Factors that Influence the Acceptance of Needle Biopsy of the Liver at a Tertiary Hospital in Nigeria

BACKGROUND

Liver biopsy is a procedure that is carried out for making the diagnosis of abnormal liver conditions.

OBJECTIVES

This study assessed the factors that influence patients' acceptance of liver biopsy.

METHODS

A hospital based prospective study among patients scheduled for outpatient liver biopsy. They completed an interviewer administered questionnaire that captured their expectations, the degree of pain, areas they think need improvement during the biopsy process and whether they would consent to a second liver biopsy. A qualitative aspect involved an in-depth interview of participants purposively selected for their experience of liver biopsy. Data from the quantitative group were entered into SPSS version 20 and analyzed using simple and inferential statistics while content analysis was done for the qualitative aspect.

RESULTS

There were 100 participants in the quantitative group, 61 males and 39 females, and 16 in the qualitative group. Participants in the quantitative group expected a painful procedure (92%) that was likely to restrict their movement (64%). After biopsy, 44%, 40%, 28%, 26%, 18% and 17% of participants were unhappy with the long monitoring hours, biopsy needle pain, number of biopsy passes, lying on the biopsy site, shoulder tip pain and pain of local anaesthetic injection respectively. The qualitative aspect identified five thematic areas and showed that liver biopsy pain was influenced by preoperative anxiety occasioned by ill-advice and was exaggerated among females.

CONCLUSION

Consenting for liver biopsy may be influenced by advice from others, while factors relating to the procedure and long monitoring period remain as deterrent factors.

Clinical Correlates of Non-alcoholic Steatohepatitis in Nigerian Patients with Metabolic Syndrome

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is a progressive form of non-alcoholic fatty liver disease (NAFLD). NASH is frequently associated with metabolic syndrome (MetS) and its prevalence is increasing due to rising global epidemics of MetS. This study aimed at determining the prevalence, risk factors and correlates of NASH in patients with MetS in a tertiary hospital in Nigeria.

METHODS

We caried out a hospital based cross-sectional study of 81 subjects with MetS. The diagnosis of NASH was made by ultrasound evidence of hepatic steatosis, and exclusion of significant consumption of alcohol as well as histologic evidence of NASH on liver biopsy. Subjects gave informed consent and ethical approval was obtained from the ethics committee of the hospital. Data obtained were entered into SPSS version 20 and analyzed using simple and inferential statistics. A p-value of < 0.05 was considered statistically significant.

RESULTS

Total of 81 subjects with MetS were studied, males 36(44.4%), females 45(55.6%), mean age(SD) of 49.77 (12.08) years. Ten (12.3%) subjects were diagnosed with NASH. Subjects with NASH had significant association with obesity, dyslipidaemia, and poor glycemic control. Regression analysis showed that morbid obesity, low HDL and presence of type 2 diabetes mellitus were independent risk factors for the development of NASH.

CONCLUSION

NASH is common in Nigerian patients with MetS and its presence is significantly associated with obesity, dyslipidemia, and type 2 diabetes mellitus.

Diagnostic utility of alpha-fetoprotein and des-gamma-carboxyprothrombin in nigerians with hepatocellular carcinoma

BACKGROUND

Alpha-fetoprotein (AFP) and Des-gamma-carboxyprothrombin (DCP) have been extensively studied as biomarkers for the diagnosis of and prognostication in hepatocellular carcinoma (HCC). However there are only few reports on the clinical characteristics of hepatocellular carcinoma in relation to the combination of the two tumor markers in hepatitis B virus-related HCC.

AIM

The aim of this study was to investigate the clinical characteristics of HBV-related HCC in relation to different sets of AFP and DCP values.

METHODS

Sixty-two patients with untreated HCC were studied. The positive value of AFP was set at 20 1U/L while DCP positive value was set at 150 mAU/ml. Patients were divided into three groups: Group 1(n=36) with AFP ≥ 20 IU/L and DCP ≥ 150 mAU/ml. Group 2(n=24) with AFP <20 1U/L and DCP ≥ 150 mAU/ml. Group 3 (n=2) with AFP < 20 1U/L and DCP < 150 mAU/ml. There were no patients in group 4 meant for those with AFP ≥ 20 1U/L and DCP < 150 mAU/ml. Clinical and laboratory variables were compared among the groups.

RESULTS

Clinical and laboratory variables were comparable among the groups with the exception of gender and values of serum alanine aminotransferase (ALT). Males were significantly more than females among the groups (p<0.03). ALT values were significantly different among the groups (p<0.006). Paired comparisons between the groups showed the mean values of serum ALT were significantly higher in group 2 than in group 1(p<0.003). The mean serum ALT values were also higher in group 2 than in group 3 (p <0.014). There was no significant difference between group 1 and group 3 (P = 0.124).

CONCLUSION

HCC patients who are sero-positive for DCP and sero-negative for AFP have significantly higher levels of serum ALT; serum ALT levels may be of diagnostic importance in AFP-negative, HBV-related HCC patients.

Fatal haemorrhage from an ultrasound guided fine needle aspiration of the liver in a patient with primary hepatocellular carcinoma: case report

A case of fatal haemorrhage is reported among 72 ultrasound (US) guided percutaneous fine-needle aspiration liver biopsies (FNAB) performed in the gastro- intestinal unit of Medicine Department in a tertiary hospital. The patient had primary hepatocellular carcinoma (PHCC) with advanced hepatic cirrhosis. Death was due to bleeding from liver nodule resulting in intra-peritoneal haemorrhage. Pre-procedure laboratory tests did not reveal the existence of major bleeding disorders in the patient. This event is our first experience, but colour flow Doppler ultrasound guidance has been reported to prevent its occurrence. The use of FNAB for the diagnosis of PHCC should therefore be guided with colour flow Doppler ultrasound scan to prevent haemorrhage. In addition, there should be proper selection of patients for FNAB especially in areas where there are no colour flow Doppler ultrasound scans.

Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital

BACKGROUND

Colonic diverticular disease is one of the most common and costly gastrointestinal disorders among industrialized societies, which have recently been described among Africans. Presentations and distribution pattern of the disease among Africans appeared to be different from that described among the Western population. We embark on this study aimed at evaluating the presentation, distribution pattern, and the management of diverticulosis in our tertiary health facility.

MATERIALS AND METHODS

A prospective descriptive study of the cases of diverticular disease seen between January 2007 and December 2011 at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria.

RESULTS

During the 5-year study period, 40 cases were seen. The patients were aged 41-85 years with a median age of 64 years. There were 29 (72.5%) male and 11 (27.5%) female with an average male to female ratio of 3:1. The most common presentation was bleeding per rectum in 28 (70%) patients, which mostly needed transfusion. Ten (25%) patients presented with recurring abdominal pain, whereas one (2.5%) patient presented with abdominal mass and features of intestinal obstruction. Thirty patients were diagnosed on colonoscopy, eight on barium enema, and two on computerized tomography scan. Thirty-four (85%) patients had a pancolonic disease. All the patients were placed on high fiber diet and antibiotics namely ciprofloxacin and metronidazole. Five patients had recurrence within 6 months of follow up, of which one had emergency colectomy.

CONCLUSION

Diverticular disease is no longer a rare disease in Nigeria. It is a common cause of lower gastrointestinal bleeding in elderly patients. High index of suspicion for diverticular disease of the colon and its complications should increase in the country.

Spectrum of colonoscopy findings in Ile-Ife Nigeria

AIMS AND OBJECTIVES

Lower gastrointestinal (LGI) diseases are the leading causes of morbidity and mortality worldwide. Colonoscopy holds an important place in screening, diagnosing and treatment of these conditions. In Nigeria, as in many other developing countries, the facility for performing colonoscopy is rarely available. This prospective report seeks to evaluate the demographic data of patients presenting for colonoscopy, the pattern and validity of referral diagnosis versus colonoscopy findings in Ile-Ife, Nigeria.

SUBJECTS AND METHODS

All patients who had colonoscopy procedure done in the Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex between January 2007 and December 2011 were included in the study.

RESULTS

During the study period, colonoscopy was carried out in 320 patients. One hundred and eighty two (56.9%) were males, while 138 (43.1%) were females. The median age was 59.5 years. Their ages ranged from 2-87 years. The most common indications were lower gastrointestinal bleeding and change in bowel habit which together accounted for 79.0%. No abnormality was seen in 93(29.1%) patients. Abnormal endoscopic findings included 66(20.6%) patients who had haemorrhoids, 50(15.6%) cases colorectal cancer, 33 (10.3%) patients had benign polyps and (30 (9.4%) patients had diverticular disease. Other findings were colitis, inflammatory bowel disease, rectovaginal fistula, vascular ectasia and extra luminal compression. Haemorrhoids, diverticulosis and polyps were the most common findings in patients presenting with lower gastrointestinal bleeding.

CONCLUSION

This present report showed that colonoscopy is a cheap, safe and effective method of investigating lower gastrointestinal disease in Ile-Ife, Nigeria. When the indication is based on symptoms, the diagnostic yield could be as high as 90%. The common causes of lower gastrointestinal bleeding in Ile-Ife, Nigeria include haemorrhoids, diverticulosis and polyps.

Characteristics of inflammatory bowel disease in three tertiary health centers in southern Nigeria

BACKGROUND

Inflammatory bowel disease (IBD) refers to two chronic inflammatory disorders of the gastrointestinal tract which is generally believed to be rare in most African countries. The objectives of the current study were to present the experience of three tertiary gastroenterology centers in southern part of Nigeria on IBD, highlighting the age distribution of the patients seen, management and the impact on the quality of their life in university-based community-type practices in Nigeria.

METHODS

This was a retrospective review of charts of inflammatory bowel disease seen between January 2007 and June 2010 at three teaching hospitals in Southern Nigeria. Diagnosis of IBD was made from clinical manifestations, colonoscopic and histopathological findings.

RESULTS

During the study period, 12 patients presented with clinical features consistent with inflammatory bowel disease. There were 8 (66.7%) males and 4 (33.3%) females and had ages ranged from 18 years to 80 years with a median of 26.5 years. Eight (66.7%) patients had ulcerative colitis while 4(33.3%) had Crohn's disease. Ten (83.3%) patients had severe disease with main clinical features being recurrent diarrhoea and passage of mucoid bloody stools. All the patients had treatments with sulphasalazine or mesalazine, steroids and antibiotics with good responses. One patient died following the occurrence of toxic megacolon.

CONCLUSION

Although IBD is uncommon in Nigeria, high index of suspicion is necessary by attending physicians managing patients with recurrent passage of mucoid bloody stools. Prompt gastroenterological referral and judicious use of colonoscopy and biopsy will assist in making the diagnosis.

Bowel preparation for colonoscopy: enema versus sodium phosphate

BACKGROUND

Colonoscopy is considered to be the gold standard investigation for assessing the colonic mucosa. Good bowel preparation is essential in order to achieve optimal visualisation of the mucosa. Traditionally water enema is used for bowel preparation in most centres in Nigeria. This prospective study was performed at the Gastrointestinal Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between July 2008 and June 2009.

AIMS AND OBJECTIVES

This study compared patients' tolerability, adverse effects, efficacy and mean duration of colonoscopy of water enema and sodium phosphate (NaP) for bowel preparation toward colonoscopy.

PATIENTS AND METHODS

Standard structured questionnaire was completed by 64 patients and the colonoscopist assessing tolerability, adverse effect, efficacy and mean duration of the procedure.

RESULTS

There were sixty four patients aged between 22 to 86 years. The mean age was 58.16 ± 15.790. Thirty eight (59.4%) patients were in patients and 26 (40.6%) were out patients. Forty one (64.1%) patients had water enema while 23 (35.9%) patients were included in the NaP group. The median age for patients in both groups was 62.0 years. Patients in NaP group rated their bowel preparation as more tolerable and found the dietary restriction much easier than those in water enema group (p < 0.0001). Better colon cleansing score was found in patient in NaP group as compared with those in water enema group in all region of the colon. The procedure took significantly longer time in patients in water enema group as compared with those in NaP group (p < 0.0001).

CONCLUSION

NaP has a better bowel cleansing score for colonoscopy than water. It has better tolerability, side effect profile, efficacy and gives a shorter mean duration for the procedure.

The contribution of alcohol to chronic liver disease in patients from South-west Nigeria

OBJECTIVE

This study aimed at determining the level and type of alcohol consumed by patients diagnosed with chronic liver disease (CLD) and, hence, the extent to which alcohol may have contributed to the development of the condition.

STUDY DESIGN

Patients with diagnosis of CLD were consecutively recruited and a structured questionnaire was administered on each of them. Diagnosis of CLD was made based on liver histology and/or typical clinical and laboratory features. Alcohol consumption was considered significant if a patient took >50 g/day for > 10 years.

RESULTS

A total of 145 patients were studied consisting of 102 males and 43 females. Their ages ranged from 20- 80 years with a mean of 46.8 ± 15.7 years. Fifty-one (35.2%) patients, all males, drank significant alcohol while consumption was not significant in 43 (29.6%) patients. Alcohol was not consumed at all by 51 (35.2%) patients made up of 18 males (35.3%) and 33 females (64.7%). Beer was the commonest form of alcohol consumed (70.2%) followed by palm wine (50%) and locally-brewed gin (20.2%). The diagnoses made were liver cirrhosis [LC] (60, 41.38%), chronic hepatitis [CH] (54, 37.20%), hepatocellular carcinoma [HCC] (23, 15.86%), alcoholic liver disease [ALD] (6, 4.14%) and non-alcoholic fatty liver disease [NAFLD] (2, 1.38%). The liver disease spectrum did not differ between the patients who drank significant alcohol and those who did not. However, the proportion of LC/HCC cases increased relative to CH with increasing age and consumption of alcohol.

CONCLUSIONS

The proportion of CLD directly attributable to alcohol (i.e. ALD) is low among the patients studied. However, the burden of LC and HCC is directly related to age and the amount of alcohol consumed and the determinants of alcohol abuse are gender and affluence.

Sexual transmission of the hepatitis B virus among blood donors in a tertiary hospital in Nigeria

INTRODUCTION

Hepatitis B can be spread by several routes, including sexually. This study aimed to determine the prevalence of sexual transmission of the virus among the Nigerian population.

METHODS

This was a prospective cross-sectional study involving 234 blood donors in a Nigerian tertiary hospital. Each prospective donor was screened for hepatitis B surface antigen using an enzyme-linked immunosorbent assay test. A structured questionnaire was used to obtain information regarding the possible routes of hepatitis B acquisition and the number of lifetime heterosexual partners. Respondents were divided into three risk groups. The data obtained was analysed, and the frequencies, percentages, means and standard deviations were obtained. The chi-square test was used to compare categorical variables, and a p-value equal or less than 0.05 was considered statistically significant.

RESULTS

A total of 234 respondents aged 18 to 56 years (mean 27.3 years) participated in the study. 223 were male and 11 were female. The overall seroprevalence of hepatitis B was 17.1 percent. The seroprevalence was higher among participants without sexual partners (20.6 percent) and those with multiple sexual partners (20.0 percent), but lower among those with single sexual partners (15.0 percent). A history of needle injuries, jaundice and injections from quacks were statistically significant when these risks were combined with a sexual risk for hepatitis B virus infection (p-value is less than 0.05).

CONCLUSION

Sexual transmission of hepatitis B was not found to be an important factor. Preventive strategies should include universal hepatitis B vaccination and discouraging the indiscriminate use of sharp objects and unauthorised medical practices.

Pattern and validity of clinical diagnosis of upper gastrointestinal diseases in south-west Nigeria

BACKGROUND

Diagnosis of upper gastrointestinal (UGI) diseases is often made on clinical grounds alone in Nigeria due to lack of endoscopic facilities. The validity of using such diagnosis is presently unknown.

OBJECTIVE

The study aimed to determine: age and sex distribution of patients presenting for UGI endoscopy; pattern of clinical and endoscopic diagnoses in patients with UGI diseases; and, the validity of clinic-based diagnosis.

METHODS

Medical records of patients presenting at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria for UGI endoscopy between September 1999 and August 2003 were reviewed. Data was analysed for sensitivity, specificity, positive predictive value, and negative predictive value of clinical diagnosis using endoscopic diagnosis as "gold" standard.

RESULTS

Males constituted 53.4% of subjects and mean age was 45 years (+/- 1.69 SD). Peptic ulcer disease (PUD) constituted 67.6% of referral diagnosis but 33.9% of endoscopic diagnosis. PUD had the highest sensitivity value (0.72) while gastritis had the least (0.04). Specificity ranged from 0.40 for PUD to 1.00 for corrosive oesophagitis. Positive predictive value ranged from 0.29 (oesophageal cancer) to 0.67 (corrosive oesophagitis) and negative predictive value ranged from 0.66 for gastritis to 0.99 for corrosive oesophagitis.

CONCLUSION

The validity of clinical diagnosis in UGI conditions varied widely, and in general, there is poor agreement between clinical and endoscopic diagnoses.

Correlation between endoscopic suspicion of gastric cancer and histology in Nigerian patients with dyspepsia

Gastric mucosal biopsies of 77 dyspeptic patients whose endoscopic features were suggestive of cancer and 56 patients with uncomplicated duodenal ulcer (DU) were subjected to histopathological analysis. Gastric cancer was confirmed in 18 (23.4%) of the 77 patients but not in 59 (76.6%). 4 (5.2%) of the 18 patients had early gastric cancer (EGC). Histopathological findings in the stomach biopsy of the 59 patients in whom cancer could not be confirmed were compared with those of the 56 patients with DU. Intestinal metaplasia (IM) was present in 32.2% of the 59 cases with endoscopic suspicion of gastric cancer and in 16.1% of the 56 DU controls (P < 0.05). Mucosa-associated lymphoid tissue (MALT) occurred in 28.8% of the cancer-resembling cases and in 12.5% of the DU patients (P < 0.05). The difference in the prevalence of gastric mucosal atrophy and Helicobacter pylori infection between the two groups (83% vs. 71.4%) did not reach statistical significance (P > 0.10). All 18 patients with gastric cancer were positive for Helicobacter pylori and the prevalence of the infection approached 95% in those with IM and MALT. This study shows that IM and MALT present with endoscopic appearances that resemble that of gastric cancer and that along with the latter, their main aetiological agent is Helicobacter pylori.

Clinical and laboratory indices of cholelithiasis in adult Nigerians with sickle-cell anaemia

The clinical and laboratory indices of cholelithiasis in adult Nigerians with homozygous sickle-cell disease (SCD) were studied in 100 consecutive patients attending the adult SS clinic of the University of Ilorin Teaching Hospital, Ilorin, Nigeria. The study examined the role of clinical (sickle cell (SS) crises, body mass indices [BMIs]), haematological (reticulocyte count, haemoglobin) and biochemical (serum bilirubin, serum alkaline phosphatase and serum amino transaminases) indices in predicting the likelihood of finding cholelithiasis in patients with SS anaemia. A positive correlation was found between the BMI, SS crises, reticulocyte count, serum bilirubin, serum alanine and asparate transferases on one hand and the development of cholelithiasis (at P values of 0.04, 0.03, 0.05, 0.01 and 0.04, respectively) on the other. No such association was found between the other indices studied and cholelithiasis.

Liver cirrhosis: Child-Pugh grading of cases seen in Nigeria

Child-Pugh grading is an important determinant of treatment options, surgical interventions and prognosis in chronic liver disease. Sixty-four liver cirrhosis patients (49 men, 15 women) seen at Ile-Ife, Nigeria were graded according to the Child-Pugh parameters. Only one (1.6%) was in Class A, while 21 (32.8%) and 42 (65.6%) were in Classes B and C, respectively. Thirty-four either had coagulopathy or were already in encephalopathy at the time of presentation. Hepatitis B virus-associated disease was present in 64% of the patients. Most Nigerian cirrhosis patients present with very advanced disease; they are thus poor-risk candidates for diagnostic procedures and surgery. Efforts should be intensified at making the diagnosis at a much earlier stage and universal immunization with the hepatitis B vaccine should be commenced to reduce the incidence of HBV-related chronic liver disease in Nigeria.

Chronic hepatitis in Nigerian patients: a study of 70 biopsy-proven cases

BACKGROUND

Liver cirrhosis and hepatocellular carcinoma are known sequelae of chronic hepatitis. Early diagnosis and treatment of chronic hepatitis could delay or even abort progression to terminal liver disease.

STUDY DESIGN

Prospective study of 70 consecutive patients with features of early liver disease or discovered with HBsAg (or anti-HCV) during pre-employment and/ or pre-donation screening at Ile-Ife, Nigeria. All the patients had liver biopsy and the histology evaluated with the Knodell Histological Activity Index.

RESULT

Fifty-three patients had symptomatic disease (M: F ratio, 1.5:1) while 17 were asymptomatic (M: F ratio, 3:1). The mean ages were 49.04 (SD+/-16.78) and 29.82 (SD+/-6.13) for the symptomatic and the asymptomatic patients respectively (P< 0.005). Major symptoms were right upper abdominal pain (68%), weight loss (51%) and fatigue (41.5%). Alcohol consumption was significantly related to symptomatic chronic hepatitis (P< 0.01). Over 50 % of patients with asymptomatic chronic hepatitis had abnormal liver scan and liver function tests. All the asymptomatic cases and 77.4 % of the symptomatic group had HBsAg while only 1 patient (symptomatic) was anti-HCV positive. On liver histology, all the patients with asymptomatic chronic hepatitis had a Knodell score of< or = 8 and none had fibrosis. Over half of the symptomatic patients had a Knodell score of > or = 9 (56.6%) and stage 2 or 3 fibrosis (51 %).

CONCLUSION

Asymptomatic chronic hepatitis patients tend to be younger and of the male sex. Symptomatic chronic hepatitis may signal the onset of significant fibrosis and alcohol abuse may accelerate this process. Serum ALT and liver scan are useful initial screening tests for asymptomatic patients with hepatitis B or C viral markers.

Gastro-oesophageal reflux disease: a review of clinical features, investigations and recent trends in management

BACKGROUND

Gastro-oesophageal reflux disease, though a common digestive disorder worldwide, is scarcely reported with very sparse literature in oursetting.

AIM

To review the clinical features, investigations and recent developments in the management of gastro-oesophageal reflux disease.

METHODS

We retrieved publications from local and international journals. We also searched Medline particularly for local references. Other sources of our data include Up-to-date in Medicine and standard texts in medicine and pathology.

RESULTS

Local literature is generally lacking; while the classical symptoms of gastro-oesophageal reflux disease are heartburn, dysphagia and acid regurgitation, clinical examination is usually silent except when there are complications. There is no gold standard investigation but oesophageal pH monitoring, Bernstein test, oesophagoscopy and oesophageal manometry have been established to be useful in the evaluation of affected patients. Radiologic investigations, though insensitive in the diagnosis, are invaluable in diagnosing complications. Response to 14-day treatment with omeprazole (20 mg daily) has now been established to have a high sensitivity and specificity in diagnosing the condition. Management strategies include lifestyle modification, medical and surgical therapies. Proton pump inhibitors are now recognized as first line therapy in management.

CONCLUSION

The prevalence and behaviour of this condition in Nigeria is not known and local references are scanty. This review article focused on the worldwide epidemiology, pathogenesis and recent trends in management to stimulate our interest in this area.

Exudative retinal detachment occurring in a patient with pyogenic liver abscess

This is a report of a rare case of bilateral exudative retinal detachment occurring in a young Nigerian male with pyogenic liver abscess. Detailed ocular and clinical examination with biochemical, haematological and microbiological studies of the blood and liver aspirate were done. Ocular and abdominal scan plus surgical drainage of abscess were also done. The main features were febrile illness with hepatomegaly and sudden loss of eyesight. Visual acuity was light perception in both eyes. The cardiovascular and renal systems were normal. Ocular scan showed bilateral bullous retinal detachment while abdominal ultrasound revealed multiple liver abscess cavities. HIV and HBsAg tests were negative. Pyogenic liver abscess should be regarded as possible cause of exudative retinal detachment and has a potential blinding complication.

Use of direct Gram stain of stomach biopsy as a rapid screening method for detection of Helicobacter pylori from peptic ulcer and gastritis patients

Four hundred and thirty five stomach mucosal biopsies were taken from 145 consecutive patients (3 from each patient) during investigations for dyspepsia in three hospitals in Western Nigeria. The aim was to determine the best suited rapid screening method to aid fast diagnosis of ulcer/gastritis in this environment, using Gram stain, CLO test kit (urease production test) and culture methods. Eighty-nine (61.4%) biopsies were positive using Gram stain, 61 (42.1%) using CLO test kit and only 28 (19.3%) using culture. Based on the various limitations of CLO test kits and culture methods, Gram stain was adjudged the best suited rapid method. The clinical implication of this finding is discussed.

Use of direct Gram stain of stomach biopsy as a rapid screening method for detection of Helicobacter pylori from peptic ulcer and gastritis patients

Four hundred and thirty five stomach mucosal biopsies were taken from 145 consecutive patients (3 from each patient) during investigations for dyspepsia in three hospitals in Western Nigeria. The aim was to determine the best suited rapid screening method to aid fast diagnosis of ulcer/gastritis in this environment, using Gram stain, CLO test kit (urease production test) and culture methods. Eighty-nine (61.4%) biopsies were positive using Gram stain, 61 (42.1%) using CLO test kit and only 28 (19.3%) using culture. Based on the various limitations of CLO test kits and culture methods, Gram stain was adjudged the best suited rapid method. The clinical implication of this finding is discussed.

Primary hepatocellular carcinoma in Ile-Ife, Nigeria: a prospective study of 154 cases

Primary hepatocellular carcinoma is a tumour with a dismal prognosis. In recent times, however, great advances have been made in its management. This 13-year prospective study done at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, was an attempt to appraise the outlook of the disease in Nigeria at the turn of the 21st century. Primary hepatocellular carcinoma affected mainly middle-aged Nigerians (peak age-group = 40-59 years), predominantly males (M:F = 2:1) and, in a sizeable proportion (78%), it co-existed with cirrhosis. Significant risk factors found were scarification marks (87%), anicteric hepatitis (71.3%), abuse of medicinal herbs and analgesics (68.6%) and injection from quack doctors (51%). Blood test for HBsAg was positive in 61% of patients. The mean duration of symptoms. before diagnosis was 12.64 weeks (SD 13.77) while, on the average, patients died within 14.0 weeks (SD 13.0) of illness, usually of liver failure (67.7%). Only symptomatic treatment could be offered in 148 patients (96.1%) while chemotherapy was merely attempted in 5 (3.25%). Majority of the patients (59.8%) were either discharged against medical advice or lost to follow-up. This study shows that Nigerian patients presenting with primary hepatocellular carcinoma already have advanced disease and this makes treatment and survival hopeless. Universal immunisation with HB vaccine should be implemented in Nigeria without further delay and health education should be directed against socio-cultural practices which are aetiological risk factors for primary hepatocellular carcinoma.

Upper gastrointestinal findings and incidence of Helicobacter pylori infection among Nigerian patients with dyspepsia

Gastroscopy is the preferred method of diagnosis of upper gastrointestinal (UGI) disorders which often present with dyspepsia. Since the discovery of helicobacter pylori (H. pylori) as an important aetiological agent in gastroduodenal disease, investigation for this organism during UGI endoscopy has become a standard clinical practice. We have studied a large number of Nigerian patients with dyspeptic symptoms referred for endoscopy for the spectrum of gastroduodenal diseases and the incidence of H. pylori infection. Detection of H. pylori was done on gastric muscosal biopsies either by the Campylobacter-Like Organism (CLO)-urease test or by histropathology. A total of 834 patients were studied out of which 268 were investigated for H. pylori. A hundred and ninety-five patients (73%) were positive for H. pylori and the peak age was in the fourth decade. Duodenal ulcer (DU) was the most common endoscopic finding (38.7%). The incidence of H. pylori infection was 76% among patients with DU, gastritis, gastroduodenitis and gastric outlet obstruction. However, all the anterior and pyloric channel Duus tested for H. pylori were positive gastric ulcer (GU) was diagnosed in only 4.7% of patients but 82% of them tested for H. pylori were positive. H. pylori was significantly associated with GU occurring with gastritis. Gastric carcinoma was diagnosed in 52 patients (6.2%) and 50% of those tested for H. pylori were positive. This study shows that H. pylori plays an important role in the aetiopathogenesis of peptic ulcer disease among Nigerian patients and that the diagnosis of anterior and pyloric channel Duus or gastroesophageal polyp disease may be an indicator of massive H. pylori infection.

P53 codon 249 mutation in hepatocellular carcinomas from Nigeria

Mutations of p53 tumour suppressor gene often occur in hepatocellular carcinoma and, in particular, codon 249 hot-spot mutation is displayed by hepatocellular carcinomas occurring in hepatitis B virus-endemic areas with high dietary aflatoxin intake. This study was done to determine the frequency of p53 codon 249 mutation in hepato-cellular carcinoma in Nigerian patients with this tumour. Tumour samples were obtained from 18 Nigerian patients (all from the Southwest of the country) with histologically confirmed hepatocellular carcinoma by autopsy (n = 14), surgical resection (n = 3) and ante-mortem liver biopsy (n = 1). Fourteen of them had co-existing cirrhosis. Amplification of exon 7 of p53 gene from DNA samples of hepatocellular carcinoma tissue was undertaken by nested polymerase chain reaction followed by restriction enzyme analysis. One out of the 18 tumour samples tested (5.5%) demonstrated codon 249 mutation. This study suggests that, in Nigeria, especially the south-western region, aflatoxins appear to play a limited role in hepatocarcinogenesis.

Interferon alfa-2a (Roferon-A) in the management of chronic hepatitis B infection: results of an open prospective study in Nigerian patients

The efficacy and safety of recombinant interferon alfa-2a (rIFN) was evaluated in 26 adult Nigerian patients with chronic hepatitis B infection. Male and female patients with serological evidence of HBV infection (HBsAg and/or HBeAg positive patients) and abnormal liver histology were monitored for six months to confirm chronicity. At the end of the six months screening period eligible patient were enrolled into the study and treated with rIFN 4.5 MIU given three times a week for 6 months. Efficacy was assessed primarily by loss of HBV-DNA and/or HBeAg from serum and secondarily by loss of HBsAg and normalization of the liver histology. Safety was assessed by monitoring the leukocyte and platelet count over the treatment period whilst tolerability was assessed by recording the occurrence of adverse events (adverse drug reaction and intercurrent illness). At the end of therapy the response rate with respect to loss of HBV-DNA was 67% and 100% for HBeAg (i.e. for the six patients who were HBeAg positive at baseline). There was loss of HBsAg in 22.2% of the patients. A significant reduction in inflammation and necrosis scores was found among the 10 patients who had both baseline and term biopsies. The frequency of occurrence of adverse events was 53.8% and the laboratory safety parameters were not significantly affected by therapy (p > 0.05). 19.2% of the enrolled patients were withdrawn from the study prematurely. These results demonstrate that rIFN is effective in the management of CHB infection even in Nigerians. The high success rate associated with HBcAg clearance is particularly noteworthy.

The incidence and characteristics of some paraneoplastic syndromes of hepatocellular carcinoma in Nigerian patients

OBJECTIVE

To determine whether paraneoplastic syndromes of hepatocellular carcinoma such as erythrocytosis, hypoglycaemia, hypercholesterolaemia and hypercalcaemia are found in Nigerian patients with this tumour, and, if present, to determine their incidence and characteristics.

DESIGN

Consecutive patients with a diagnosis of hepatocellular carcinoma seen over a 10-year period at Ile-Ife, Nigeria, underwent haematocrit (100 patients), plasma glucose (65), cholesterol (65) and calcium studies (30). Shortage of laboratory reagents did not allow all the 100 patients to be tested for plasma glucose, cholesterol and calcium.

METHODS

Haematocrit was determined by the microhaematocrit method, and the glucose oxidase-peroxidase, Liebermann-Burchard and O-cresolphthalein complexone methods were employed for the estimation of plasma glucose, cholesterol and calcium respectively.

RESULTS

The haematocrit values ranged from 19 to 63% with a mean of 34.51% (SD 7.72). Only 1 out of 100 patients (1%) had erythrocytosis (haematocrit 63%). Sixty-five patients had their plasma glucose determined. The range of values for fasting plasma glucose (FPG) was 1-8.4 mmol/l with a mean of 4.3 (SD 1.6). Hypoglycaemia occurred in 18 patients (27.7%)(14 males, 4 females). The mean liver span for patients with FPG > 5.0 mmol/l was 16.87 cm (SD 3.03), while the value for those with FPG < 3.0 mmol/l was 22.0 cm (SD 6.14, P < 0.05). Plasma cholesterol was determined in 65 patients and the range of values was 2.1 -18.1 mmol/l with a mean of 5.65 (SD 2.42). Hypercholesterolaemia occurred in 16 patients (24.6%) (15 males, 1 female). The range of plasma calcium obtained in 30 patients was 1.6-3.15 mmol/l with a mean of 2.36 (SD 0.32). Three patients (10%) (all males) had hypercalcaemia.

CONCLUSION

While erythrocytosis has a low incidence, hypoglycaemia and hypercholesterolaemia are important paraneoplastic syndromes of hepatocellular carcinoma in Nigerian patients. The study confirms that the larger the liver mass, the greater the tendency towards hypoglycaemia. Also, the paraneoplastic syndromes studied occurred predominantly in hepatocellular carcinomas with cirrhosis.

Hepatitis D virus antigen in HBsAg positive chronic liver disease in Nigeria

Hepatitis B virus (HBV) is strongly associated with an aggressive type of chronic active liver disease (CALD) and hepatocellular carcinoma, which tend to present in the relatively young, in sub-Saharan Africa. It is known that co-existent infection with HDV tends to aggravate the course of HBV-associated liver disease. This study was carried out to determine the sero-prevalence of hepatitis D virus (HDV) among thirty one consecutive southwestern Nigerians with HBsAg-positive, HCV antibody-negative chronic liver disease. Alongside, we tested for HBsAg and the HDV antigen in fifty randomly selected sera each from blood donors and university freshmen undergoing pre-admission medical tests and who had no clinical evidence of liver disease. The HDV antigen (HDVAg) was found in the sera of two of 31 (6.5%) patients. Among the blood donors and university freshmen, HBsAg prevalence was twelve and eight per cent respectively, while HDVAg was present in none. In addition, liver biopsies of 28 other patients were stained for HDVAg. None of these was positive. These findings show that HDV prevalence is low in our community, and suggest that the virus might play only a minor role in the pathogenesis of HBsAg-associated chronic liver disease among our patients. A review of reports on the epidemiology of HDV in sub-Saharan Africa shows a rather complicated pattern that makes its impact on HBsAg-associated CALD difficult to assess. More studies designed to elucidate this pattern of HDV epidemiology are called for.

Abdominal tuberculosis with fatal gastro-intestinal haemorrhage

We describe a patient who presented with chronic diarrhoea and features of malabsorption, suspected clinically to be due to abdominal tuberculosis and who developed fatal haematochezia a few days into a therapeutic trial of antituberculous chemotherapy. At autopsy, multiple tuberculosis ulcers were found in the jejunum, ileum and descending colon.

Hepatitis B virus markers, hepatitis D virus antigen and hepatitis C virus antibodies in Nigerian patients with chronic liver disease

Although carrier rates for the HBsAg as well as the prevalence of HBV-associated chronic liver disease (CALD) are known to be high in Nigeria, not much is known about the role of the hepatitis C (HCV) and D (HDV) viruses. We undertook a prospective serological study of a cohort of 50 new patients and attending a Nigerian teaching hospital for various forms of histologically characterised chronic liver disease. Forty-five patients (90%) had antibodies to HBcAg (anti-HBcAb). Thirty one patients (62%) were HBsAg-positive, out of whom 15 were HbeAg-positive. Two (4%) of the HbsAg-positive patients, both suffering from liver cancer, were also hepatitis D antigen positive. Similarly, two (4%) patients were positive for anti-HCV antibodies. There were no cases of co-infection by the HBV and HCV. This study suggests that while the HBV is the major aetiological agent of chronic liver disease in Nigeria, the HDV is not an important aggravating factor save in a small number of patients. The HCV is probably not yet an important cause of chronic liver disease but this situation might change when HBV infection is controlled.

Diabetic mortalities in Ilesa, Nigeria: a retrospective study

Twenty five patients (15 males and 10 females) died out of a total of 114 diabetics (21.9 pc) admitted over a six year period. Fourteen of them were new cases diagnosed for the first time on presentation. Death occurred within 72 hours of admission for eight (57 pc) of these new cases. Among the 11 known diabetics who died, eight were clinic defaulters. Diabetic ketoacidosis (DKA) was the cause of death in eight (32 pc) of the patients studied and this proved to be the commonest cause of death. Results of laboratory tests for five patients were not available before their death and two patients with DKA could not afford the over the counter cost of insulin and normal saline as they were unavailable in the hospital pharmacy at the time of their presentation. This study clearly demonstrates that the risk of death among Nigerian diabetics is increased by a high defaulting rate and delayed diagnosis and treatment. This is further aggravated by the near absence of emergency laboratory services and drug shortages in the hospital.

Epidemiology and clinical presentation of a seasonal ataxia in western Nigeria

The epidemiological and clinical presentation in 37 patients (males/females 1.5:1, median age 37 years, range 12-85 yrs) with a seasonal ataxic syndrome of unknown etiology peculiar to parts of Western Nigeria is reported. All patients belonged to the low socio-economic strata, and all subsisted on a monotonous diet of high-carbohydrate meals with minimal protein supplementation. All patients consumed a stew containing the roasted larvae of Anaphe venata, a seasonal protein supplement peculiar to the area of endemicity in their last meals prior to the onset of disease. The clinical features seen in the patients studied were mainly those of acute cerebellar ataxia in all, with ophthalmoplegias and encephalopathy in the more severe cases. These features are remarkably similar to those of acute thiamine deficiency and the results in concert provide clinical and epidemiological support for an etiological hypothesis of acute thiamine deficiency in this seasonal ataxic syndrome.

Typhoid and paratyphoid fever: a retrospective study

Sixty-eight proved cases of typhoid and paratyphoid fever were reviewed in a retrospective study covering 5 years (1986-1990). Patients within the age range of 10 to 39 years constituted 82.3 per cent of cases and there was equal incidence in both sexes. The mean duration of illness before presentation was 9.67 days. The major clinical features were fever (97%), abdominal tenderness (-9.4%), headache and abdominal pain (70.58%) each). Intestinal perforation was the commonest complication (27.9%) with a male preponderance (M:F-3:1). Perforation occurred after the first week of illness in 73.7 per cent of cases. Fourteen out of the nineteen patients who perforated were not on therapy at the time of perforation and they constituted 80 per cent of those cases of mortality in which perforation played a role. Surgical management of perforation gave better results than conservative management (mortality rates of 16.7% and 40% respectively). Salmonella was sensitive to Chloramphenicol in all the cases where the organism was grown. There were 10 recorded deaths (14.9%) of whom 60 per cent (i. e. 6 patients) presented after two weeks of illness.