and Clinical Findings of Colorectal Iran.

Aims & objective: To determine the age and gender distribution and clinical presentation of patients together with histological types of colorectal cancer cases presented to Ibn Sina specialized hospital. Patients and methods: This retrospective study was conducted in Ibn Sina Hospital (Sudan). Seventy three (73) patients of colorectal cancer who presented in the period from January 2010 to December 2012 were included. Data were collected from their hospital records and analyzed using SPSS computer program 17. Results: More than 17 % of the study populations was below the age of 40 years, and 43.84% was below 50 years. The male to female ratio was 1:1.02. Rectal bleeding is the commonest presenting symptom and well differentiated adenocarcinoma is the dominating tumor grade. 8.3 % of patients presented with liver metastasis. Conclusion: Colorectal cancer in this study was found more in young age groups with a peak frequency at the fifth and sixth decades.


Introduction
Colorectal cancer (CRC) ranked as the 4th most common cancer in males and the 2nd for females 1 . The estimated number of cases diagnosed worldwide in the year 2000 was 944,717 with 64.6% in more developed countries 2 . Hereditary factors increase the risk of development of colorectal cancer; people with positive family history in the first degree relatives have two to three folds increased risk than the general population 3 . Screening for CRC can reduce mortality 4 . Colorectal cancer presents usually with rectal bleeding, tenesmus is a common presenting symptom of low rectal cancer 5 . The preoperative evaluation is critically important to treat the cancer optimally and achieve sphincter preservation. With this information, surgeons must individualize the treatment and care of each patient 6 .
The objective of this study is to determine the age and gender distribution and clinical presentation together with histological types of patients with colorectal cancer presented to Ibn Sina specialized hospital.

Patients and methods
This is a retrospective descriptive hospital based study. It included patients who presented with colorectal cancer to Ibn Sina specialized hospital as elective cases in the period from January 2010 to December 2012. Total number of patients presented to the hospital with colorectal cancer was 81 patients, of them 73 patients were included in this study and the other 8 cases were excluded from the study because of incomplete data. Ibn Sina specialized hospital is a tertiary hospital which accepts cases of gastrointestinal diseases from Khartoum state and other states of the Sudan. Demographic data of all patients was obtained with their presenting symptoms. Also, the positive physical signs with positive relevant results of investigations were recorded. Incomplete patient's record was the main limitation of this study together with the fewer number of cases. The data was fed in to and computed by the statistical package for social sciences (SPSS 17).

Results:
A total of 73 patients were included in the study. There were 37 males (50.68%) and 36 females (49.32%) for the study with a male: female ratio of 1: were between the ages of 41 and 60 years, the age and geographical distribution in Sudan are shown in (table  1). The most common presenting symptom was rectal bleeding (71.23%) and (31.50%) of them had tenesmus, the symptoms showed in (table 1&2). Palpable tumor per rectum was found in 27.34% of patients and in 72.66% it was seen during full colonoscopy and during flexible sigmoidoscopy. The diagnosis in all cases was confirmed by biopsy, in 65% the biopsy was taken at the initial colposcopy and in 20% it was taken during colonoscopy after the initial sigmoidoscopy and in 15% it was taken after re-colonoscopy. Colonic cancer constitutes 60.27% of the cases and rectal cancer found in 39.73% of cases. The biopsy results showed 96.87 was adenocarcinoma and its shown in table 1&2. After work up of all patients 8.3 % were found to have liver metastases, 3.3 % had brain metastases and 1.7 % had bone metastasis. In 15.06% 11 of cases there was positive family history of colorectal cancer, 63.64 (7 out of 11) of them are below 50 years of age.

Discussion
Colorectal cancer (CRC) is a common cancer worldwide. CRC affects men and women of all racial and ethnic groups, and is most often found in people aged 50 years or older in developed countries 7 . No age group is exempt; an adenocarcinoma of the colon has been reported in a nine-month-old girl 8  All these data reflects that the colorectal cancer in Middle East and Africa is more common in the young than in Western countries.
Agrawal S et al 17 recommended screening of African Americans at a younger age (45 rather than 50 years) as they were found to have a higher incidence of developing colorectal cancer at a younger age. Colorectal cancer affecting the younger population (<40 years old) is associated with poor prognosis 18 . Dukes and Bussey suggested a much higher rate of lymphatic metastasis in patients less than 40 years of age due to a more rapid progression of the disease in young patients 18 22 .
On the other hand the highest incidence was identified in the age group 41-60 years (50.68%) which coincides with that reported by Ahmed et al 10 but differs from David et al whose peak incidence was at 75 years 23 .
In this study males were more than females but the ratio was almost similar Tumor grade pattern in our study was mainly well differentiated adenocarcinoma (45%) then poorly differentiated (26.67%), in a similar study in Saudi Arabia 25 moderately differentiated was the most common followed by poorly differentiated adenocarcinoma. Metastasis to the liver at presentation in this group of patients was dominating other sites and it looks similar to the Iranian study 12 they found a higher incidence of liver metastases were associated with rectal cancer followed by transverse colon cancers.

Conclusion
Colorectal cancer was found to affect Sudanese patients at younger age groups (43.84% was below 50 years) with a peak frequency at the fifth & sixth decades. A greater awareness of the potential for colorectal cancer in young people must be emphasized to all physicians. Further study is required to be undertaken to find out whether colorectal cancer affecting young population is due to regional factors or whether it is indicative of a changing pattern of occurrence of colorectal cancer. If the latter, additional studies are required to define genetic factors.

Notice
The authors declare that ethical approval was obtained from Ibn Sina hospital ethical committee and they have not received any financial support from any sector for preparation of this manuscript