Inflammatory Bowel Disease in Adults - Experience and Challenges in Gastroenterology Practices in Calabar, South-South Nigeria

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract that is reported to be rare in Africans. The objective of this study is to share the experience of our Gastroenterology practice in Calabar, Cross River State on IBD.

METHODS

This is a ten-year review of the records of patients visiting the Gastroenterology clinic of the University of Calabar Teaching Hospital and two private gastroenterology clinics in Calabar Municipality. The diagnosis of IBD was made based on clinical, laboratory, endoscopic, and histological data obtained.

RESULTS

Eight patients presented with features consistent with IBD. Six had ulcerative colitis while 2 had Crohn's disease. Seven patients had moderate disease with the main clinical features being recurrent mucoid bloody diarrhoea. All the patients had treatments with either sulphasalazine or mesalazine as well as azathioprine, steroids and antibiotics with variable response. One patient had strictures requiring a colostomy, while another developed colorectal cancer as complications of IBD.

CONCLUSION

Although IBD is uncommon in Nigeria, a high index of suspicion is important, especially in patients presenting with the recurrent passage of mucoid bloody stools. Hence, the role of colonoscopy and histology are invaluable in establishing the diagnosis.

Knowledge of hepatitis B virus infection among traders

INTRODUCTION

Hepatitis B virus (HBV) is a public health problem in Nigeria, with 13% of its general population having evidence of a previous or current infection. Lack of awareness of HBV, its risk factors, and its consequences are recognized as major deterrents to adopting positive preventive behavior including immunization among HBV high-risk groups.

OBJECTIVE

The objective of this study is to evaluate the knowledge, attitude, and practice (KAP) of HBV infection among traders.

MATERIALS AND METHODS

A structured KAP questionnaire on HBV infection was administered to traders as part of the activities to mark the World Hepatitis Day in 2014. A score was created for the correct answer to 20 questions.

RESULTS

A total of 335 traders were interviewed for this study. The mean age was 33.08 ± 13.8 years and the median age was 29 years. There were 165 males and 170 females. Majority of the traders had secondary education (57.1%) and were of the Ibibio and Igbo tribes. Only 10.4% had HBV vaccination. Only 44.2% of the traders reported having any knowledge of HBV. The most common source for the knowledge was television/radio (25%) and hospitals (22%). The median (interquartile range) of the overall KAP score was low (11, 5-16). The score was least in persons aged 35 years and above, but the difference was not statistically significant (P = 0.33).

CONCLUSION

The knowledge of HBV is low among traders in Calabar metropolis. There is need to intensify educational campaigns for the general public.

Trauma death in a resource constrained setting: mechanisms and contributory factors, the result of analysing 147 cases

AIMS AND OBJECTIVES

The objective of the following study is to analyze the trauma type (causes), injury pattern and factors that may have contributed to death within 72 h of admission into our emergency department (E.D).

MATERIALS AND METHODS

An 18 month prospective observational study, done from April 2009 to September 2010. All the patients were that admitted for 72 h following a full assessment by the attending clinician were enlisted for the study. The demographic data of each patient, time of arrival at the E.D, type of injury sustained, time of incident, previous care at any peripheral hospital, clinical state of the patient, Glasgow coma scale (GCS), Injury severity score (ISS) and treatment offered before death were entered into a Proforma.

DATA ANALYSIS

This was done using EPI-Info statistical programme version 3.4.3 of 2007(by CDC Atlanta Georgia , USA).

RESULTS

A total of 4011 patients were seen in the E.D during the period. 1943 (48.4%), were trauma emergencies, with a (147; 41.4%) mortality. Their ages ranged from 4 to 87 years, with an average of 34.5 years. The male:female ratio was 7:1. The assessed GCS ranged from 6 to 15, with an average of 9.1, the ISS ranged from 9 to 75 with an average of 31.3. Road traffic accidents (RTAs) accounted for 118 (80.3%) of the deaths, assaults 14.3%, falls from height 4.0% and gunshot injuries 1.4%. The overall mortality was 17.1%.

CONCLUSION

The major source of trauma death was RTA; The most frequently injured part of the body was head, with death resulting clinically hemorrhage. The 17.1% mortality is multifactorial: The late presentation (in some cases occasioned by interference by persons not knowledgeable in the basics of trauma care) lack of trained personnel and the systemic deficiencies.

Functional disturbances in children after ano-rectal surgery

OBJECTIVE

To determine the prevalence, clinical presentation, highlight management methods and outcome of treatment modalities in children who presented at the University of Calabar Teaching Hospital, Calabar with complications from previous ano-rectal operations.

DESIGN

Prospective study of ano-rectal complications from previous ano-rectal surgery in children over a seven year period.

SETTING

University of Calabar Teaching Hospital, Calabar, a referral and teaching hospital.

SUBJECTS

All cases of complications from previous ano-rectal surgery in children that presented at the paediatric surgical clinic of the University of Calabar Teaching Hospital (UCTH), Calabar, between January 1994 and December 2000.

INTERVENTION

Conservative measures were commenced in all cases and involved diet manipulation, enema and physiotherapeutic training.

RESULTS

The age of maximum presentation was within the 6-10 year age bracket. The main presenting complain was faecal soilage and poor bowel habit. The children notably presented late and was as a result of societal embarrassment at school. Before then the child was within the home environment hence parents may not bother. Complications from anal agenesis operation accounted for the majority of patients 45(54%) while aganglionic megacolon accounted for 39 patients (46%). Treatment in all cases started conservatively with diet manipulation, cleansing enema and physiotherapeutic training. However, with non improvement in faecal soilage, a simple repair involving a narrowing at the ano-rectal junction was carried out. In a follow-up period of between 6-12 months, 45 children had satisfactory clinical status while in 27 children their general conditions had improved.

CONCLUSION

Perseverance and tolerance from the surgeon, the parents and the patient-child is required in these conditions. The late presentation may have helped as the fibres of the external sphincter muscles perhaps have further developed. At this period the child is also psychologically aware of his problem.

Oestrogen and progesterone receptors in Nigerian breast cancer: relationship to tumour histopathology and survival of patients

BACKGROUND

Expression of oestrogen receptors (ER) and progesterone receptors (PR) in breast carcinomas identifies patients that are more likely to respond to adjuvant therapy.

OBJECTIVES

Our aim was to evaluate the prevalence and prognostic value of histologically confirmed ER and PR immunoreactivity in breast carcinoma seen at Calabar, Nigeria.

DESIGN

Cross sectional study.

SETTING

University of Calabar Teaching Hospital, Nigeria.

SUBJECT

Sections of formalin-fixed, paraffin-embedded samples from 129 breast carcinomas were immunostained for ER and PR.

RESULTS

ER and PR were immunohistochemically detected in 24.0% and 13.9%, respectively, of the breast carcinomas. The staining results were significantly associated, though negatively, with the axillary lymph node status, clinical stage, and histological grade. In survival analysis of the whole material, neither ER nor PR positivity showed any prognostic value. In the premenopausal group, both ER and PR showed a prognostic potential. However, they had no independent prognostic value.

CONCLUSION

Further studies to assess the frequency and prognostic values of these hormone receptors in breast cancers, after standardized processing and a longer follow up period may be necessary to validate these findings. Furthermore, a consensus must be developed for scoring and reporting ER/PR in Nigerian material.

Tubular differentiation in African breast cancer

In an effort to determine numerical thresholds for histological breast cancer grading, we evaluated the fraction of fields with tubular differentiation (FTD) in Nigerian breast cancers (n=300). Analyses were based on Kaplan-Meier survival curves, and univariate and multivariate analyses by Cox's regression. The mean (SD) value of FTD in Nigeria, 16.7 (19.3)%, was much lower than reported in European breast cancer. Decreasing FTD was associated with increasing histological grades (p < 0.0001) and clinical stage (p = 0.0190). The most significant cut-point for FTD in predicting outcome was 15.0%. In univariate analysis, FTD 15% was a significant prognosticator in the whole material, in larger than 5cm tumours, among postmenopausal and premenopausal patients, and LN+ patients. After multivariate analysis with mitotic count, FTD was an independent prognosticator among tumours larger than 5cm, but not in other groups. We conclude that the rational grading of breast cancers need be optimised according to diagnostic and therapeutic environment. We propose FTD 15% as a cut-point to grade breast cancer in Nigerian material.

Influence of age and prognosis of breast cancer in Nigeria

OBJECTIVE

To determine the relationship between the age at diagnosis and established prognostic factors of breast cancers in Calabar, Nigeria. Attempts made to assess the prognostic value of age at presentation.

DESIGN

Retrospective study of invasive breast cancer seen in Calabar over a seventeen-year period. Pearson's correlation, univariate and multivariate Cox's regression were used.

SETTING

University of Calabar Teaching Hospital, Calabar, Nigeria, a referral and teaching hospital.

SUBJECTS

Three hundred cases of invasive breast cancer diagnosed between 1983 and 1999 in Calabar, Nigeria. The necessary follow-up data was available for 129 patients.

RESULTS

The mean age at diagnosis of breast cancer in Nigeria was 42.7 years (SD 12.2, range 18-85 years). Patients less than 40 years accounted for 39.8% of the total number of patients with infiltrating breast carcinoma. In the whole material (n=300), there was a positive association between age and tumour size (r=0.44, p=<0.0001), stage (r=0.47, p=<0.0001), the degree of necrosis (r=0.21, p=0.0002), histological grade (r=0.11, p=0.0476), MAI (mitotic activity index, r=0.12, p=0.0338), and MNA (mean nuclear area, r=0.17, p=0.0033). The correlation between age and SMI (standardized mitotic index), AI (apoptotic index), SMI/AI ratio, and FTD (fraction of fields showing tubular differentiation) were not statistically significant. The optimal decisive prognostic cut point for age was 33 years (p=0.0064). Age was also a significant prognosticator when used as a continuous variable (p=0.0240). Survival was better in the younger patients. However, in the Cox's multivariate analysis involving SMI, tumour size and age (both as a continuous variable and using the determined cut point of 33 years), the age at diagnosis lacked an independent prognostic value.

CONCLUSION

The more advanced nature of breast cancers and the possible more aggressive tumours (reflected by the higher MNA values) in the older patients may explain the poorer survival seen in patients diagnosed at 40 years or above. It is also probable that the lifestyle differences between the two studied age groups may influence the early detection and prompt commencement of therapy. Screening and treatment approaches between the two age groups may differ in view of the differences.

Breast cancer in Nigeria and Finland: epidemiological, clinical and histological comparison

BACKGROUND

We compared the histology and patterns of occurrence of breast cancers in Nigeria (n = 297) and Finland (n = 285).

PATIENTS AND METHODS

The histology of invasive ductal carcinoma (IDC) was re-evaluated using similar criteria. The clinical data were extracted from medical records.

RESULTS

The mean age at presentation was 42.7 (12.2) years in Nigeria vs. 58.7 (12.5) years in Finland. In both populations there was an association between reproductive factors and the occurrence of breast cancer. In Nigeria, 53.2% of cases belonged to stages 3 and 4 (vs. 6.7% in Finland). In Finland there were higher frequencies of lobular, tubular and mucinous types than in Nigeria. The Nigerian material had more medullary type (2.7% vs. 0.7% in Finland), extensive necrosis, nuclear atypia and pleomorphism, with coexisting pleomorphic ductal carcinoma in situ. At 2 years after treatment, the survival figures for Nigeria and Finland were 72.8% and 96.4%, respectively.

CONCLUSION

The histology of Nigerian and Finnish cancers clearly differ. Nigerian cancers appear more advanced with higher grade. The atypical in situ component is clearly more common in Nigeria. Part of the differences can be explained by diagnostic and treatment delays associated with misguided socio-cultural beliefs, poor health care access and impaired immunity.

Intestinal obstruction in southeastern Nigerian children

In a 10-year (1981-1990) retrospective study of acute intestinal obstruction in the University of Calabar Teaching Hospital, Calabar, Nigeria, of the 295 paediatric cases reviewed, the major causes were ascaris worms (25%) and intussusception (22%). Other important lesions include imperforate anus (11%), volvulus (10%), external hernias (9%) and adhesions (7%) each. Ascaris-induced and hernial obstruction were most rampant in children aged above 5 years while intussusception had its peak frequency at the ages one to 12 months. Intussusception was largely (95%) ileo-caecal; volvulus involved mainly the ileum and ileo-caecum in 50% of cases each. The obstructed hernias were more common in the umbilicus (59%) than the groin (41%). The mortality (13%) was chiefly due to associated infection but lack of expertise in management of cases cannot be ignored. Generally, the pattern of intestinal obstruction among children in this region appears markedly different from that seen in Europe and North America. There is a need to create a specialist paediatric surgical unit as a means of reducing morbidity and mortality from this condition.