Organic and functional disorders in 2000 gastroenterology outpatients.

To determine the relative frequency of different diseases and of functional gastrointestinal disorders among patients referred by general practitioners to a gastroenterology clinic, 2000 patients referred over a five-year period were studied. 980 had organic diseases, of which peptic ulcer, oesophagitis, and inflammatory bowel disease accounted for about half. 888 patients had functional disorders of the gastrointestinal tract, without any disease. Among these, various syndromes could be distinguished; abdominal pain with altered bowel habit (irritable bowel syndrome, spastic colon type) accounted for about half of these patients. More attention could profitably be directed towards understanding these common functional syndromes so that they can be more readily diagnosed and better managed.

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.

Louse-borne relapsing fever in the Sudan. A historical review and a clinico-pathological study.

A small outbreak of louse-borne relapsing fever in Khartoum (May-June 1974) provided material for a clinico-pathological study. The history of the disease in the Sudan is reviewed and the clinical and laboratory findings in 32 patients are presented. Fever, headache, jaundice, epistaxis and hepatosplenomegaly were the commonest clinical findings; thrombocytopenia was detected in 93% of cases. Although elevated levels of fibrin degradation products were found in most patients, disseminated intravascular coagulation could not be diagnosed. Hepatocellular derangement was found in 68% of cases, while 78% had high blood urea. In five autopsied bodies there was bronchopneumonia, interstitial edema with focal myocardial fibrosis, hepatic necrosis, splenic infarcts, increase in size and cellularity of the glomeruli and brain edema and congestion. Intracranial haemorrhage was found in three of the autopsied cases.

Morbidity in relation to the clinical forms and to intensity of infection in Schistosoma mansoni infections in the Sudan.

A study of morbidity in Schistosoma mansoni infection was made in 593 Sudanese patients seen in a four-year period in Khartoum Civil Hospital. Clinical and laboratory findings were compared in three egg-count groups and in four clinical forms of the infection. Patients were divided into three levels of intensity of infection: light (up to 100 eggs/gram of stool), moderate (101--400 eggs/g) and heavy (more than 400 eggs/g). According to the presence or absence of visceral enlargement, infected subjects were divided into one of four clinical forms: intestinal, hepatic, hepatosplenic and splenic. Among the symptoms only the passage of blood in the stools was significantly related to intensity of infection, and fever was significantly related to the presence of hepatosplenic disease. Hepatomegaly and splenomegaly were significantly more frequent in the heavy infection group. Anaemia, eosinophilia, raised ESR and an increase in both serum alkaline phosphatase and serum globulins were significantly related to the intensity of infection. On the other hand, haematological and biochemical changes, as well as histopathological changes, were more marked and severe in patients with hepatosplenic disease. For comparison, the findings of 117 patients with S. haematobium infections and of 41 with dual S. mansoni/S. haematobium infections are included.

Detection of antibodies by enzyme-immunoassay in human schistosoma mansoni infections: a clinical and chemotherapeutic study.

Sera from patients with S. mansoni infections, before and six weeks after successful treatment with hycanthone, were examined for antibodies reacting with S. mansoni adult worm antigen, employing the enzyme-linked immunosorbent assay (ELISA) technique. 50 local individuals who had no schistosomiasis and 48 patients with S. haematobium infection were studied for comparison. All sera from untreated patients gave positive results. Significantly higher levels of antibody were given by sera from patients with visceral enlargement than by those from patients without visceral enlargement. A rise in antibody levels was seen in 87% of treated patients and the post treatment values of antibody were significantly higher than those obtained before treatment (p less than 0.001). 94% of sera from patients with S. haematobium infection gave a cross-reaction but with a significantly lower antibody values than for the homologous infection. A weakly positive reaction was obtained in 16% of controls and the actual values of antibody were much lower in this group than in the S. mansoni and S. haematobium groups.

Drug metabolism in hepatosplenic schistosomiasis in the Sudan: a study with antipyrine.

The disposition of antipyrine following oral administration of 1200 mg has been investigated in 10 patients with histologically confirmed hepatosplenic schistosomiasis and 11 normal subjects living in Sudan. Drug metabolising activity as assessed by antipyrine clearance was similar in patients when compared with normal controls. We conclude that antipyrine disposition is normal in patients with clinically compensated hepatosplenic schistosomiasis.

Racial differences in drug metabolizing ability: a study with antipyrine in the Sudan.

The kinetic disposition of antipyrine following oral administration of 1,200 mg has been investigated in 11 normal Sudanese subjects living in Sudan, 9 Sudanese subjects living in England for at least 2 yr, and 19 normal English subjects living in England. Sudanese subjects living in Sudan had significantly lower mean antipyrine clearance and higher volume of distribution than the English group (-28% and +30%, respectively). There was no significant difference for antipyrine clearance between English and Sudanese subjects living in England, but the volume of distribution of antipyrine was higher (16%) in the Sudanese subjects. The mean half-lives of the three groups differed significantly. We conclude that differences in disposition of antipyrine between native English and Sudanese populations was predominantly due to environmental factors.

Serum immunoglobulin concentrations in human S. mansoni and S. haematobium infections in the Sudan, with special reference to the effect of chemotherapy.

The serum immunoglobulin concentrations of IgG, IgA and IgM were studied in 111 selected Sudanese patients with S. mansoni infections and 48 with S. haematobium infections before and 6 weeks after successful treatment with hycanthone; 52 local individuals were studied as controls. Both IgG and IgM were found to be significantly raised in S. mansoni patients compared with controls, while only IgG was significantly raised in patients with S. haematobium infection. S. mansoni patients with the hepatosplenic and splenic forms had higher IgG and IgM levels than those with the intestinal and hepatic forms. No relationship could be established between the levels of immunoglobulins and parasite loads. A rise in IgG was noted in 60% of patients with S. mansoni infection 6 weeks after successful treatment with hycanthone whereas IgM decreased.

Hycanthone therapy in selected patients with S. mansoni and S. haematobium infections in the Sudan.

The results of a clinical trial of hycanthone in 601 selected Sudanese patients with S. mansoni and S. haematobium infections are reported. Hycanthone was given as a single intramuscular injection at a dose of 3.0 mg per kilogramme body weight. The commonest side effects were nausea and vomiting which occurred in 35 per cent and 32 per cent respectively. No incidence of acute hepatic damage and no deaths were encountered. About one third of patients reported for follow-up. Cure rate for S. mansoni was 90 per cent at 6 weeks of treatment and 97 per cent at three months and six months, while for S. haematobium infection it was 82 per cent at 6 weeks and 91 per cent at 3 months and 6 months. A significant reduction in egg excretion was achieved in those who were not cured.

Observations on hepato-cellular carcinoma in the Sudan.

The clinical and histopathological features of hepato-cellular carcinoma in 24 Sudanese patients seen in Khartoum Civil Hospital in a 4 year period are described. The tumour represented 1.97 per cent of total medical admissions and constituted 40 per cent of all malignancies seen. The age range was 30 to 88 with a mean age of 54 years. The male:female ratio was 6:1. A regional variation was apparent and is possible that the disease is more common in the Western Sudan than in other parts of the country.

Louse-borne relapsing fever: I. A clinical and laboratory study of 363 cases in the Sudan.

Louse-borne relapsing fever seems to have become endemic in the southern Sudan. The epidemic history of the disease in the Sudan is reviewed. We have studied 363 Sudanese patients involved in an outbreak of louse-borne relapsing fever in Khartoum (Sudan) between January and June 1974. 318 of the 363 patients were new immigrants from the soughern Sudan to Khartoum. The clinical presentation varied. The common clinical fetures of the disease were: fever (94%), headache (85%), hepatosplenomegaly (74%), body and joint pains (66%), abdominal pain and tenderness (63%), jaundice (46%) and epistaxis (40%). Thrombocytopenia was common. Biochemical evidence of hepatocellular and renal damage was present in most patients. The mortality rate was 5-5% with treatment. Post-mortem examination was performed on six cases. The organs predominantly involved were the liver, spleen, brain and lungs. The common causes of death were severe hepatic damage, lobar pneumonia, subarachnoid haemorrhage and splenic rupture.

Louse-borne relapsing fever: II. Combined penicillin and tetracycline therapy in 160 Sudanese patients.

One hundred and sixty patients with louse-borne relapsing fever were treated with a combination therapy of procaine penicillin and tetracycline. Fortified procaine penicillin B.P. was given as 400,000 units in the first day. This was followed the next day by 2 g tetracycline orally in divided doses for seven days. A mild rise in temperature was observed in 22 (13-7%) patients within four hours of administering penicillin. Rigors and hypotension occurred in one patient. Relapse occurred in two patients, of whom one had concomitant typhoid and one visceral leishmaniasis. The combined therapy has been found to be effective and safe. It lacks the disadvantages of penicillin (relapses) and tetracycline (severe reaction), when each drug is used alone.

Symptomatic giardiasis in Sudanese adults and its treatment with tinidazole.

The main symptoms of infection with Giardia intestinalis in 33 Sudanese adults were abdominal pain, flatulence and diarrhoea. Other symptoms were offensive stools, loss of weight, milk intolerance, mucoid stools, nausea and vomiting. Tinidazole given orally as 150 mg. twice daily dose for seven days or as a single 1,000 mg. dose, eradicated the infection in 32 out of the 33 patients. This parasitological cure was obtained in all 21 patients who received the seven day course and in 11 out of 12 patients who were given the single dose. All symptoms disappeared in 16 out of the 32 patients and in the remaining half improvement was marked particularly as regards the three main symptoms of the disease. The single dose gave no side effects but nausea, headache, skin rash and worsening of abdominal pain and diarrhoea occurred in some patients who received the seven day treatment course.

Salmonellosis complicating schistosomiasis in the Sudan.

Salmonella typhi or Paratyphi A was isolated from the blood in 16 out of 21 Suanese patients who had prolonged fever of one of 10 months' duration and hepatesplenic schistosomiasis. Most patients had severe anaemia. The serum alkaline phosphatase was raised in 16 patients. Bilharzial lesions were demonstrated in the liver biopsies of 10 patients. Three patients had in addition the nephrotic syndrome and moderate proteinuria was present in nine other patients. Changes of proliferative glomerulonephritis were noted in the renal biopsies of two patients with the nephrotic syndrome. Treatment with chloramphenicol cured the salmonella infection in all patients, reversed the raised alkaline phosphatase and the proteinuria, and led to a marked reduction in the size of the hepatosplenomegaly.