Role of vesicostomy in the management of posterior urethral valve in Sub-Saharan Africa.

OBJECTIVE: To review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting. METHODS: A review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0. RESULTS: The 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days-3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2-8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115-280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings. CONCLUSION: Vesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.

Management of anorectal malformation: Changing trend over two decades in Zaria, Nigeria.

BACKGROUND: Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. MATERIALS AND METHODS: A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. RESULTS: There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pull through (Stephen's operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05). CONCLUSION: There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.

Management of anorectal malformation: changing trend over two decades in Zaria, Nigeria

Background: Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades. Materials and Methods: A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out. Results: There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5) and 106 (65.8) emergency operations in groups A and B; respectively. There were 61 (45.5) and 55 (34.2) elective operations in groups A and B; respectively. Regarding treatment; in group A; patients requiring colostomy had transverse loop colostomy; while in group B; sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5); anal transplant 5 (8.2); sacroabdominoperineal pullthrough (Stephen's operation) 6 (9.5) and others 21 (34.4). In group B; posterior sagittal anorectoplasty (PSARP) 46 (83.7); anal transplant 1 (1.8); posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6) and anal dilatation 6 (10.9) were done. Early colostomy-related complication rates were similar in the two groups (P 0.05). The overall late complication rate was 65.5in group A and 16.4in group B (P 0.05). The mortality was 25 (18.6) in group A compared to 17 (10.6) in group B (P 0.05). Conclusion: There have been significant changes in the management of anorectal malformations in this centre in the last two decades; resulting in improved outcomes

Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria.

BACKGROUND: A cross-sectional study carried out at a teaching hospital in Kaduna, Nigeria, to investigate the extent and reasons for the delay between onset of symptoms and admission for treatment of symptomatic breast cancer. METHODS: The patients had histologically proven breast cancer and had been admitted for treatment. Data were obtained from interviews and patients' clinical and referral records. RESULTS: One hundred and eleven consecutive breast cancer patients were interviewed from July 2003 to June 2005. Only 12 (10.8%) could be admitted for treatment within a month of onset of symptoms. Delays were significantly associated with younger patients, elementary or no Western education, and domicile outside the Kaduna metropolitan area. Patients who were referred from, or received initial treatment at, peripheral hospitals had longer delays than those who came for first consultation at the teaching hospital. The proportion of early breast cancer cases (stages I and II) decreased from 45.9% at diagnosis to 25.2% at treatment, as concerns about mastectomy and hospital treatment led a significant number of the patients to temporarily abandon hospital treatment for alternatives, only to return with advanced cancers. The predominant reasons among the 99 patients who had delays of more than a month before admission were: ignorance of the seriousness of a painless breast lump (47.5%), non-acceptance of hospital treatment (46.5%), and preference for traditional treatment (38.4%). A significant number of patients referred from peripheral hospitals had inappropriate surgeries and biopsy management which contributed to the advanced stage on admission. CONCLUSION: This study shows that delayed treatment of symptomatic breast cancer at this centre in Nigeria is as much related to the quality of medical care as it is to local beliefs, ignorance of the disease, and lack of acceptance of orthodox treatment.

Persistent umbilical discharge in infants and children.

BACKGROUND: Umbilical discharge is not an unusual presentation in infants and children. However, the evaluation and management are rarely discussed. METHOD: A retrospective review of 18 patients presenting with persistent umbilical discharge over a period of 22 years, excluding neonates with omphalitis. RESULTS: The patients' ages ranged between 11 days and 9 years. Presentation was usually discharge of clear, serous or purulent fluid or faecal matter from the umbilicus, sometimes dating back to the neonatal period. Evaluation consisted of bacteriology, fistulogram (one patient) and histopathology. The cause of discharge was patent vitello-intestinal duct in 11 patients, umbilical granuloma in three, umbilical sinus in two and patent urachus and osteomyelitis of the ischium in one each. Definitive treatment was exploration and complete excision of the lesion and antibiotics. Two patients with patent vitello-intestinal duct died, one before surgery from hypokalaemia and sepsis, and the other from anaesthetic complications. CONCLUSION: There is a need for early referral and treatment in patients with persistent umbilical discharge. Conservative treatment is usually not successful as the common causes would normally require complete excision.

Adhesion intestinal obstruction in children in northern Nigeria.

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

Gastrointestinal injuries from blunt abdominal trauma in children.

OBJECTIVE: To determine the pattern, presentation and outcome of gastrointestinal injuries from blunt abdominal trauma in children. DESIGN: A retrospective study. SETTING: Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. SUBJECTS: Twenty one children managed for gastrointestinal injuries from blunt trauma from 1984-2002. MAIN OUTCOME MEASURES: The pattern, presentation, management and outcome of gastrointestinal injuries from blunt trauma. RESULTS: In the 19 year period, 1984-2002, 92 children were treated for blunt abdominal trauma, 21(23%) of who had injuries to the gastrointestinal tract. Three presenting after 24 hours had evidence of peritonitis. In six children with isolated gastrointestinal tract (GIT) injury who presented within two hours, abdominal signs were vague at initial evaluation but became marked over a few hours at repeated examination. In eight with associated intraabdominal injuries, abdominal signs were marked at initial examination and five presented with shock. Free peritoneal air was present on plain abdominal and chest radiograph in three of ten patients, dilated bowel loops in six and fluid levels in one. Diagnostic peritoneal lavage or paracentesis was positive in four patients with isolated GIT injuries and eight with associated intraabdominal injuries. There were 24 injuries in the 21 patients consisting of 15 perforations, five contusions, two seromuscular tears, and two gangrene from mesenteric injury. The small intestine was involved in 11 patients, colon six, stomach five, duodenum one and rectum one. Seven (35%) patients had associated extraabdominal injuries. Treatment consisted of simple closure of perforations, over sewing of contusions, resection and anastomosis for gangrene and repair with protective stoma for the rectal injury. One patient each developed prolonged ileus, urinary tract infection and chest infection, respectively postoperatively. Mortality was 28%, all of who had associated intraabdominal or extraabdominal injuries. CONCLUSION: Gastrointestinal injury from blunt abdominal trauma in children, though uncommon, carries a high mortality, usually from associated intraabdominal or extraabdominal injuries.

Fournier's gangrene in neonates and infants.

BACKGROUND: Fournier's gangrene is uncommon in childhood and little is known about the disease in this age group. METHOD: A retrospective review was carried out of neonates and infants treated for Fournier's gangrene over a period of 16 years. RESULTS: Twelve neonates and infants aged 5 days-3 months (median 3 weeks) were treated in our hospital. The precipitating cause was omphalitis in 7 babies, strangulated inguinal hernia in 2 and in 3 babies there was no identifiable cause. Gram-negative bacteria were cultured in 3 patients, but in most the culture was sterile. Treatment consisted of debridement of devitalised tissue and administration of broad-spectrum antibiotics. Primary closure was achieved in 1 baby and secondary closure in 2 others. In 7 babies the wound contracted rapidly and healed. There was no mortality. CONCLUSION: Fournier's gangrene in neonates and infants in our environment is largely preventable. Early debridement and appropriate antibiotics give good results.

Small intestinal leiomyoma in childhood: a case report.

A 6-year old girl presented with a painless, progressive abdominal mass for 4 weeks without alteration in bowel habits. Physical examination showed a non-tender, irregular and mobile abdominal mass. Abdominal ultrasonography was unable to define the exact origin of the mass. An ileal tumour was found at laparotomy necessitating resection and anastomosis. Histology confirmed an intestinal leiomyoma. The patient has remained well at 3.5 years of follow up. Leiomyomas of the small intestine are rare in childhood. This report discusses the presentation, diagnosis and management of this condition by briefly reviewing the literature.

Hirschsprung's disease in the newborn: experience in Zaria, Nigeria.

In a 10-year retrospective review of 15 newborns aged < or = 42 days presenting with Hirschsprung's disease, there were 12 boys and three girls aged 4-42 days (median 18 days). Twelve babies presented with complete intestinal obstruction. In 12 babies, there was a history of delayed passage of meconium (after 2-6 days). One baby each developed caecal and sigmoid perforation. Barium enemas in three babies without complete intestinal obstruction suggested Hirschsprung's disease in two. Following resuscitation, the two infants who had perforated had caecostomy and sigmoid repair with right transverse colostomy, respectively. One infant had ileostomy for total colonic aganglionosis associated with ileal atresia. All the others had initial diversion colostomy. Rectal biopsies confirmed Hirschsprung's disease in all the babies. The ileum was injured during colostomy in one case, requiring repair. Postoperative anastomotic leakage occurred in the infant with ileal injury and colostomy necrosis occurred in another infant. Five babies (33%) died, three from overwhelming infection (caecal perforation, sigmoid perforation, ileal injury), one from hypokalaemia (ileostomy) and one from an unidentified cause. Few cases of Hirschsprung's disease present in the newborn period in our environment and, when they do, they usually present with complete intestinal obstruction with high morbidity and mortality.

Cervical cystic hygroma: pre-, intra-, and post-operative morbidity and mortality in Zaria, Nigeria.

The management of extensive cystic hygromas in the cervical region (CCH) presents difficult challenges. A retrospective study of 41 children with CCH treated over 24 years in Nigeria was carried out; there were 28 boys and 13 girls with an age range of 3 days to 10 years (median 6.5 months). Thirty-three (80%) presented with 34 life-threatening complications including infection in 11 (27%), rapid increase in cyst size in 10 (24%), respiratory obstruction in 7 (17%), and intracystic hemorrhage in 6 (15%). Complete excision was possible in only 14 of 34 (41%) patients, and injuries to neighboring structures occurred in 6 (18%) (facial nerve 2, recurrent laryngeal nerve 1, internal jugular vein 1, parotid duct 1, pharynx 1). Postoperatively, 8 (24%) patients developed 9 complications. Wound infections occurred in 5 incompletely-excised cysts and 2 patients had respiratory obstruction. One patient with a wound infection developed edema of the tongue lasting several days and drainage was prolonged (> 6 weeks) in 1. Five patients died, 3 from respiratory obstruction and 1 each from wound and chest infection. Four patients (12%) developed a recurrence within 5 years of surgery. The pre-, intra-, and post-operative morbidity were high in this series. Although complete excision is the ideal treatment for CCH, this need not be pursued if neighboring structures are liable to injury. When cysts are incompletely excised, antibiotic prophylaxis is necessary as the incidence of wound infection is high.

Emergency neonatal surgery in a developing country.

With better understanding of neonatal physiology and improvements in diagnostic facilities and neonatal intensive care units (NICU), the outcome of neonatal surgery has improved in developed countries. In developing countries, however, neonatal surgery is problematic, particularly in the emergency setting, but there are few reports from these countries. A retrospective analysis of 154 neonates who had emergency surgery over a 10-year period at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. Emergency surgery represented 40% of surgical procedures in neonates in the hospital. The majority of the patients (94.8%) were delivered at home or in rural health centers. The median weight was 2.7 kg (range 2.0-3.7 kg). In 89 cases (58%) the indications for surgery were intestinal obstruction, anorectal malformations in 60(67%) and in 33(21%) complicated exomphalos or gastroschisis. Nine patients (6%) required surgery for ruptured neural-tube defects. A colostomy was the commonest procedure (51, 33%), 27(53%) of which were performed using a local anesthetic without adverse effects. Thirty-three abdominal-wall defects were closed by various methods (fascial closure 23, skin closure 6, improvised silo 4). Overall, 37 (24%) procedures were performed using local anesthesia. Fifty-nine patients (38%) developed postoperative complications (infections 33, respiratory insufficiency 16, colostomy complications 8, anastomotic leak 2). The mortality was 30.5%, 66% due to overwhelming infection, 28% to respiratory insufficiency, and 4.3% to multiple anomalies. Other factors considered to have contributed to morbidity and mortality were late referral and presentation and a lack of NICUs. Thus, emergency neonatal surgery is attended by high morbidity and mortality in our environment at the present time. Early referral and presentation and provision of NICUs should improve the outcome.

Pyomyositis in adults: a 12 year review.

From January 1988 to December 1999, 43 adults with pyomyositis were managed at Ahmadu Bello UniversityTeaching Hospital, Zaria, Nigeria. Staphylococcus aureuswas the most commonly cultured organism (92.5%). All the 41 patients responded well to incision and adequate drainage, antibiotics and partial thickness skin grafting in 10 patients (23.2%).Two patients (4.65%) died from septicaemia, while being resuscitated.

Childhood achalasia in Zaria, Nigeria.

OBJECTIVES: To study the presentation, management and outcome of achalasia of the oesophagus in children. DESIGN: A retrospective case study. SETTING: Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. SUBJECTS: Seven children managed for achalasia of the oesophagus in a period of 19 years. RESULTS: There were six boys and one girl. The median age at presentation was ten years (range three months to fifteen years). The median duration of symptoms before presentation was 20 months (range: 2-24 months). Three children were treated on several occasions for pneumonia before the diagnosis was made. Dysphagia, vomiting and regurgitation were the main presenting symptoms. Diagnosis was by barium oesophagogram. Six had modified Heller's myotomy via celiotomy and a Thal fundoplication in a three month old. Transthoracic Heller's myotomy was done in the seventh child. There was complete resolution of symptoms in six children. One patient had post-operative retrosternal pain, which was controlled by oral nifedipine. CONCLUSION: Achalasia of the oesophagus should be excluded in children with recurrent chest infection. Modified Heller's myotomy without antireflux procedure via the abdominal route is effective in relieving symptoms of achalasia in children.

Gastrointestinal obstruction from phytobezoar in childhood: report of two cases.

This is a report of two children aged twenty seven months and six years respectively presenting with gastrointestinal obstruction from phytobezoar. In the 27-month old child, laparotomy and gastrotomy was performed to evacuate the bezoar. However, death occurred from hypokalaemia. The six-year old child had a sacro-abdomino-perineal pull through for anorectal malformation previously and the bezoar lodged just above the neoanus. Neoanal dilatation allowed removal of the bezoar and relief of the obstruction. There has been no recurrence. The literature on bezoar is briefly reviewed.

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country.

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5-9 years. Falls were the cause of trauma in 36%, 60% of them aged 10-15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorrhage, and a lacerated accessory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available.

Intestinal atresia and stenosis: a retrospective analysis of presentation, morbidity and mortality in Zaria, Nigeria.

Over a period of 19 years 22 children with intestinal atresia and stenosis were managed at the Ahmadu Bello University Teaching Hospital Zaria. The condition ranks as the fourth most common cause of neonatal intestinal obstruction after anorectal malformation, Hirschsprung's disease and strangulated inguinal hernia at the hospital. Three patients had duodenal atresia, 18 had jejunoileal involvement (atresia 15, stenosis 3) and one colonic atresia. The median age at presentation to the surgeon was 6 days (range 1 day-2 years). The common features were bilious vomiting and abdominal distension, the latter being more common in patients with lower atresia. Non-passage of meconium in the first 24 hours of birth occurred in 11 patients; mostly in those with lower jejunal, ileal and colonic involvement. Eight patients had associated anomalies, 5 of them with ileal atresia or stenosis. Diagnostic investigation was mainly plain abdominal radiography showing double-bubble shadow in duodenal atresia and varying degrees of air-fluid levels in other atresias. Contrast studies were not employed for diagnosis in any patient. The patients with duodenal atresia and had duodenoduodenostomy and duodenojejunostomy respectively while the jejunoileal atresia and stenosis were treated by resection and anastomosis. One patient with ileal atresia associated with total colonic Hirschsprung's disease and extensive atresia from terminal ileum down to descending colon had ileostomy. Postoperatively, 7 patients had infections of varying degrees and 3 anastomotic dehiscence. Mortality was 9 (41%) due mostly to septic complications and prematurity. While the survival of children with intestinal atresia and stenosis has improved over the years in developed countries, ours is still low (59%) due to late presentation and lack of neonatal intensive care facilities.

Intestinal volvulus: aetiology, morbidity, and mortality in Nigerian children.

In developed countries, intestinal volvulus in children is most frequently due to malrotation. To review the experience in Nigeria, a retrospective analysis of 28 patients managed over 25 years at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. There were 22 boys and 6 girls with an age range of 4 days to 14 years (median 4 years). There were equal numbers over and less than 5 years of age. Vomiting (89%) and abdominal distension (79%) were the most prominent features. Thirteen children (46%) had fever, associated with bowel gangrene in 5, while 8 (29%) presented with severe dehydration and shock. A plain abdominal radiograph was the only investigation performed, but the features were not specific for volvulus. In 11 children (39%) the volvulus was idiopathic, in 9 (32%) due to adhesions or bands, in 5 (18%) to malrotation, and in 1 each a Meckel's diverticulum, internal herniation, and ventriculoperitoneal shunt. Twenty-three patients had a small-bowel, 4 sigmoid, and 1 caecal volvulus. The bowel resection rate for gangrene was 46% (small bowel 9, sigmoid 3, caecum 1). All patients with malrotation had Ladd's procedure performed. Wound infections occurred in 10 patients (36%), complete wound dehiscence in 1, and recurrence in 1 (idiopathic terminal ileal volvulus). The mortality was 21%, mostly from overwhelming infection (2 neonates, 11-year-old, 3 >/= 5 years). Intestinal volvulus in our environment differs in aetiology from other reports. The resection rates are similar, however. This condition carries high morbidity and mortality.

Colorectal adenocarcinoma in children and adolescents: a report of 8 patients from Zaria, Nigeria.

Colorectal adenocarcinoma is predominantly a disease of the old and less than 1% of patients are below 20 years in most reports. Though increasingly younger patients are seen in Africa, most reports indicate that the disease is extremely rare in children and adolescents. This is a report of 8 patients below 20 years managed for colorectal adenocarcinoma in a 10-year period in Zaria, Nigeria. They represented 16.3% of all cases of colorectal adenocarcinoma seen at the institution, an incidence higher than that in other parts of Africa and developed countries. All the tumours were in the rectosigmoid region and are accessible to digital rectal examination and proctosigmoidoscopy. The histology was mucinous adenocarcinomas in 6 patients, 5 of who had a Duke's stage C or D disease and well-differentiated in 2 (Duke's stage B and C respectively). Haemorrhoids was found in association in 2 patients and schistosoma mansoni in one and were responsible for delay in referral and diagnosis. Only palliative treatment could be offered in most patients due to advanced disease. Three patients died within 7 months and one after 2 years from their disease. One patient died from sepsis following surgery. The outcome in 3 patients could not be ascertained. It is emphasized that children and adolescents with rectal bleeding must have digital rectal examination and proctosigmoiscopy as this is the only hope of making an early diagnosis.

Tuberculous osteitis of the cranium: a case report.

A 3-year old male presented with a 12-month history of painless scalp swellings associated with cough, fever and night sweats. Physical examination showed tender, fluctuant, pulsatile right frontotemporal and temporoparietal masses. Skull radiographs showed osteolytic skull lesions in the frontal and temporal bones. Microscopy of drained caseous material and histology of biopsies from the affected bone edges confirmed tuberculous osteitis. Though there was an initial response to antituberculous agents, the child died after 5 weeks from hepatic failure. Tuberculosis of the skull bones though rare, may become more common with the recent upsurge of tuberculosis worldwide. A high index of suspicion is necessary for early diagnosis and treatment.