How often are Ghananian gallbladder stones cholesterol-rich.

BACKGROUND: Although the prevalence of symptomatic gallbladder stone disease in Ghana increased almost four-fold between 1966 and 1991, little is known about the composition of and aetiopathogenesis of these stones, nor about their suitability for non-surgical (dissolution) treatments. METHODS: To study this, gallstones from 67 out of 90 patients coming to cholecystectomy were retrieved and, based on their external appearance, classified provisionally as cholesterol(chol) (n = 8), black pigment (n = 28) and brown pigment (n = 31) stones. The gallstones were then homogenised, their cholesterol(chol) content measured chemically and the stones re-classified as cholesterol-poor (< 10% chol by weight), intermediate (10-75% chol) and cholesterol-rich (> 75% chol). The relationship between the initial and the definitive classifications was then examined and the biliary bacteriology (carried out on fresh samples of gallbladder(GB) bile obtained by fine needle aspiration) on gallstone composition, analysed. RESULTS: The external appearance correctly predicted stone composition in the 28 thought, initially, to have black pigment stones (all of whom had stones containing < 10% chol by weight, on chemical analysis) and the eight believed, originally to have "cholesterol" stones (all of whom had stones with > 75% chol) but it proved unreliable in the 31 considered, at the time of surgery, to have brown pigment stones (mean chol content 58+ SEM 35%; range 0-98%. By chemical analysis, more than half the patients 35 of 67 or 52% had cholesterol-poor stones, nine (13% of the total) had intermediate stones, while 23 (34%) had cholesterol-rich stones. Cholesterol-rich gallstones were also more frequent in women than in men (p < 0.03). Only nine of 43 patients (21%) whose GB bile was aspirated, had positive bacterial cultures. There was no obvious difference in stone composition between those with positive, and those with negative, cultures. CONCLUSION: Since the majority of Ghanaian patients with cholecystolithiasis have gallbladder stones with < 75% chol by weight, when active treatment is indicated surgery is more appropriate than dissolution therapy. However contrary to common belief, cholesterol-rich gallstones do occur in West Africa: 34% of the present series had stones with > 70% chol by weight.

Changing pattern of intestinal obstruction in Accra, Ghana.

BACKGROUND/AIMS: Over the past 50 years acute intestinal obstruction has remained among the commonest causes of the acute abdomen, along with peritonitis, appendicitis and gastrointestinal perforations. However several observers have noticed over the past 2 decades a shift in the etiological spectrum. The study aims at ascertaining the precise nature of the change. METHODOLOGY: Published data on intestinal obstruction from the Korle Bu Teaching Hospital over the past 50 years were reviewed, as the consistent report format permitted ready comparison of the series. Emphasis was placed on clinical features, established cause and resulting complications. RESULTS: The case load of intestinal obstruction has dwindled over the past 3 decades, accounting for 0.7% of all hospital admissions compared with 1.4% 30 years earlier. External hernias together with adhesive bands still constitute the bulk of presenting cases, but the proportions have changed with strangulated hernias accounting for 59.8% instead of 77.6%. The change has paralleled a rise in elective hernia day case surgery. The incidence of intussusception has almost doubled (7.4% from 4.0%) and it still afflicts the very young. Colonic neoplasms have been commoner over the past 2 decades although the incidence (3.3%) falls short of Western figures. Overall mortality has remained unchanged at 9.4% and this has been associated with a rise in resection rates to 18.3%. CONCLUSIONS: The patterns of intestinal obstruction have been much influenced by changing attitudes regarding elective hernia surgery and evolving financial policies.

Clinical spectrum of acute abdominal pain in Accra, Ghana.

In a 12-month prospective study 370 patients with acute abdominal pain were admitted to a single surgical unit of a large teaching hospital. The most common diagnoses were appendicitis (23.5 percent), Non-specific abdominal pain (NSAP) (21.4 percent), acute intestinal obstruction (10.8 percent), gynaecological causes (9.5 percent, and peptic ulcer (9.2 percent). Emergency operations were performed in 146 patients (39.5 percent). Appendicectomy was the commonest operation (77 cases or 52.7 percent) and there was a high incidence of complicated appendicitis (41.6 percent). Eleven patients (3.0 percent) died within 30 days of admission (8 postoperative and 3 non-operative deaths). The clinical spectrum of the acute abdomen in this study shows that surgeons in developing countries are not facing surgical challenges similar to those of their counterparts in developed countries and the most important diagnostic distinction surgeons in both localities have to make is that between acute appendicitis and non-specific abdominal pain.

Effect of acute dietary fibre supplementation on colonic pH in healthy volunteers.

Dietary fibre and undigested starch are fermented to short chain fatty acids by colonic bacteria with acidification of the colon. It has been suggested that acidification of the colon by these fatty acids inhibits bacterial metabolism, but this concept has been disputed. The aim of this study was to investigate the short term effect of a dietary fibre load on colonic metabolism. Colonic pH and breath hydrogen was measured in healthy omnivorous British male volunteers following ingestion, in turn and at weekly intervals, of 15g lactulose, wheat bran biscuits, oat bran biscuits and ispaghula husk. All the test meals caused a reduction in caecal pH and an increase in breath hydrogen production. The changes were greatest with lactulose. Lactulose and wheat bran caused acidification of the right and left colon whereas oat bran and ispaghula husk caused acidification of mainly the right colon. An inverse correlation between right colonic pH and breath hydrogen was observed in only the oat bran study. This study has demonstrated the ability of dietary fibre to lower right colonic pH and to increase breath hydrogen excretion. The changes were greater with soluble fibre than with insoluble fibre but the change in luminal pH was persistent all round the colon with insoluble fibre.

Effect of chronic dietary fibre supplementation on colonic pH in healthy volunteers.

Dietary fibre supplementations studies to evaluate the effect of dietary fibre on colonic and faecal pH have relied on the use of the unabsorbed disaccharide and osmotic laxative lactulose. We studied the effect of chronic dietary fibre supplementation on colonic pH in healthy British volunteers who consumed a normal mixed diet but who consumed a normal mixed diet but who were asked to double their daily intake of dietary fibre from their usual fibre sources. The median dietary fibre intake of the 5 male volunteers was 17.5 g/day. This was doubled to 34.4 g/day. The pH in all the parts of the colon decreased progressively during the period of study, being lowest at the end of two weeks of fibre supplementation. The pH returned to the presupplementation values within two weeks of cessation of fibre supplementation. This study has shown that the effect of dietary fibre on colonic pH is short-lived and therefore its use for dietary intervention in large bowel diseases should be indefinite.

Acute appendicitis and dietary fibre intake.

It has been postulated that acute appendicitis is the first serious disease to emerge with the adoption of fibre-depleted diets. The incidence of acute appendicitis is rising in Africa and this has been attributed to socio-economic advancement and the adoption of low residue diets. The aim of this study was to determine whether income levels and the level of dietary fibre intake play any role in the rising incidence of acute appendicitis in Ghana. Between June and November 1997 patients aged 13 years and above with acute appendicitis were studied. Their monthly net income levels or those of their parents if they were minors were ascertained and a dietary fibre questionnaire completed on each patient in order to assess his or her dietary fibre intake. The clinical details of each patient were recorded on a proforma. One hundred and seventy-three patients, 128 males and 45 females, mean age 29.2 (range 13-75) years were studied. 14 percent presented within 6 h, 46.8 percent within 24 h and 41.6 percent after 2 or more days. 53.2 percent had acute appendicitis and 42.8 percent presented with complicated appendicitis. The appendix was normal in 4.0 percent. Two patients died (1.2 percent). 61.3 percent of patients were low income earners and 38.7 percent were high income earners. The overall dietary fibre intake was 39.4 g per day with no significant difference in fibre consumption between low income earners (39.0 g/day) and high income earners (43.5 g/day). We conclude that dietary fibre may not be the important factor in acute appendicitis and other luminal and/or morphological factors may be predisposing factors.

Day surgery at Korle Bu Teaching Hospital: a six year review.

Day surgery is not simply a matter of economics for the health institution or the individual patient, or improved utilization of scarce and dwindling resources, or even a matter of increasing access to health care, fundamental as this is to us in the developing world. The ultimate question is to what extent does it satisfy the true needs of the patient and meet the requirements of his care as a whole. To address this day surgery in a general surgical unit has been reviewed over a 6 year period. This covered a total of 1547 cases consisting of hernias, hydroceles, excision biopsies, varicose veins etc. Infiltrative local anaesthesia using lignocaine (4 mg/kg) mostly with 1 in 200,000 adrenaline added proved effective in 98 percent of cases; there were no deaths. For the institutions day surgery has proven cost effective, lowering cost of operative treatment and improving utilization of scarce resources. It has also proven eminently acceptable to patients and their families, enhancing access to care and significantly reducing the personal cost of treatment. To demonstrate enhanced health economics future studies should ideally show a parallel diminution of in-patient bed facilities with increasing load of day surgery.

The changing pattern of cholelithiasis in Accra.

One hundred and sixty-five cholecystectomies were performed in the 12 year period 1980-1991 Only 67 were performed in the first 10 year period but in the last 2 years (1990-1991), 98 patients underwent cholecystectomy. While patients with biliary tract disease occupied 0.4% of General Surgical beds in 1966-68 patients for cholecystectomy now occupy 1.5% of all General Surgical beds. The rising incidence of gall stone disease is the result of a genuine increase in the incidence as well as better diagnosis supported by the use of ultrasonography.

The microflora of bile in Ghanaians.

Bile was obtained from the gall bladder of 104 patients undergoing cholecystectomy for gall stone disease. Bile was also obtained from the common bile duct and T-tube of 17 patients who also had exploration of common bile duct. During the same period, 148 cholecystectomies were performed. The specimens were sent for culture and sensitivity and 32.7% of the specimens grew bacteria. The factors that were associated with positive culture were emergency cholecystectomy for acute cholecystitis and empyema of gall bladder, carcinoma of gall bladder and obstructive jaundice. The commonest organisms were E. Coli (28.2%) and Klebsiella (17.9%). Pseudomonas surprisingly formed 10.2% of the cultured organisms. Salmonella that causes typhoid, which is an endemic disease in Ghana, formed only 7.7% of the isolates. Most of the organisms were resistant to Ampicillin and tetracyclines. The antibiotics that most were sensitive to were Gentamicin and Cefuroxime. Therefore the antibiotics that are recommended for use as prophylaxis in biliary tract surgery are Gentamicin or Cefuroxime.

Cancer of the colon and rectum in Ghana: a 5-year prospective study.

A prospective study of 134 patients who presented to a teaching hospital in Ghana for the first time with colorectal cancer between January 1987 and December 1991 is reported. The mean number of new patients per year was nearly three times that of a decade ago. The disease afflicts both sexes equally and the age of highest incidence is in the seventh and eighth decades. Some 65 patients had colonic cancer and 69 rectal lesions. Most patients presented with advanced disease and only four of 109 in whom disease was staged (3.7 per cent) had Dukes A tumours. Right-sided cancer of the colon was more common than that of the left. The importance of rectal examination is emphasized by the finding that 78 per cent of rectal tumours were within reach of the examining finger. 'Curative' resection was possible in 60 per cent of patients with colonic cancer but in only 36 per cent of those with rectal tumours. The postoperative mortality rate of patients who underwent laparotomy was 13.6 per cent and in those who had resection 5.5 per cent. Long-term follow-up was poor. These results emphasize the need for accurate data collection on colorectal carcinoma, public education on the importance of early diagnosis and follow-up after treatment. These findings also call for a study of the epidemiology and aetiology of colorectal cancer in Ghana.

Changing pattern of acute intestinal obstruction in Accra.

Five hundred and fifty-two cases of intestinal obstruction were seen over a two year period, January 1987 to December 1988. Strangulated external hernias and adhesions still remain the most common causes of intestinal obstruction in Accra, but there has been a change in their relative incidence with external hernias falling to 59.8 per cent and adhesive obstruction increasing to 21.0 per cent. There has been no change in the overall mortality and mortality from inguinal hernia which are still 9.4 per cent and 4.9 per cent respectively. However, there has been a significant improvement in mortality rate from volvulus and a slight improvement in mortality from adhesive obstruction even though the overall resection rate has increased from 12.7 per cent to 17.6 per cent.

Acute upper gastrointestinal haemorrhage in Ghanaians: an endoscopic review at Korle-Bu Teaching Hospital

Upper gastro-intestinal (UGI) endoscopy was performed at the Korle-Bu Teaching Hospital; between 1981-83; on patients with history of acute upper gastro-intestinal haemorrhage. Eight-six (86) such patients were endoscoped and results have been retrospectively analysed to establish the major symptomatology; the underlying lesions; and any other relevant contributory factors. The role of endoscopy in the management of acute upper gastro-intestinal haemorrhage as well as its potential cost effectiveness are discussed. The term endoscopy; in the text refers to oesophago-gastro-duodenoscopy; and GI bleed refers to upper gastrointestinal haemorrhage