title: 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 such as Nepal. The aim of this study was 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 using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 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 >18 y were included in this analysis.
  
  
  RESULTS
  A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%).
  
  
  CONCLUSIONS
  The Nepal health care 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 health care 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 lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.
authors.affiliation: Department of Surgery, University of California San Francisco East Bay, Oakland, California. Electronic address: robert.tessler@gmail.com.
authors.forename: Robert
authors.initials: R
authors.lastname: Tessler
authors.affiliation: Department of Surgery, University of California San Francisco East Bay, Surgeons OverSeas, Oakland, California.
authors.forename: Shailvi
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Kathmandu Medical College, Kathmandu, Nepal.
authors.forename: John
authors.initials: J
authors.lastname: Pathak
authors.affiliation: Department of Critical Care and Emergency Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal.
authors.forename: Pranita
authors.initials: P
authors.lastname: Ghimire
authors.affiliation: Department of Surgery, Memorial Sloan Kettering Cancer Center, Surgeons OverSeas, New York, New York.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Kingham
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Surgeons OverSeas, Baltimore, Maryland.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Kushner
authors.affiliation: Department of Surgical Oncology, Bhaktapur Cancer Hospital, Bhaktapur, Nepal.
authors.forename: Kapendra Shekhar
authors.initials: KS
authors.lastname: Amatya
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Surgeons OverSeas, Columbus, Ohio.
authors.forename: Benedict C
authors.initials: BC
authors.lastname: Nwomeh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003108:Colonic Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D003430:Cross-Sectional Studies; D003906:Developing Countries; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D009390:Nepal / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D015995:Prevalence; D012002:Rectal Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D012007:Rectum
keywords: Access to surgical care; Anorectal disease; Global surgery; Nepal; Rectal bleeding; Southeast Asia; Surgeons OverSeas