Nonalcoholic fatty liver disease: Synopsis of current developments.

Non-alcoholic fatty liver disease (NAFLD) which is defined as the accumulation of fat>5% of liver weight is increasingly becoming an important cause of chronic liver disease. This article tries to chronicle advances that have occurred in the understanding of the pathogenesis, pathology as well as the management of this disease. We have done a Medline search on published work on the subject and reviewed major conference proceedings in the preceding years. The Pathogenesis involves a multi-hit process in which increased accumulation of triglycerides in face of insulin resistance results in increased susceptibility to inflammatory damage mediated by increased expression of inflammatory cytokines and adipokines, oxidative stress and mitochondrial dysfunction, endoplasmic reticulum stress and gut derived endotoxemia. An interplay of multiple metabolic genetic expression and environmental factors however determine which patient with NAFLD will progress from simple steatosis to non-alcoholic steatohepatitis (NASH) and liver cirrhosis. The minimum criteria for diagnosis of NASH are steatosis, ballooning and lobular inflammation; fibrosis is not required. The NASH Clinical Research Network (CRN), histological scoring system is used to grade and stage the disease for standardization. The management of NAFLD consists of treating liver disease as well as associated metabolic co-morbidities such as obesity, hyperlipidaemia, insulin resistance and type 2 diabetes mellitus (T2DM). Patient education is important as their insight and commitment is pivotal, and lifestyle modification is the first line of treatment. Improvement in liver histology in non-diabetic NASH patients has been reported with use of Vitamin E. Other liver-related therapies under investigations include pentoxyfiylins, Caspar inhibitors, Resveratrol as well as probiotics. The prognosis (both overall and liver-related mortality) for simple steatosis is not different from that of the general population however.

Colonoscopy practice in lagos, Nigeria: a report of an audit.

Background. Colonoscopy effectiveness depends on the quality of the examination. Community-based report of quality of colonoscopy practice in a developing country will help in determining standard and also serve as a stimulus for improvement in service. Aim. To review the quality of colonoscopy practice and document pattern of colonic disease including polyp detection rate in Lagos, Nigeria. Method. A protocol that captured the patients' demographics, indication, and some quality indices of colonoscopy was developed and sent to all the identified colonoscopy units in Lagos to complete for all procedures performed between January 2011 and June 2012. All data were collated and analyzed. The quality indices studied were compared with guideline standard. Results. Twelve colonoscopy centers were identified but only nine centers responded. The gastroenterologist/endoscopists were physicians (3) and surgeons (5). Six hundred and seven colonoscopy procedures were performed during this period (M : F = 333 : 179) while the sex was not disclosed in 95 subjects. The examination indications were lower GI bleeding (24.2%), altered bowel habits (9.2%), lower abdominal pain (9.1%), screening for CRC (4.3%) and unspecified (46.8%). Conscious sedation was generally used while bowel preparation (good in 81.4%) was done with low residue diet and stimulant laxatives. Caecal intubation rate was 81.2%. Common endoscopic findings were haemorrhoids (43.2%), polyps/masses (13.4%), diverticulosis (11.1%), and no abnormality (23.4%). Polyp was detected in 6.8% of cases. Conclusion. Colonoscopy utilization is low, and the quality of practice is suboptimal; although limited resources could partly explain this, however it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence.

KRAS and BRAF mutations in Nigerian colorectal cancers.

PURPOSE: Activation of the KRAS oncogene is implicated in colorectal carcinogenesis and mutations have been reported in 30-50% of cases. BRAF mutation, though less common, is also reported and importantly associated with shorter progression-free interval. This study aims to determine the KRAS and BRAF mutation statuses of Nigerian colorectal cancers (CRC). METHODS: Mutation analysis was carried out on archival paraffin-embedded blocks of CRC tissues. KRAS codons 12, 13 and 61 and BRAF V600E were assessed by pyrosequencing after DNA extraction from 200 cases at the Leeds Institute of Molecular Medicine, St. James's University Hospital, UK. Mutation rates and the spectra were determined. RESULTS: Pyrosequencing was successful in 112 of 200 cases. KRAS mutation in codons 12 and 13 was demonstrated in 23 of 112 cases (21%); none in codon 61. BRAF mutation in codon 600 was demonstrated in 4.5%. CONCLUSION: This study shows that 21% of Nigerian CRC patients carry a KRAS mutation; half the rate in Caucasians; and that BRAF mutation also occurs in Nigerian CRC cancers.

Chronic liver disease and hepatic encephalopathy: clinical profile and outcomes.

BACKGROUND: Hepatic encephalopathy (HE) is an important neuropsychiatry complication of liver disease causing significant morbidity and mortality worldwide. Efforts at improving the outcome have resulted in development of new strategies in the management given the background of new insights in the pathogenesis of this disease entity. Understanding the disease profile including precipitants as well as prognostic factors will contribute in this regard as new strategies are yet to be widely applied. The aim of this report is to document the profile of patients with HE, the precipitants, prognostic factors as well as the scope of the burden associated with it. MATERIALS AND METHODS: In this prospective study, all patients managed for HE from January to December 2008 were recruited. A questionnaire was used to extract their basic demographics, clinical features noting any possible precipitants, complications, management protocol as well as outcome. RESULTS: A total of 21 subjects (11 females and 10 males) within the age range of 16-83 years were seen during the period under review. (mean age 57.9 ± 13). There was no significant difference in the mean ages of males and females. Two patients had acute encephalopathy, while others had acute-on chronic encephalopathy. The risk factors for liver disease included significant alcohol ingestion, hepatitis B virus infection, and previous jaundice, while other complications of liver disease noted were deepening jaundice, ascites, bleeding tendencies, and renal failure. The identified precipitants for HE were sepsis 6 (29%), electrolyte inbalance 3 (14%), gastrointestinal bleed 5 (24%), drugs (5%), and possible malignant transformation 6 (29%). Focus of sepsis was bacterial peritonitis in two cases. Majority of our patients (61%) came during advanced stage of liver disease (Child-Pugh class C). Length of hospital stay ranged from 1 to 7 weeks and a mortality of 48% was observed. Predictors of mortality were a history of significant alcohol ingestion, previous blood transfusion, Hepatitis B and C infections, and severe liver dysfunction on presentation (Child-Pugh class C). CONCLUSIONS: HE is associated with a high mortality rate and this scenario is associated with a history of previous blood transfusion, Hepatitis B and C infections, and severe liver dysfunction on presentation. Measures to reduce the burden of viral Hepatitis B and C, safe blood transfusion, and responsible use of alcohol should be promoted. Screening of those at risk of encephalopathy (liver disease patients) with a psychometric test of good predictability should be part of their routine evaluation in daily practice so as to detect cases of latent encephalopathy. Intensive care facilities and necessary personnel should be provided.

Clinico-pathological review of malignant gastric tumours in Lagos, Nigeria.

BACKGROUND: Gastric cancer is one of the most common cancers and the 2d most common cause of cancer deaths worldwide. Contrary to earlier reports from Africa, prevalence of this cancer has been found to be comparable to that of other parts of the world. OBJECTIVE: To describe the clinico-pathological features of gastric cancer diagnosed in Lagos and determine the prevalence of H. pylori infection in gastric adenocarcinoma. METHODS: This was a retrospective histopathological study of all gastric cancer seen between 1995 and 2007 in the Morbid Anatomy Department of Lagos University Teaching Hospital as well as two other private histopathology laboratories in Lagos (2002-2007). The blocks and slides of gastric cancer tissue were the materials used for the study. The patients' bio data and relevant clinical details were extracted from the demographic records. RESULTS: There were 105 cases of gastric cancer (M:F = 2:1, mean age-55.3 years), 81% of which occurred above 45 yrs. There were 95 cases (90%) of adenocarcinomas, 8 (7.6%) mesenchymal tumours with one case each of small cell non-Hodgkin's lymphoma and carcinoid tumour. H. pylori was detected in 15.5% of 45 cases of adenocarcinoma with 36% showing evidence of chronic gastritis in adjacent non cancerous gastric tissue. All patients with clinical data had one or more alarm features; most recurring being abdominal fullness, recurrent vomiting, anorexia and weight loss. CONCLUSION: This study suggests that gastric malignancies are not uncommon in Lagos and often manifest with alarm features which should raise a suspicion particularly in our setting with poor diagnostic endoscopic facilities.

Clinico-pathological review of malignant gastric tumours in Lagos, Nigeria

Gastric cancer is one of the most common cancers and the 2d most common cause of cancer deaths worldwide. Contrary to earlier reports from Africa;prevalence of this cancer has been found to be comparable to that of other parts of the world.To describe the clinico-pathological features of gastric cancer diagnosed in Lagos and determine the prevalence of H. pylori infection in gastric adenocarcinoma.This was a retrospective histopathological study of all gastric cancer seen between 1995 and 2007 in the Morbid Anatomy Department of Lagos University Teaching Hospital as well as two other private histopathology laboratories in Lagos (2002-2007). The blocks and slides of gastric cancer tissue were the materials used for the study. The patients' bio data and relevant clinical details were extracted from the demographic records.There were 105 cases of gastric cancer (M:F = 2:1; mean age-55.3 years); 81of which occurred above 45 yrs. There were 95 cases (90) of adenocarcinomas; 8 (7.6) mesenchymal tumours with one case each of small cell non-Hodgkin's lymphoma and carcinoid tumour. H. pylori was detected in 15.5of 45 cases of adenocarcinoma with 36 showing evidence of chronic gastritis in adjacent non cancerous gastric tissue. All patients with clinical data had one or more alarm features; most recurring being abdominal fullness; recurrent vomiting; anorexia and weight loss.This study suggests that gastric malignancies are not uncommon in Lagos and often manifest with alarm features which should raise a suspicion particularly in our setting with poor diagnostic endoscopic facilities

A clinicopathologic review of oesophageal carcinoma in Lagos.

BACKGROUND: Oesophageal cancer is the 6th most common cause of cancer death world wide. While the incidence is low in some parts of Africa such as Nigeria accounting for 0.4-0.6% of all malignant tumours, it is endemic in Transkei, in South Africa, which is regarded as an epicentre of the disease in Africa. OBJECTIVE: To document the age and sex distribution, clinical as well as histopathological characteristics of oesophageal carcinoma in Lagos, SW Nigeria, METHODS: The paraffin embedded blocks and slides as well as pathology reports of oesophageal carcinoma collected between 1995 and 2007 from Morbid Anatomy Department of the Lagos University Teaching Hospital and between 2002 and 2007 from two private histopathology laboratories in Lagos State were reviewed. The clinical data such as the age, sex, and clinical summary were extracted from demographic information in patients' case file. RESULTS: Twenty cases representing 2.8% of all gastrointestinal tumours were recorded. The mean age was 65.4 years (SD-12.3) with M:F ratio of 1:1. Squamous cell carcinoma predominated; 18 cases (90%); the remaining two cases (one of which showed evidence of Barrett's oesophagus) were adenocarcinoma (10%). All presented at advanced stage with dysphagia and weight loss with or without vomiting, regurgitation, and/or haematamesis. Two third had mid oesophageal fungating masses, the remaining were located in the lower third. Two cases had surgery, the rest were not fit for any intervention. CONCLUSION: Oesophageal cancer is not common in Lagos, Nigeria, majority are squamous cell carcinoma. Late presentation gives it a dismal outlook. Although the overall survival is poor, efforts at improving quality of life by palliative measures should be encouraged.

Upper gastrointestinal endoscopy findings in Nigerians: a review of 170 cases in Lagos.

BACKGROUND: The advent of flexible endoscopy has made it possible to visualise the mucosa of virtually the entire intestine. This service is yet to be widely available in Nigeria. Existing reports on indications and findings at endoscopies are sometimes conflicting, with some recent reports suggesting a changing pattern of gastrointestinal diseases. OBJECTIVE: The study set out to evaluate the indications, endoscopic findings and their frequencies as well as any adverse outcome from the endoscopic examinations. METHODOLOGY: This was a retrospective study in which we reviewed the endoscopy records of the first one hundred and seventy patients that underwent upper gastrointestinal endoscopy at the Lagos State University Teaching Hospital. The patients' bio data, indications and findings during endoscopic examinations as well as any adverse outcome were documented. Data obtained were analysed using SPSS version 11. RESULTS: The majority of the patients were in the middle to elderly age with a peak in the 5th decade. The commonest indications for upper gastrointestinal endoscopy were; Dyspepsia, upper gastrointestinal haemorrhage, previously diagnosed peptic ulcer unresponsive to treatment and retrosternal discomfort or pain. Endoscopic request for variceal screening were uncommon. The commonest endoscopic findings were; features of gastroesophageal reflux disease, followed by gastroduodenitis (non-ulcer mucosal lesions in stomach and duodenum) and peptic ulcer disease. In 14 patients the endoscopy examination revealed normal findings. CONCLUSION: The role of endoscopy in the diagnosis and management of gastrointestinal disorders cannot be overemphasised. It is hereby recommended that provision of endoscopic facilities and training of necessary personnel be encouraged by all relevant agencies so that the services can be accessible and affordable by all who require it in view of its importance in patient management.

Prevalence of serological markers of chronic hepatitis B virus infection in diabetics in the Lagos University Teaching Hospital, Lagos.

Hepatitis B virus (HBV) infection, a major world health problem, is hyper endemic in South-East Asia and sub-Saharan Africa including Nigeria. Being a major cause of morbidity and mortality, prophylaxis using the highly efficacious hepatitis B vaccine is recommended for those at risk. The prevalence of serological markers of chronic HBV infection was determined in a population of 100 outpatient diabetics and 80 non-diabetic controls at the Medical Outpatient Department of the Lagos University Teaching Hospital Idi-Araba between January and July 1992. Twenty diabetic patients [20%] and 14 controls [17.5%] had serological markers (HbsAg and antiHBc) indicating ongoing chronic HBV infection. The difference between diabetics and non-diabetic controls was not statistically significant (P>.05). None of the HbsAg and antiHBc positive diabetics [45%] and 8 control patients [57%] were HbeAg positive. The presence of serological markers was not related to the duration, type of diabetic treatment and degree of diabetic control. Our findings suggest that diabetics in Lagos appear not to be more predisposed to chronic HBV infection than the rest of the population, and therefore would require no special antiHBV prophylaxis.