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.

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.

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.

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.

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.

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.

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.

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.