Prevalence of hepatitis B virus infection in the Gezira state of central Sudan

AIM

This is a cross-sectional study to determine the prevalence and risk factors for transmission of hepatitis B virus (HBV) infection in the Gezira state of central Sudan prior to the introduction of blood screening and vaccination against HBV.

MATERIALS AND METHODS

The study was carried out on the population of Um Zukra village in Gezira state of Central Sudan. The village was surveyed on five consecutive days in Dec 2000. Epidemiological characteristics were recorded and participants were interviewed for risk factors of viral hepatitis. Blood samples were then collected and tested for HBsAg and HBcAb.

RESULTS

A total of 404 subjects were screened with a mean age of 35 years; 54.9% were females, HBsAg and HBcAb were reactive in 6.9% and 47.5% of the studied population, respectively. Exposure to HBV increased with increasing age. The only significant risk factor for transmission of infection was a history of parenteral antischistosomal therapy.

CONCLUSION

This study shows that prevalence of HBV infection is high in the studied population and it is hoped that introduction of blood screening and vaccination against HBV would decrease the carrier pool in the next few years.

Prevalence and common genotypes of HCV infection in Sudanese patients with hepatosplenic schistosomiasis

A cross-sectional hospital based study was carried out at the National Center for Gastrointestinal and Liver Disease in Khartoum, Sudan to determine the prevalence, common genotypes and risk factors for hepatitis C virus infection in Sudanese patients with hepatosplenic schistosomiasis. A total of 176 patients with hepatosplenic schistosomiasis were tested for HCV antibodies and 4.5% of the samples were reactive. PCR was positive in 2.3% of cases and genotype 4 was the major genotype isolated with subtypes 4, 4e, and 4c/4d. It is concluded that HCV was of low seroprevalence in the study population and that parenteral antischistosomal therapy was not a significant risk factor in transmission of infection in the Sudan.

Presentation and management outcome of inflammatory bowel disease in Sudan

This is a retrospective study conducted at the National Center for Gastrointestinal and Liver disease in Khartoum, Sudan on patients diagnosed with inflammatory bowel disease (IBD) during the period between January 1990 and May 2001. The study was conducted to determine the pattern of presentation and management outcome of inflammatory bowel disease (IBD) among Sudanese patients. All patients underwent a colonoscopy/ sigmoidoscopy with histopathological diagnosis, or a barium study. Seventy three patients were diagnosed as Ulcerative colitis (UC), and twelve patients as Crohn's disease (CD). The majority of our patients with UC improved with medical treatment. We concluded that IBD is not a rare disease in Sudan, UC being more common than CD. The disease tends to be more common in men in both UC and CD.

Gastro-oesophageal reflux disease in Sudan: a clinical endoscopic and histopathological study

This study was conducted to assess the frequency of gastroesophageal reflux disease (GERD) and Barrett's esophagus among Sudanese patients with clinical symptoms of heartburn. One hundred and five patients were included in the study; forty seven patients had evidence of reflux oesophagitis, 61.7% of whom had grade B oesophagitis according to the modified Los Angeles classification and 10.6% had Barrett's oesophagus. 78.7% of the biopsies from the esophageal cardia revealed presenced of inflammation (Carditis). Dysplasia was documented in 21.3% of these biopsies. Helicobacter pylori was detected 59.6% of gastrooesophageal reflux disease patients and 56.8% of patients with carditis. However, 80% of patients with Barrett oesophagus were positive for Helicobacter pylori. It was concluded that gastro-oesophageal reflux disease affects all age groups with males being affected more than females and Helicobacter pylori infection did not play a major role in gastro-oesophageal reflux disease orits complications.

Familial achalasia in Sudan

An 8-month old Sudanese male child with a history of recurrent vomiting since the age of 4 months was referred for upper gastrointestinal edoscopy, which showed a dilated oesophagus and a tight lower esophageal sphincter. The child was diagnosed as having achalasia, which was successfully treated with pneumatic dilatation under General anaesthesia.

Endoscopic sclerotherapy for bleeding oesophageal varices: experience in Sudan

INTRODUCTION

Bleeding due to oesophageal varices is the commonest cause of upper gastrointestinal tract haemorrhage in Sudan. Endoscopic injection sclerotherapy (EST) is a valuable therapeutic modality for the management of variceal bleeding. Other options for treatment such as variceal banding are either expensive or unavailable.

STUDY AIMS

A retrospective study to evaluate the outcome of EST in the management of bleeding oesophageal varices due to portal hypertension in a developing country (Sudan).

PATIENTS AND METHODS

A total of 1070 patients over a period of 10 years (1986-1996) were studied. Inclusion criteria was bleeding oesophageal varices consequent to portal hypertension. EST was performed using a standard technique. Ethanolamine oleate 5% was the sclerosing agent utilized. The procedure was done on a day- case basis.

RESULTS

There were 904 males (84.5%) and 166 females (15.5%). The cause of portal hypertension was schistosomal periportal fibrosis (PPF) in 999 (93.3%) patients, liver cirrhosis 59 (5.5%), mixed PPF and cirrhosis 5 (0.46%), portal vein thrombosis 6 (0.64%) and congenital hepatic fibrosis was present in 1 patient. A total of 100 (9.4%) patients presented with bleeding which occurred after surgery. Full obliteration of varices required a mean of 4 sessions with a range of 2-6. 462 (43.2%) have been followed up until complete sclerosis of varices.

CONCLUSION

This study provides evidence that endoscopic injection sclerotherapy is an essential component in the management of bleeding oesophageal varices caused by portal hypertension. It is a feasible and a cost-effective therapeutic strategy in developing countries.

Peritoneoscopy: experience in Sudan

INTRODUCTION

The use of peritoneoscopy is an established method for diagnosis of intra abdominal diseases. In industrialized countries such as USA and Germany its use has declined with the advent of modern imaging techniques. However it is believed that there is an important rationale for its use in developing countries.

STUDY AIMS

A retrospective study to assess the value of peritoneoscopy in a developing country (Sudan).

PATIENTS AND METHODS

A total of 274 patients were included in this study. Peritoneoscopy was performed in the endoscopy theatre, using standard techniques. Biopsy specimens were taken, when required, from relevant tissues. The patients were closely monitored during and following the procedure.

RESULTS

Peritoneoscopy was indicated for assessment of hepatomegaly in 108 (39.1%) patients, exudative ascites 66 (24%), diagnosis of abdominal mass 48 (17.5%) and miscellaneous indications 52 (19.4%). The final diagnosis of all cases after peritoneoscopy included malignancies other than hepatocellular carcinoma (HCC) 81 (29.8%) patients, miscellaneous conditions 60 (21.8%), HCC 45 (16.4%), liver cirrhosis 26 (9.4%), abdominal tuberculosis 24 (9.4%), normal liver 16 (5.8%), hepatosplenic schistosomiasis (HSS) 15 (5.5%) and amoebic liver abscess 7 (2.5%). The peritoneoscopic appearance of HSS was very characteristic.

CONCLUSION

This large study confirms that peritoneoscopy has a high diagnostic yield and is a cost-effective technique for use in developing countries.

The role of hepatitis B and hepatitis C viral infections in the incidence of hepatocellular carcinoma in Sudan

In Sudan, the incidence of hepatocellular carcinoma (HCC) is high and increasing. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are important risk factors of HCC. This study aims to assess the role of HBV and HCV infections in the incidence of HCC in 2 regions of Sudan. A case-control study was conducted in 1996-98 among 150 HCC patients and 205 controls from 2 regions in Sudan. Their demographic characteristics as well as food habits and chronic conditions have been investigated. In this study, 115 cases and 199 controls were tested for hepatitis B surface antigen (HBsAg) and for HCV antibodies. Strong positive associations were found between HBV or HCV, and HCC with odds ratios (ORs) 9.8 (95% CI 5.1-18.9) and 8.3 (95% CI 2.3-29.9), respectively. After adjustment for age, by logistic regression, the ORs for HBV and HCV were 16.1 (95% CI 7.4-34.9) and 4.5 (95% CI 1.1-18.6), respectively. Further adjustment for region, education level and job type did not appreciably affect the results. Given a prevalence of HBV and HCV of 7.0% and 1.5% among controls, about 57% of all HCC cases can be attributed to these viral infections. Hepatitis infections seem to be important risk factors for HCC in Sudan.

Role of genetic polymorphism of glutathione-S-transferase T1 and microsomal epoxide hydrolase in aflatoxin-associated hepatocellular carcinoma

Exposure to aflatoxins is a risk factor for hepatocellular carcinoma (HCC). Aflatoxins occur in peanut butter and are metabolized by genetically polymorphic enzymes such as glutathione-S-transferases encoded by glutathione-S-transferase mu 1 gene (GSTM1) and glutathione-S-transferase theta 1 gene (GSTT1) and microsomal epoxide hydrolase encoded by epoxide hydrolase gene (EPHX). The rate at which aflatoxins become activated or detoxified may depend on polymorphisms in the encoding genes. GSTM1 homozygous deletion was indeed found to modify the association between peanut butter consumption and HCC. In this study, we investigate possible roles of GSTT1 and EPHX polymorphisms in this relationship. From a Sudanese case-control study on HCC, we analyzed data of 112 incident cases and 194 controls. All participants were interviewed using a standardized questionnaire inquiring about social and demographic factors, peanut butter consumption, and other known HCC risk factors. Univariate analysis showed that GSTT1 polymorphism was not associated with HCC, whereas EPHX 113HH and 139HH genotypes increased the risk of HCC (Odds ratio, 3.10; 95% Confidence interval, 1.18-8.12). Adjustment for age and region of origin slightly attenuated this association (Odds ratio, 2.56; 95% Confidence interval, 0.83-7.95). Interestingly, unlike GSTM1, both GSTT1 and EPHX polymorphism did not modify the association between peanut butter consumption and HCC. In conclusion, these epidemiological findings do not suggest significant roles of GSTT1 and EPHX in aflatoxin metabolism, although EPHX polymorphism is possibly related to the increased risk of HCC. Further studies are needed to investigate mechanisms by which the EPHX polymorphism potentially modifies cancer risk.

Laparscopic cholecytectoy: a local experience in Sudan

OBJECTIVE

Poverty, pressing priorities and tropical diseases prevailed added to the factors that delay the implementation of Laparoscopic Cholecystectomy (LC). The objective of this study was to assess the feasibility and safety of LC in this country (Sudan).

SUBJECTS AND METHODS

From June 1995-May 1999, we enrolled 288 patients presented with symptomatic gallstone disease without pre-selection criteria. 242 were females and 46 were males, mean age 48.1 years.

RESULTS

LC was successful in 201 (94.81%) patients including 49 patients with acute cholecystitis. The operation was done the same day of admission and 60 (29.35%) were able to leave as a day case. There was no mortality and no common bile duct injury.

CONCLUSION

LC is feasible, safe and cost effective in Sudan.

Does CagA contribute to ulcer pathogenesis in a developing country, such as Sudan?

BACKGROUND AND OBJECTIVE

In Western populations, peptic ulcer disease is closely associated with Helicobacter pylori (H. pylori) strains expressing the CagA antigen. In Africa the prevalence of H. pylori infection and peptic ulcer disease is high, although information regarding potential virulence factors is lacking. This study examines the prevalence of antibodies to CagA both in African patients with dyspepsia who are undergoing gastroscopy, and in asymptomatic healthy African volunteers.

METHODS

Eighty two consecutive patients (median age 34 years, range 15-73 years), attending for gastroscopy were studied, of whom 78 (95.1%) were subsequently found to be Helicobacter positive. Three antral biopsies were obtained from each patient and 5 ml of blood was taken for determination of CagA seropositivity using western blot analysis. CagA seropositivity was also determined in 65 H. pylori positive healthy volunteers (median age 30 years, range 18-70 years), with no symptoms or previous history of gastroduodenal disease.

RESULTS

Of the 78 H. pylori positive patients, CagA seropositivity was present in all 22 patients with active peptic ulcer disease (100%), in eight of nine patients with duodenitis (89%), in 15 of 19 patients with macroscopic gastritis (78.9%), and in 24 of 28 patients with a normal endoscopy (85.7%). On histological assessment, 46 patients had chronic active gastritis, 29 patients had gastritis with atrophy and three patients had intestinal metaplasia. CagA seropositivity rates were 84.7%, 93% and 100%, respectively, for these groups. In the 89 healthy volunteers studied, 57 of the 65 H. pylori positive subjects (87.7%) were seropositive for the CagA protein.

CONCLUSIONS

As in Western countries, CagA seropositivity in this African population was closely related to endoscopic gastroduodenal disease, and to the presence of more advanced histological lesions in the antrum. However, there was also a high prevalence of CagA seropositivity in asymptomatic healthy individuals, suggesting that factors other than CagA predominate in ulcer pathogenesis in this population.

Seasonal variation in the incidence of endoscopically diagnosed duodenal ulcer in Sudan

The seasonal pattern of endoscopically diagnosed duodenal ulcer disease in an endoscopy unit in Suba University Hospital and Ibn Sina Hospital, Sudan, was evaluated retrospectively for the period 1980-1988. We reviewed all the 12443 endoscopy records and found 1348 cases of duodenal ulcers. The incidence of duodenal ulcer was then calculated for each month separately. We found that in Sudan the frequency of duodenal ulcer is significantly higher during winter (January-February), and significantly lower during summer (May-August).

Acarboxy prothrombin (PIVKA II) as a tumour marker for hepatocellular carcinoma and other liver diseases

The clinical usefulness of plasma abnormal prothrombin, defined as protein induced by vitamin K absence or antagonist II: (PIVKA II) as a tumour marker for hepatocellular carcinoma (HCC) and other liver diseases has been evaluated. PIVKA II concentrations were determined using an enzyme-linked immunosorbent assay (ELISA) with monoclonal antibody that reacts with PIVKA II but does not cross-react with normal prothrombin. Seventy four patients (74%) out of 100 with HCC had abnormal PIVKA II levels above 0.5 AU/ml (median = 3.4 AU/ml). The level was above 1.0 AU/ml in 66 (66%) of the patients. In contrast the level of PIVKA II was low in patients with bilharzial periportal fibrosis (median = 0.09 AU/ml), patients with liver cirrhosis (median = 0.13 AU/ml), patients with hepatitis (median = 0.025 AU/ml), and essentially undetectable in all the 34 controls. The diagnostic ability of serum alphafoetoprotein (AFP) was also evaluated in these patients. AFP alone can diagnose 51% of the HCC cases. Of the remaining patients with low or negative AFP levels (65%) can be diagnosed using PIVKA II. Abnormal prothrombin is a potential marker for the laboratory diagnosis of hepatocellular carcinoma.

Detection of Helicobacter pylori in endoscopic biopsies in Sudan

We studied the prevalence of Helicobacter pylori in Sudanese subjects with gastroduodenal inflammation. H. pylori was looked for in biopsy specimens taken from the antrum by two methods: rapid urease test [Campylobacter-like organism (CLO) test] and culture using Skirrow's selective supplement. One hundred subjects were studied. H. pylori was found in 80% of patients with gastritis, 56% of patients with duodenal ulcer, 60% of patients with duodenitis and 16% of normal control subjects. It was neither detected in patients with gastric ulcer, nor in patients with oesophagitis or in those with oesophageal varices due to schistosomiasis, when using culture. However, it was found in 50% of patients with oesophagitis, when using CLO test.

Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy: experience in the Sudan

Over a 5 year period 626 endoscopic retrograde cholangiopancreatography (ERCP) examinations were attempted in Khartoum, Sudan. The relevant duct was successfully cannulated and visualized in 94% of cases of biliary tract disease and in 73% of cases of pancreatic disease. This was due to the large number of cases with advanced pancreatic cancer. The commonest abnormal finding was stones in the biliary tree in 214 cases (35% of all cases). Cholangiocarcinoma was seen in 18 cases, pancreatic cancer in 64 cases, chronic pancreatitis in 48 cases and periampullary carcinoma in 20 cases. ERCP was considered normal in 100 cases. Endoscopic sphincterotomy (EST) was performed in 48 cases; 44 had common duct stones. ERCP and EST are feasible and useful procedures in a developing country. However they are expensive and should be carried out in referral centres.

Hepatitis B virus markers in patients with schistosomiasis, liver cirrhosis and hepatocellular carcinoma in Khartoum, Sudan

Markers of hepatitis A and B virus were tested in 88 adult Sudanese subjects in Khartoum, Sudan. The subjects consisted of 25 control hospitalized patients, 21 volunteer blood donors, 23 patients with hepatosplenic schistosomiasis, 13 patients with liver cirrhosis and 6 patients with hepatocellular carcinoma (HCC). Antibody to hepatitis A virus was detected in 96% of the total. Hepatitis B surface antigen (HBsAg) was positive in 4, 24, 22, 31, and 67% of the subject groups, respectively. Antibody against hepatitis B core antigen (HBcAb) of undiluted serum was positive in 60, 57, 65, 77 and 83%, and there was no difference in incidence among the groups. It was positive in 200X diluted serum in 4, 24, 17, 23 and 60%. HBsAg and HBcAb (200X) were detected more often in HCC patients than in the control subjects (p less than 0.01). Hepatitis B virus is an important factor in the etiology of HCC in the Sudan.

Endoscopic retrograde cholangiopancreatography in Sudanese diabetics

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 40 Sudanese patients with diabetes mellitus. 25 were insulin-dependent and 15 were noninsulin-dependent. ERCP was normal in all the patients with insulin-dependent diabetes. Two patients with noninsulin-dependent diabetes had pancreatographic changes compatible with minimal-change pancreatitis. Diabetes mellitus in Sudan unlike in other tropical countries is not associated with structural changes in the exocrine pancreas.

The xylose absorption test in normal Sudanese subjects

The xylose absorption test was carried out in 50 healthy Sudanese men. The 5 g d-xylose oral loading dose was used. Nine subjects (18%) had a d-xylose absorption below the normal range. Thirty of the subjects were of low socioeconomic status and 20 of the subjects were of middle socioeconomic status; there was no difference in the xylose absorption between the two groups.

The pathology of the small intestine in human schistosomiasis mansoni in the Sudan

Peroral small intestinal biopsies were obtained from 17 patients with Schistosoma mansoni infection and 13 control subjects. There was no difference between the dissecting microscopic appearances of patients and controls. The histological sections of patients showed significant shortening and broadening of villi compared to controls. There was no significant difference in the cellularity of the Lamina propria between patients and controls except that patients had significantly more eosinophils. The biopsies from the control subjects showed appearances of tropical enteropathy.

Acute gastric dilatation following upper gastrointestinal endoscopy

A patient who developed symptoms and signs of acute gastric dilatation following upper gastrointestinal endoscopy is described. Relations of endoscopy to the development of the condition are discussed.

Exocrine pancreatic function in hepatosplenic schistosomiasis in the Sudan

Exocrine pancreatic function was studied in 36 patients with hepatosplenic schistosomiasis and 31 control subjects. The secretin test and the Lundh test meal were used to assess exocrine pancreas function. Patients with hepatosplenic schistosomiasis had a significantly lower bicarbonate concentration, less than 90 mmol/l in duodenal aspirate, than the control group (p less than 0.001). There were statistically insignificant differences in the volume of the duodenal aspirate after the secretin test and in the mean tryptic activity after the Lundh test meal between patients and controls. We conclude that exocrine pancreatic function is impaired with regard to bicarbonate secretion in hepatosplenic schistosomiasis.

The effects of sorghum and wheat bran on the colonic functions of healthy Sudanese subjects

The effects of sorghum and wheat bran were compared and contrasted in a group of healthy Sudanese subjects. Ten medical students were studied while taking their normal diet, a diet of 20 g/day of sorghum bran and a diet of 20 g/day of wheat bran, each for 3 wk. Toward the end of each dietary period the wet stool weight, gut transit time, and frequency of bowel evacuation were estimated. The mean stool weight on normal diet was 136.6 +/- 43.1 g/day, on sorghum bran 173.3 +/- 48.4 g/day, and on wheat bran 219.1 +/- 98.3 g/day. The increase produced by wheat bran was significant, p less than 0.001. Both brans produced a similar number of bowel evacuations. The results suggest that sorghum bran, which is both cheap and readily available in the Sudan, produces a similar number of bowel evacuations to those of wheat bran without significantly affecting stool weight or transit time.

Upper gastrointestinal fibreoptic endoscopy experience in the Sudan. Analysis of 2500 endoscopies

The results of 2500 upper gastrointestinal fibreoptic endoscopies carried out at Soba University Hospital, Khartoum, between January, 1980, and June, 1982, were reviewed. 42% of the patients had no disorder visible on endoscopy, 9% had oesophageal varices, 0.7% gastric ulcer, 17% duodenal ulcer, and 2% pyloric obstruction. Duodenal ulcer was seen more commonly in men (male/female ratio 4.5/1) and in young people. Endoscopy is a feasible procedure in developing countries. It is more informative and cheaper than barium meal radiology.

Changes in certain blood constituents during Ramadan

Fasting serum cholesterol, triglycerides, thyroxine, triiodothyronine, uric acid, gastrin, and insulin were measured in a group of 24 Muslims at the beginning and end of Ramadan--the Muslim month of fasting. There was a significant increase in the levels of total serum cholesterol, thyroxine, and uric acid and a significant fall in body weight. There was no significant change in the levels of total serum triglycerides, triiodothyronine, gastrin, insulin (fasting), or in the rise in gastrin or insulin 1/2 h after food. These changes, although unlikely to affect normal people, may be significant in patients. Physicians working in Muslim countries should be aware that Ramadan may affect some laboratory findings.

Serum immunoreactive trypsin in beta-thalassaemia major

To assess the exocrine pancreatic function in beta-thalassemia major with iron overload, serum immunoreactive trypsin (IRT) was measured in 38 patients with this condition. In 23 (60%) patients' IRT was abnormal: it was subnormal in 16 patients and supranormal in seven. Whereas subnormal IRT concentrations were more frequent in patients of more than 12 years old, supranormal IRT concentrations were more frequent in younger patients. These data provide the first antemortem evidence of exocrine pancreatic damage in this condition. They also suggest that this acinar cell damage is initially associated with a rise in IRT which is followed by a fall in the serum concentration of this enzyme.

Effect of coffee on human lower oesophageal function

The effect of coffee on lower oesophageal sphincter pressure (LOSP) and intraoesophageal pH was assessed in 10 healthy volunteers, in the fasting state and after a standard Lundh test meal. LOSP was measured by the rapid pull-through technique. Coffee with or without milk has no significant effect on LOSP in the fasting subject. The Lundh meal alone (mean drop = 2.01 cm H2O), or when coffee with (mean drop = 1.80 cm H2O) or without milk (mean drop = 3.47 cm H2O) was taken after it, produced a significant drop in LOSP. Heartburn following coffee does not appear to be due to an effect of coffee on the lower oesophageal sphincter but is more likely due to the effect of a previous meal on sphincter pressure with associated acid reflux.

Trypsin and lactoferrin levels in pure pancreatic juice in patients with pancreatic disease

Levels of immunoreactive trypsin were measured in pure pancreatic juice obtained endoscopically from 44 patients with suspected pancreatic disease. Patients with pancreatic cancer all had low trypsin concentrations (median 3.6 micrograms/ml, range 0.6--12.0), but those with chronic pancreatitis had very variable levels (median 14.2 micrograms/ml, range 3.2--76.8), showing a considerable overlap with patients without pancreatic disease (median 37.1 micrograms/ml, range 10.4--66.0). When levels of lactoferrin in pancreatic juice were measured, all patients with chronic pancreatitis were found to have much higher levels (all greater than 900 ng/ml) than control subjects or patients with pancreatic cancer (all less than 400 ng/ml). The combined measurement of trypsin and lactoferrin in pure pancreatic juice appeared to be more promising than any other currently available test for the separation of patients with pancreatic cancer from those with chronic pancreatitis.

Radioimmunoassay of lactoferrin in pancreatic juice as a test for pancreatic diseases

Lactoferrin, a protein present in pancreatic juice and other exocrine secretions, was measured by radioimmunoassay in pure pancreatic juice obtained by endoscopic cannulation of the pancreatic duct. Lactoferrin concentrations were high in pancreatic juice from patients with chronic pancreatitis, but they were considerably lower in juice from control subjects and patients with carcinoma of the pancreas. The measurement of lactoferrin concentrations in pure pancreatic juice may be useful in the diagnosis of pancreatic diseases.