU also has adequate space for
placing soiled linen, a cleaning area (endoscopic reprocessing), and a lavatory. MEU
has adequate light, CCTV, and state-of-the-art equipment integrated for recording
and transmission of video signals. All the facilities make it a safe, modern, reliable,
and efficient endoscopy mobile unit complying with the medical standards.
Health Screening Camps
The Government of Maharashtra helped organize medical camps at two community centers.
Community center 1 (CC1) (January 28 and 29, 2020) included Thane, Maharashtra, while
community center 2 (CC2) (October 30 and 31, 2020) was at Satara, Maharashtra. Patients
in the selected locality were already briefed regarding the free gastroenterology-related
health camp (by advertising in newspapers and other media). The two nearby coordinating
centers were Civil Hospital Thane, and Morarji Gokuldas Rural Hospital, Satara, respectively.
The doctors of the latter hospital ensured that patients at CC2 had undergone RT-PCR
for COVID-19.
All patients had to previously undergo routine laboratory investigations, in addition
to an electrocardiogram. The diagnostic indications for upper gastrointestinal endoscopy
were met. A subset of patients also had dyspeptic alarm symptoms which needed a standard
gastroscopy evaluation. Patients had a detailed clinical examination. Endoscopic procedures
were performed under local anesthesia with the patients in the left lateral position.
The procedures were done by a senior endoscopist with > 30 years of experience and
two senior gastroenterology fellows with adequate endoscopy training. Only diagnostic
endoscopic procedures were performed using the gastroscope (GIF HQ190, Olympus, Japan).
During esophagogastroduodenoscopy (EGD), esophagitis (Los Angeles classification scale),
flap valve length, circumference, and Hills grade were assessed.[9]
[10] Once the diagnosis had been made, doctor-prescribed medicines were provided free
of cost ([Fig. 1]). The presence of any pathological state (gastric malignancy, esophageal varices
needing ligation/chronic liver disease) needing further interventions was referred
to tertiary care government hospitals to enable patients for free treatment. Endoscope
disinfection was done by utilizing both manual and automated methods in the portable
SCOPE BUDDY™ PLUS Endoscope Flushing Aid (SBP-1000, Cantel Medical, Canada) for optimal
cleaning. Endotech Endosauber-fully automatic endowasher was also available at both
the community hospitals for alternate scope cleaning.
Fig. 1 Doctors providing community services in the mobile endoscopy unit.
We included all patients who attended the health camp for analysis. We excluded those
patients who had incomplete details or missing information and symptoms unrelated
to gastrointestinal diseases. Demographics of all patients including those undergoing
endoscopic procedures were entered into MS Excel (Office 2019 Professional for Windows;
Microsoft). The statistical analysis was performed using IBM Statistical Package for
the Social Sciences (SPSS) Statistics for Windows [version 23.0, Professional] (IBM
Corp., Armonk, N.Y., USA). Categorical variables are reported as frequency and percentages.
For continuous variables, descriptive statistics were used.
Results
At the two health camps, 729 individuals visited the MEU. Five patients had incomplete
details, hence were excluded from the final analysis; therefore, 724 patients were
studied. There was male preponderance noted in 424 (58.5%) patients. Their mean (SD)
age was 48.5 (5.2) years. The commonest presenting symptom was heartburn in 377 (52.1%)
patients, followed by abdominal pain in 188 (25.9%) patients ([Table 1]). The median duration of symptoms was 6.5 (range: 2–36) months. A total of 724 consultations
resulted in the need for minimally invasive EGD in 235 (32.4%) patients. It was safely
performed in all the patients without any immediate adverse events. Gastroesophageal
reflux disease (GERD) was seen in 16 (6.8%) patients and laxity of the lower esophageal
sphincter in 17 (7.2%) patients ([Table 2]). An ulceroproliferative growth was seen in the stomach in 3 (1.3%) patients possibly
malignant. Biopsies were taken and sent for histopathological examination to nearby
centers. These patients were asked to follow up at the nearby tertiary care centers
for further treatment. Proton-pump inhibitors (PPI) were the most commonly prescribed
drugs in 692 (95.6%) patients ([Table 3]). Eighteen (7.6%) patients had a positive rapid urease test and received Helicobacter pylori eradication therapy for 14 days (PPI, amoxicillin 1 g and clarithromycin 500 mg each
twice daily). All patients were asked to complete the full course of treatment. Eleven
(4.7%) patients had peptic ulcers, out of which five patients had a history of NSAID
for osteoarthritis. Nine (1.2%) patients had chronic liver disease secondary to alcoholism.
These patients were counseled for abstinence from alcohol and smoking. The patients
with identified ulceroproliferative growth and liver diseases were incidentally identified
in the camps. Patients who had an indication for colonoscopy were given symptomatic
therapy and were referred to the nearby tertiary care center to get a colonoscopy
at the earliest.
Table 1
Demographic characteristics of patients
|
Patient characteristics
|
CC1
|
CC2
|
|
N (%)
|
N (%)
|
|
Total no. of patients, n (%)
|
426 (100)
|
298 (100)
|
|
Mean (SD) years
|
42.4 (6.5)
|
50.1(4.9)
|
|
Male
|
221 (51.9)
|
203 (68.1)
|
|
M:F
|
1.1:1
|
2.1:1
|
|
Diet
|
|
|
|
Mixed
|
101 (23.7)
|
59 (19.8)
|
|
Vegetarian
|
325 (76.3)
|
239 (80.2)
|
|
BMI, mean (SD), kg/m2
|
24.9 (1.1)
|
23.5 (1.8)
|
|
Duration of symptoms, median (range), (months)
|
6 (2–36)
|
7 (2–30)
|
|
Alcohol
|
20 (4.7)
|
12 (4)
|
|
Smoking
|
18 (4.2)
|
11 (3.7)
|
|
Presenting symptoms[*]
|
|
|
|
Heartburn
|
259 (60.8)
|
118 (39.6)
|
|
Bloating
|
115 (26.9)
|
46 (15.4)
|
|
Abdominal pain or discomfort
|
128 (30)
|
60 (20.1)
|
|
Nausea/vomiting
|
25 (5.9)
|
20 (6.7)
|
|
Extra esophageal symptoms
|
5 (1.2)
|
2 (0.7)
|
|
Constipation/defecation disorder
|
54 (12.7)
|
45 (15.1)
|
|
Ascites
|
4 (0.9)
|
2 (0.7)
|
|
Anorexia
|
29 (6.8)
|
15 (5)
|
|
Weight loss
|
15 (3.5)
|
9 (3)
|
* Some patients may have more than one presenting symptom.
Table 2
Endoscopic findings of patients
|
Procedural details
|
CC1[*]
|
CC2[*]
|
|
N (%)
|
N (%)
|
|
Total no. of patients, n (%)
|
137 (100)
|
98(100)
|
|
Endoscopy diagnosis
|
|
|
|
GERD LA A
|
5 (3.6)
|
4 (4.1)
|
|
GERD LA B
|
3 (2.2)
|
2 (2)
|
|
GERD LA C
|
2 (1.4)
|
−
|
|
laxity (LAX) LES
|
11 (8)
|
6 (6.1)
|
|
Hiatus hernia
|
7 (5.1)
|
5 (5.1)
|
|
Esophageal varices
|
3 (2.2)
|
2 (2)
|
|
Gastric ulcers
|
4 (2.9)
|
3 (3.1)
|
|
Duodenal ulcers
|
2 (1.4)
|
2 (2)
|
|
Proliferative growth
|
2 (1.4)
|
1 (1)
|
|
Portal hypertensive gastropathy
|
3 (2.2)
|
2 (2)
|
|
Gastric antral vascular ectasia (GAVE)
|
1 (0.7)
|
−
|
|
rapid urease test (RUT)-positive
|
10 (7.3)
|
8 (8.2)
|
|
Patients referred to government tertiary care centers
|
5 (3.6)
|
4 (4.1)
|
* Some patients may have more than one diagnosis.
Community center 1 (CC1), Community center 2 (CC2).
Table 3
Medications
|
Medications
|
CC1#
N = 426
|
CC2#
N = 298
|
|
Proton-pump inhibitors
|
325 (76.3)
|
224 (75.2)
|
|
Proton pump inhibitors + prokinetics
|
90 (21.1)
|
53 (17.8)
|
|
Digestive enzymes
|
35 (8.2)
|
26 (8.7)
|
|
Helicobacter
pylori eradication therapy (14 days)
|
10 (2.3)
|
8 (2.7)
|
|
Cyproheptadine
|
12 (2.8)
|
6 (2)
|
|
Multivitamins
|
25 (5.9)
|
18 (6)
|
|
Rifaximin
|
10 (2.3)
|
3 (1)
|
|
Drotaverine
|
22 (5.2)
|
12 (4)
|
|
Lactitol monohydrate with ispaghula
|
54 (12.7)
|
45 (15.1)
|
*Some patients may have more than one medication.
Community center 1 (CC1), Community center 2 (CC2).
Discussion
Health care in rural parts of the world needs adequate medical attention. By retrospectively
analyzing patients who visited the two health camps, we studied the usefulness of
MEU in day-to-day gastroenterological needs in rural India. The results highlight
the need for camp-based screening services at regular intervals in the community.
Currently, the program is active across Maharashtra, India. There have been similar
attempts done in gynecology and general medicine in rural India and other parts of
the world.[11]
[12] But super-specialty mobile health camps especially in gastroenterology are explored
to a lesser extent. One such health camp was initially successful when introduced
in early 2012;[13] however, there has been no follow-up of such initiatives.
We found that 43(18.3%) patients had endoscopic evidence of GI ailments. GERD was
seen in 16 (6.8%) patients and laxity of the lower esophageal sphincter in 17 (7.2%)
patients. Some patients were not ready for the endoscopic procedure; hence, it was
not performed and symptomatic treatment was given. The patients were told about lifestyle
modifications viz. to avoid lying down immediately after a meal, minimization or avoidance
of caffeinated drinks, the head end of the bed to be elevated before sleep and to
eat smaller meals. GERD affects the quality of life, contributes to sleep disturbances,
and affects eating habits.[14] These patients are at increased risk of developing esophageal cancer.[15] Hence, there is a need to identify these individuals and treat them accordingly.
An ulceroproliferative growth was seen in the stomach in three (1.3%) patients, which
was possibly malignant. The patients' caretakers were briefed regarding the condition
and were asked to follow up at a nearby center for further treatment. An emergency
medical helpline number of the host institute was provided to them for any urgent
queries. Constipation and bloating were other common problems encountered by patients.
Patients with constipation were given stool softeners and were asked to do regular
physical activities and consume adequate fluids.
The incidence and prevalence of liver disease in India are growing exponentially.
We had 9 (1.2%) patients with chronic liver disease secondary to alcoholism and were
counseled for abstinence. Two patients had moderate ascites and were told to undergo
paracentesis at a nearby hospital. Eleven (4.7%) patients had peptic ulcers, out of
which five patients had a history of NSAID for osteoarthritis. They were told to avoid
over-the-counter analgesic medications and were referred to an orthopedics department
of a nearby hospital.
Transportation is a major barrier to health care access, impacting as little as 3%
to as much as 67% of patients.[16]
[17]
[18] The initial challenges were time management and the availability of limited resources.
Through our analyses in each of these community health camps, we could not put forth
some recommendations related to public health in rural India. However, the majority
of the barriers can be easily dealt with community-based camps utilizing MEU. We presume
the usefulness seen through such camps might bring in policy changes that may help
patients in rural districts. The study does have its limitations. This was a descriptive
study, findings of which are not generalizable outside this environment. Although
not likely, selection bias might be present. But, because it was a cross-sectional
study with a noncomparative design, it may not have influenced any outcomes. We did
not do a follow-up to see if our camp has led to improved health and health behaviors
among these patients. However, such community health camps have helped improve access
to and use of essential medical services.[19]
[20]
To summarize, the gastroenterology ailment-related health camps conducted at two prime
community centers with the use of MEU were found to be very useful in the diagnosis
of GI symptoms. The success of this camp was seen through effective community consultation
and good patient participation. There is a need for more research in low- to middle-income
countries including India to treat rural patients so that the epidemiology of GI ailments
is studied and remains low.
