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Agri-pv (agrivoltaics) in developing countries: advancing sustainable farming to address the water–energy–food nexus.

Graphical Abstract

1. Introduction

1.1. background and context, 1.2. introducing a special focus on central asia, 1.3. the need to introduce agri-pv in uzbekistan, 2. research design, 2.1. research question.

• What are the optimal configurations for integrating photovoltaic systems with different crop types in Uzbekistan’s agricultural landscape?
• How do Agri-PV systems impact crop yield, water usage, and energy efficiency in general for Uzbekistan/developing countries?

2.2. Research Methodology

2.3. novelty of the research, 3. modelling and assessing agri-pv system performance, 3.1. case study area and crop selection, 3.2. calculation of photosynthetic active radiation (par), 3.3. selection of type of module technology and inverter, 4. simulation and modelling approach.

• Case 1 was when the distance between the modules was equal to the distance between the rows of the modules. These varied from 1 m to 3 m at an equal interval of 1 m;
• Case 2 was when the distance between the modules was kept constant at 1 m and only the row distance was varied;
• Case 3 was when the distance between the modules was kept constant at 2 m and only the row distance is varied.

4.1. Scenario 1: Constant Tilt Angle

4.2. scenario 2: variable tilt angle, 5. results and discussion, 5.1. scenario 1: constant tilt angle, 5.2. scenario 2: variable tilt angle, 5.3. selected configuration based in parametric study, 5.4. implementation of the chosen agri-pv configuration across different regions, 6. outlook and challenges, 7. conclusions and future scope, author contributions, data availability statement, conflicts of interest.

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Share and Cite

Mehta, K.; Shah, M.J.; Zörner, W. Agri-PV (Agrivoltaics) in Developing Countries: Advancing Sustainable Farming to Address the Water–Energy–Food Nexus. Energies 2024 , 17 , 4440. https://doi.org/10.3390/en17174440

Mehta K, Shah MJ, Zörner W. Agri-PV (Agrivoltaics) in Developing Countries: Advancing Sustainable Farming to Address the Water–Energy–Food Nexus. Energies . 2024; 17(17):4440. https://doi.org/10.3390/en17174440

Mehta, Kedar, Meeth Jeetendra Shah, and Wilfried Zörner. 2024. "Agri-PV (Agrivoltaics) in Developing Countries: Advancing Sustainable Farming to Address the Water–Energy–Food Nexus" Energies 17, no. 17: 4440. https://doi.org/10.3390/en17174440

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New Times, New Thinking.

• The Weekend Essay

The tragedy of progress in the developing world

Kenya and Bangladesh are doomed to walk the crooked road of history.

By Robert D Kaplan

“It was the best of times, it was the worst of times,” begins Charles Dickens’s 1859 novel, A Tale of Two Cities , about the French Revolution. The phrase, which so concisely captures the complexity of life, has become a cliché. But this underrates its descriptive power: it defines a society caught between two eras, both a France in the process of overthrowing its ancien régime , but also Dickens’s contemporary Britain, still feeling its tentative way through the realities of an industrial economy.

Applied to the present, it captures the situations in a host of developing countries where decades of steady economic and social progress have nonetheless resulted in riots and political upheaval. More specifically: Kenya, which has experienced a summer of widespread unrest, ostensibly in opposition to a new finance law; and Bangladesh, whose long-time prime minister Sheikh Hasina resigned in August after a series of violent protests.

“But weren’t those countries supposed to be success stories?” many might ask. They are, and that is the point. Kenya has gone from a rural, tribal-based society to a much more complex and middle-class one. Bangladesh has gone from one of the poorest countries on Earth to a country of light industry and dramatically increased literacy. Both are developing the vigorous middle class that is a prerequisite for democracy. Both countries have also rapidly emerged as geopolitical powers in their regions. Kenya with 56 million people has been designated as the US’s principal ally in sub-Saharan Africa. Bangladesh with 171 million people (25 million more than Russia, which sprawls across 11 time zones) has also emerged as a key country, especially owing to the weakening of Myanmar, torn apart by civil war, next door.

But success only leads to new patterns of instability, including riots and revolutions. This is part of how countries build complex institutions. These societies are climbing the ladder of success, and the steps include periodic revolts. No one understood this concept better than the late Harvard political scientist Samuel P Huntington, who made the crooked path of progress in the developing world the theme of his greatest book, Political Order in Changing Societies , published in 1968. It may still be the most arresting guide to the rigours of globalisation ever published. By reading developing countries through his analysis, we can see the tragedy of their condition – as well as better understand the path before them.

Huntington begins by noting how hard the West finds it to understand this development. The US’s happy circumstances – a stable mass democracy on a resource-rich continent, protected by oceans – has led its citizens to believe in what he called the “unity of goodness”, a collective assumption that national development flows in concert, to the benefit of all. But that is not the case for much of the rest of the world. Indeed, as a general rule, “the faster the enlightenment of the population, the more frequent the overthrow of the government”. This is why long periods of economic growth and reform, however uneven – and much more so than periods of stagnation and repression – lead to popular upheavals. Growth and change restructure the developing country’s class system.

The Saturday Read

Morning call.

Kenya and Bangladesh have followed this pattern closely. The governments in both, while corrupt and autocratic in important respects, have overseen significant periods of economic growth and particularly the creation or enlargement of middle classes, as people flooded into the cities from the countryside. Another example: Tunisia, where the mass revolt known as the Arab Spring began in 2011, had the most developed middle class of any Arab country that was not rich in oil. Middle classes are, quite simply, harder to govern than rural and illiterate peasantries. They are not fatalistic, and are rarely grateful. They have more acquisitive needs and desires and always demand more. As Huntington explains, while the existence of a large middle class becomes a moderating force in political life, its genesis can be highly destabilising.

The creation of a middle class is of course necessary for well-functioning political institutions, which rely on literate bureaucrats. And the more complex a society becomes, the more such institutions are needed – and efficient ones at that. In less developed societies, loyalty to clans and tribes predominates; in more developed societies loyalty instead flows to institutions and the state. Kenya and Bangladesh, as well as many other societies in the developing world, are moving in that direction. You can discern this by what people complain about. Demonstrations about taxes, corruption and press freedoms – which is what drove much of the summer unrest in Kenya and Bangladesh – are signs of populations demanding higher standards of governance. This is progressive in itself. Better that they complain about corruption in general than about this tribe getting more favours than that one.

Corruption is a complex phenomenon in two respects, as Huntington points out. It is a sign of intense modernisation, since it indicates that institutions, even as they are being built, cannot keep up with the demands of the population and alternative networks for getting things done emerge, while functionaries are poorly paid and must seek income from other sources. But corruption is also a sign of perceived “backwardness” in a society, of people being ashamed of their own state authorities, and thus demand cleaner and more efficient performance. Progress in politics always begins with complaints.

As Isaiah Berlin wrote: “Men who live in conditions where there is not sufficient food, warmth, shelter, and the minimum degree of security can scarcely be expected to concern themselves with freedom of contract or of the press.” That complaints about the lack of press freedoms and of protection for journalists are widespread in these societies is a sign of how much they have progressed in recent decades. Kenya’s youth-led revolt, which began in late June and featured riots and demonstrations, was not over a tribal or ethnic dispute but a tax hike that threatened to increase the price of basic goods. When the Kenyan president William Ruto withdrew the tax, protesters continued to demand his resignation for corruption and mismanagement.

In Bangladesh, Sheikh Hasina – who had been in office for two decades and had overseen a dramatic expansion of the economy and middle class – was forced from power in early August because of repression, democratic backsliding and the curbing of media freedom. Again, issues such as famine and communal tensions had little to do with the demonstrations. Those motivations belong to the past – at least for the moment. It is also notable that an aspirational youth played a dominant role in both countries’ protests. They are digitally literate in a new way, and subject to a deeper engagement with global influences. Whereas in the past, each country in the developing world was consumed by its own issues, today, thanks to a form of political-cultural globalisation, local issues can be subjected to Western standards. This stokes demand for change. Such outside influences were always present, but not in the immediate and intense way they are now through technology.

This does not make the process of development easier: rather, it is even more tumultuous than in the past. Revolts, driven by higher and higher standards for governance, are easy – a mere matter of producing crowd formations. Solving the problems that revolts rally against is much harder. And that’s why the building of order, by way of institutions, is more progressive than even the holding of elections, as Huntington explains. What is required are more and better institutions, which are painstakingly hard and time-consuming to construct. The lag time between revolts and institution-building constitutes the age that these developing societies will inhabit for some time.

“The truly helpless society is not one threatened by revolution but one incapable of it,” Huntington writes. Countries mired in low-level and communal or territorial conflict – and there are plenty of those – are incapable of modernising revolt. Kenya and Bangladesh are in a more advanced state. But that is the key to their current instability. Probably the best example in history of a truly bloody and extreme uprising was the French Revolution, Dickens’s subject, which despite great cost in lives produced a modern, democratic state with civil liberties. Other revolutions, such as in Russia and Iran, have led to Bolshevism and Islamic radicalism. But that is not what Kenyans and Bangladeshis are yearning for. There is little hint of religion or communism in their revolts: only better governance. The very absence of extremism is a sign of healthy modernity.

This is a happy story, if it continues. The problem is with Western elites who see progress as linear, without the great chicanes of history in the road. But when Joe Biden held a state dinner in the White House in May to honour Ruto and to announce Kenya as a major American ally, he was only being somewhat naive. Biden thought Kenya and its society had already “arrived” . But Kenya will never “arrive”, it will continue to evolve in periodic and tumultuous ways. And that is not a tragedy, but a hope.

[See also: Van Gogh in the yellow house ]

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• Case report
• Open access
• Published: 08 September 2024

Familial adenomatous polyposis: a case report

• Endeshaw Asaye Kindie 1 ,
• Tigist Desta Beyera 2 ,
• Ephrem Tafesse Teferi 1 ,
• Daniel Zemenfes Ashebir 3 &
• Henok Bahru Wodajeneh 3  

Journal of Medical Case Reports volume  18 , Article number:  415 ( 2024 ) Cite this article

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Familial adenomatous polyposis is characterized by the presence of multiple colorectal adenomatous polyps and caused by germline mutations in the tumor suppressor gene and adenomatous polyposis coli, located on chromosome 5q21–q22. Familial adenomatous polyposis occurs in approximately 1/10,000 to 1/30,000 live births, and accounts for less than 1% of all colorectal cancers in the USA. It affects both sexes equally and has a worldwide distribution. The incidence of colon cancer in low- and middle-income countries is rising. In addition to the increasing incidence, lack of early detection and impeded access to optimal multidisciplinary treatment may worsen survival outcomes. Developing quality diagnostic services in the proper health context is crucial for early diagnosis and successful therapy of patients with colorectal cancer, and applying a resource-sensitive approach to prioritize essential treatments on the basis of effectiveness and cost-effectiveness is key to overcoming barriers in low- and middle-income countries. We report a case of familial adenomatous polyposis presenting as adenocarcinoma with multiple colorectal adenomatous polyps. The diagnosis of familial adenomatous polyposis was made by the presence of numerous colorectal adenomatous polyps and family history of colonic adenocarcinoma. Due to its rarity, we decided to report it.

Case presentation

A 22-year-old Ethiopian female patient presented to Addis Ababa University College of Health science, Addis Ababa, Ethiopia with rectal bleeding. Abdominopelvic computed tomography scan was done and showed distal rectal asymmetric anterior wall thickening in keeping with rectal tumor. Colonoscopy was done and she was diagnosed to have familial adenomatous polyposis with severe dysplasia. In the meantime, colonoscopy guided biopsy was taken and the diagnosis of adenocarcinoma with familial adenomatous polyposis was rendered. For this, total proctocolectomy was carried out. On laparotomy there was also incidental finding of left ovarian deposition for which left salpingo-oophorectomy was done, and 4 weeks after surgical resection, the patient was started on oxaliplatin, leucovorin, fluorouracil chemotherapy regimen.

In the clinical evaluation of a patient with rectal bleeding, familial adenomatous polyposis must be considered as a differential diagnosis in subjects having family history of colonic adenocarcinoma for early diagnostic workup, management, family genetic counseling, and testing.

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Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by mutations in the APC gene. Classic FAP is characterized by the presence of 100 or more adenomatous colorectal polyps. When fully developed, patients can have up to thousands of colorectal adenomas and a 100% risk of colorectal cancer. Screening for tumors associated with FAP should be performed in individuals with a pathogenic APC mutation. Screening for FAP -associated cancers should also be performed in individuals at risk for FAP who have either not undergone genetic evaluation or have indeterminate genetic test results. Screening for colorectal cancer and other FAP -associated cancers in these patients must be individualized on the basis of their personal and family history of adenomas and cancer. Individuals at risk for FAP include first-degree relatives of those with FAP and individuals with > 10 cumulative colorectal adenomas or colorectal adenomas in combination with extracolonic features associated with FAP (for example, duodenal/ampullary adenomas, desmoid tumors, papillary thyroid cancer, congenital hypertrophy of the retinal pigment epithelium, epidermal cysts, or osteomas) [ 1 ]. Polyps occur in the upper gastrointestinal tract in 83–100% of patients with FAP [ 2 , 3 ].

Considering the increasing number of locally advanced and advanced cases of colorectal cancer (CRC) in low- and middle-income countries (LMICs), there is an urgent need to implement screening strategies for early disease detection. Screening programs are aimed at early detection, recognizing early signs and symptoms of the presence of the disease, and treating patients with curative intent. Screening programs were reported to be more effective in slow-growing cancers with a natural history of multistage progression, such as the adenoma-carcinoma sequence in CRC. Delays in the diagnosis of CRC are multifactorial. There are social, cultural, and structural reasons such as poverty, the misbelief of the incurability of any tumor, the fear of stigma (especially in women), and structural barriers related to proper health facility accessibility due to long distances or unaffordable cancer services not covered by national health schemes of insurance [ 4 , 5 ]. There is a lack of standard diagnostic facilities in Ethiopia, generating a cancer delay in Ethiopia, which causes increased mortality due to locally advanced presentation. There are a limited number of gastroenterologists and colonoscopy units in Ethiopia, primarily located in urban areas, leaving the rural population needing access to such diagnostic facilities. Due to the shortage of workforce and endoscopic facilities, training programs need to be developed.

Primary assessment of rectal bleeding includes: careful attention to history, presence or absence of perianal symptoms, age of patient (in view of likely differential diagnosis with each age group), family history of colorectal malignancy, and red flag symptoms such as weight loss, symptoms suggestive of anemia, and change in bowel habits [ 6 ].

Examination of the abdomen to exclude abdominal mass and digital rectal examination to examine for fissure and exclude rectal cancer may be useful. Fecal calprotectin is a useful screening tool in younger, lower risk patients with suspected inflammatory bowel disease. A positive fecal calprotectin result has a high positive predictive value for finding inflammatory bowel disease at colonoscopy. Proctoscopy is useful for primary care clinicians as a screening tool in patients with rectal bleeding; however, it should not be used as a substitute for flexible sigmoidoscopy to rule out serious pathology. Secondary assessment of rectal bleeding includes: localization of the site and determination of the cause of bleeding to allow for treatment to be appropriately focused. The cause and site of massive lower gastrointestinal hemorrhage should be determined following the early use of colonoscopy and use of computed tomography, computed tomography angiography, or digital subtraction angiography. Flexible sigmoidoscopy is the investigation of choice for patients < 45 years old with persistent rectal bleeding who have received treatment for hemorrhoids and still have persistent bleeding. If there is a family history of colorectal malignancy, colonoscopy may be a better investigation for rectal bleeding as these patients have a higher risk of right colon cancers. Patients > 45 years old with persistent rectal bleeding should be offered either colonoscopy or flexible sigmoidoscopy [ 6 ].

Herein, we report a case of FAP presenting as rectal bleeding that was clinically considered as ulcerative colitis. As a result, we are reporting this case due to its rarity and to emphasize the importance of considering FAP in the differential diagnosis of rectal bleeding for early diagnostic workup, management, family genetic counseling, and testing.

A 22-year-old Ethiopian female patient presented to Addis Ababa University College of Health science, Addis Ababa, Ethiopia, with a complaint of on and off type of rectal bleeding of 2-year duration with recent worsening 6 months prior to her current admission. She had visited a nearby health center on multiple occasions for this complaint and took unspecified medications, but experienced no improvement. There was no history of fever, cough, weight loss, night sweating, or loss of appetite. She was having mild abdominal distension, vomiting, abdominal pain, bloody diarrhea, and constipation starting 1 week prior to her current admission. She had family history (first degree relatives) of colon cancer but no history of diabetes or hypertension. Her past medical history was not significant. She had no previous history of admission to hospital. She had no history of any form of surgical procedures. She was not married and lived with her parents. On physical examination, there was mild abdominal tenderness, pale conjunctiva, and nonicteric sclera. On the basis of the above findings, a provisional clinical impression of ulcerative colitis was entertained.

Liver was not palpable below costal margin. There was no splenomegaly. Other clinical findings were within normal limits. Laboratory investigations carried out on the same day of her presentation, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), and chest and abdominal X-ray, were noncontributory. On CBC, total white blood cell (WBC) count was 4000 µL with 50% granulocytes, 45% lymphocytes, 1% eosinophils, and 4% monocytes. Platelet count was 300,000 µL. Hemoglobin was 11.5 g/dL with mean corpuscular volume (MCV) of 75 fL. ESR was 14 mm/hour. Renal function test revealed blood urea nitrogen (BUN) of 12 mg/dL, and serum creatinine level was 0.68 mg/dL. On liver function test, total bilirubin was 0.6 mg/dL, serum albumin was 4.2 g/dL, and serum aspartate transaminase (AST/SGOT) and serum alanine transaminase (ALT/SGPT) were 28 IU/L and 30 IU/L, respectively. Serum electrolytes were in the normal range. Repeated carcinoembryonic antigen (CEA) level was 25 ng/mL. Urinalysis was also done and it was normal. Sputum was negative for acid-fast bacilli. Serum was negative for human immunodeficiency virus (HIV) antibody. Abdominopelvic CT scan was done and showed distal rectal asymmetric anterior wall thickening in keeping with rectal tumor. Uterus, liver, spleen, bilateral ovaries, and kidneys were free of tumor. Colonoscopy was done and reveals numerous colorectal adenomatous polyps; in the meantime, colonoscopy guided biopsy was carried out and the patient was diagnosed with adenocarcinoma. Due to limited number of surgeons and long waiting list of patients, she underwent total proctocolectomy 1 week after her initial presentation. On laparotomy there was also incidental finding of left ovarian deposition, for which left salpingo-oophorectomy was carried out. The specimen was sent to pathology department for gross and histopathologic examination. Gross cut surface examination of proctocolectomy specimen showed numerous adenomatous polyps involving rectum and the entire colon, while there was gray white solid infiltrating mass on left salpingo-oophorectomy specimen (Figs.  1 , 2 , 3 , 4 ).

Gross total proctocolectomy specimen

Gross cut surface specimen of total proctocolectomy showing numerous polyps

Gross cut surface specimen of total proctocolectomy showing numerous polyps (block arrows) involving distal to splenic flexure

Gross left salphingo-oophorectomy specimen (block arrow) and cut surface of it showing gray white solid infiltrating mass (star)

Microscopic examinations from both adenomatous polyps and infiltrating gray white solid mass of left salpingo-oophorectomy specimen showed proliferations of highly pleomorphic round-to-oval to polygonal cells having hyperchromatic nuclei and frequent mitotic activities forming variable sized glands admixed with desmoplastic stroma (Figs.  5 , 6 , 7 ). Out of 20 lymph nodes sampled, 7 were involved by tumor. On the basis of above findings, the case was diagnosed as adenocarcinoma with lymph node and left ovary metastasis plus FAP. The patient had good postoperative condition, and 4 weeks after surgical resection, she was started on FOLFOX (oxaliplatin 85 mg/m 2 intravenous, leucovorin 400 mg/m 2 intravenous, fluorouracil 400 mg/m 2 intravenous bolus then 2400 mg/m 2 intravenous administered over 46 hours) chemotherapy regimen every 2 weeks for 12 rounds. Since then, she was followed up with regular serum CEA, CBC, organ function tests and abdominopelvic CT scan. The patient was having a smooth course with no significant adverse effects encountered. Currently the patient has completed her chemotherapy regimen and is doing well.

Gross cut surface specimen of polypectomy (block arrow) and low power microscopic examination of it (star) showing variable sized glands lined by highly pleomorphic round-to-oval to elongated pencil shaped cells having hyperchromatic nuclei on a desmoplastic stroma (hematoxylin and eosin stain)

High-power microscopic examination of polypectomy specimen showing variable sized glands (block arrows) lined by highly pleomorphic round-to-oval cells having hyperchromatic nuclei on a desmoplastic stroma (star) (hematoxylin and eosin stain)

High-power microscopic examination of gray white solid infiltrating mass of salpingo-oophorectomy specimen showing variable sized glands (block arrow) lined by highly pleomorphic round-to-oval cells having hyperchromatic nuclei on a desmoplastic ovarian stroma (star) (hematoxylin and eosin stain)

There is an urgent need for screening strategies for the early detection of colorectal cancer in LMICs, with delays in diagnosis due to social, cultural, and structural barriers. Cost considerations play a role in the success of screening programs, and primary prevention strategies such as education and healthy living are essential. Screening policies for CRC require the engagement of medical leaders, advocacy groups, education, and national cancer control plans. Investment opportunities in the healthcare system need to be identified to maximize benefits. There is a lack of standard diagnostic facilities, imaging techniques, and pathology reporting consensus in most low-income countries, causing a delay in cancer diagnosis and increased mortality due to locally advanced presentation; and while molecular biomarkers are increasingly utilized in management, their implementation in LMICs should prioritize those that are clinically useful, validated, and cost-effective, and building partnerships with HICs for developing research precision biomarkers laboratory and cost-effective strategies should be part of future planning for LMICs. To improve CRC care in LMICs, there is a need to promote clinical research and include clinical data from LMICs in international literature, expand clinical trials, and establish research collaborations between HICs and LMICs. Improving the infrastructure for diagnosis, surgery, and medical and radiation oncology, as well as ensuring access to essential chemotherapy drugs and palliative cancer care is necessary to provide optimal treatment to patients with CRC in LMICs, and should be incorporated into national health policies with adequate funding. Primary prevention strategies are essential in educating the general population, including a healthy diet and living, physical activity, avoiding smoking and alcohol use, and encouraging them to participate in CRC screening. Implementing these primary prevention strategies in LMICs at a population level may control risk factors of noncommunicable disease. We may also have to focus on populations with a high risk of developing colorectal tumors. Well-defined inherited syndromes such as Lynch’s syndrome or familial adenomatous polyposis can occur in 2–5% of CRCs.

Education needs to be improved, and it is crucial to provide access to genetic testing to identify high-risk populations for screening and provide primary preventive surgery or personalized endoscopic plans [ 7 ]. Although there are few private sector clinical laboratories in Ethiopia that help clinicians in molecular diagnosis of cancer, the majority of patients cannot afford the high cost of molecular studies. The same was true for our patient.

Practical management of lower gastrointestinal (LGI) bleeding depends on the severity of the hemorrhage and the availability of diagnostic and therapeutic methods at the admitting facility. Endoscopic and radiological techniques have improved to the point that the site of bleeding can be localized in the majority of cases. In addition, episodes of LGI bleeding are less serious than upper gastrointestinal bleeding, with an 80% rate of spontaneous cessation of bleeding and a lower mortality of 2–4% [ 8 ] versus 6–13% [ 9 ]. It is therefore appropriate to stabilize the patient hemodynamically for transfer to a larger center if expertise in noninvasive diagnostic and therapeutic interventions is not available locally. Similarly, if the bleeding has stopped spontaneously and all investigations are noncontributory, supportive medical management can be continued with repetition of examinations if bleeding recurs. While there is no clear consensus for management as there is for upper gastrointestinal (UGI) bleeding, the following course of management can be proposed on the basis of an overview of all the diagnostic and therapeutic modalities and in accordance with the recommendations of the French Society of Digestive Endoscopy (SFED), American Gastroenterological Association (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) [ 10 , 11 , 12 ]. Proposed management of acute LGI and chronic LGI bleeding with no hemodynamic instability is shown in Figs.  8 and 9 , respectively.

Management of acute lower gastrointestinal bleeding

Management of chronic lower gastrointestinal bleeding with no hemodynamic instability

All patients with lower gastrointestinal bleeding should undergo initial upper endoscopy and urgent colonoscopy after bowel preparation. If there is active ongoing bleeding, angiography also seems indicated as an initial investigation. Currently, Computed Tomography Angiography (CTA) has many advantages: it is available in most centers, can be performed quickly with a satisfactory diagnostic yield when there is active bleeding, and helps to guide a therapeutic colonoscopy or embolization. At this stage, the site of bleeding has been localized in most cases. If diagnostic studies are negative, continued efforts should be made to locate the bleeding site rather than resorting to “blind” exploratory surgery, which has a high mortality and is likely to be non-contributory. Video capsule enteroscopy (VCE) has gradually emerged as a second-line modality for visualizing the small intestine, even in the emergency setting [ 13 ]. Our patient had also undergone colonoscopy, and the clinical diagnosis of ulcerative colitis was ruled out and she was diagnosed with FAP. Colorectal cancer accounts for 65% of ovarian metastases, with an increasing percentage reported in recent years [ 14 , 15 , 16 ]. Conversely, ovarian metastases occur in 5–10% of women with metastatic colorectal cancer [ 17 ]. Our patient was also diagnosed with poorly differentiated colonic adenocarcinoma involving distal to the splenic flexure with lymph node and left ovary metastasis.

In the ideal situation, patients with FAP would undergo a prophylactic colectomy shortly before CRC would otherwise have developed. However, it is difficult to predict when exactly the adenomas will develop into cancer. The number, size, and endoscopic and histopathological aspect of colorectal adenomas determine whether further endoscopic surveillance is safe. Indications for colectomy generally include the presence of multiple polyps > 10 mm, polyps that are high-grade dysplastic, and a rapid increase in the number of polyps [ 18 ]. However, timing of colectomy in FAP should always be a shared decision with the patient, taking into account social and educational/career factors. Colectomy should be performed on a moment in time that suits both the severity of polyposis and the preference of the patient. When the indication for colectomy is set, the next decision to be made is on the type of operation, that is, whether only the entire colon will be removed or the rectum as well. The preferred and most often performed procedures are a subtotal colectomy with an ileorectal or ileosigmoidal anastomosis or a more extensive proctocolectomy with ileal pouch–anal anastomosis [ 19 , 20 ]. Our patient had also undergone total proctocolectomy.

Our FAP case report signifies there is an urgent need to develop national cancer screening in LMICs. Developing screening policies for CRC will involve many factors, including workforce, medical equipment, and cost-effectiveness varying across LMICs, as well as increasing health literacy and educating the general population to discuss cancer in the community and detect it early by recognizing signs and symptoms. To maximize the benefits of cancer prevention programs, it is worth identifying and defining investment opportunities in the healthcare system, with clinical research collaborations between HICs and LMICs being a helpful strategy to improve health indicators and prevent the burnout of health workers. The patient was very satisfied with the intervention and care given.

Interprofessional management of patients with FAP is essential to ensuring appropriate screening and management of these complex cases. Early endoscopic surveillance is essential to determine the appropriate timing of surgical resection. Although medical treatments can aid in the stabilization of the disease, the mainstay of FAP treatment is colectomy with or without proctectomy. Extra-colonic manifestations also require intensive screening recommendations with close clinical follow-up of patients with FAP. With surveillance and surgical resection, patients with FAP can substantially reduce their risk of colorectal cancer and other associated malignancies.

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Abbreviations

High-income countries

• Low- and middle-income countries
• Familial adenomatous polyposis
• Adenomatous polyposis coli

Oxaliplatin, leucovorin, fluorouracil

Carcinoembryonic antigen

Colorectal cancer

Assisted enteroscopy

Video capsule enteroscopy

Computed tomography enteroscopy

Magnetic resonance imaging enteroscopy

Tc99 m radio-labelled RBC scan

Intraoperative enteroscopy

Lower gastrointestinal

American Gastroenterological Association

American Society for Gastrointestinal Endoscopy

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Acknowledgements

We would like to express our deepest gratitude to Addis Ababa University College of Health science, Addis Ababa, Ethiopia.

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Contributions

EAK and TDB performed the gross and histopathologic examination of the proctocolectomy and salpingo-oophorectomy specimen, and were major contributors in writing the case report. ETT, DZA, and HBW revised the case report. All authors read and approved the case report.

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Correspondence to Endeshaw Asaye Kindie .

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Written informed consent for participation was obtained from the patient. We have also obtained ethical approval regarding the case from school of medicine ethical review board of University of Gondar. A copy of the consent form as well as ethical approval is available for review by the editor of this journal.

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Kindie, E.A., Beyera, T.D., Teferi, E.T. et al. Familial adenomatous polyposis: a case report. J Med Case Reports 18 , 415 (2024). https://doi.org/10.1186/s13256-024-04724-8

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Received : 10 November 2023

Accepted : 25 July 2024

Published : 08 September 2024

DOI : https://doi.org/10.1186/s13256-024-04724-8

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