Gastroesophageal reflux disease in a typical African population: a symptom-based multicenter study.

BACKGROUND: The prevalence of gastroesophageal reflux disease (GERD) in Africa is not known but is believed to be increasing because of demographic and epidemiologic transition. The main objectives of this study were to determine the prevalence and risk factors of GERD, and its degree of overlap with dyspepsia and irritable bowel syndrome (IBS) in Nigeria, a typical African population. METHODS: This was an observational, cross-sectional and descriptive study of adult Nigerians. Diagnosis of GERD was by means of the gastroesophageal reflux disease questionnaire (GERDQ) while the diagnosis of dyspepsia and IBS was based on the Rome III criteria for the diagnosis of functional gastrointestinal disorders. The GERDQ and Rome III questionnaires for dyspepsia and IBS were merged into a composite questionnaire and administered to the study participants who were recruited with a multi-stage sampling technique. RESULTS: Out of 3520 subjects who participated in the study across the country, 269 (7.6%) satisfied the diagnostic criteria for GERD, while 107 (3.0%) had GERD associated with significant impairment of quality of life. Risk factors of GERD (represented by odds ratios) were age 1.014(95% CI: 1.006-1.022), use of analgesics 1.461 (95% CI: 1.060-2.025), and use of herbs 1.318 (95% CI: 1.020-1.704). Overlap of GERD with dyspepsia and/or IBS was observed in over 50% of cases. CONCLUSIONS: The prevalence of GERD in this study is 7.6%. Age, use of analgesics and use of herbs increase the risk, albeit minimally. A high degree of overlap with dyspepsia and IBS exists in Nigerian patients with GERD.

High degree of duodenal inflammation in Nigerians with functional dyspepsia.

BACKGROUND: Functional dyspepsia (FD) is a heterogeneous disorder associated with diverse pathophysiological mechanisms, including immune activation and low-grade mucosal inflammation. Genetic factors, physiological functions, and environmental factors may determine the relative importance of various pathophysiological mechanisms. This study was designed to determine the histological alterations in the duodenal mucosa of Nigerian patients with FD. METHODS: Consecutive patients with dyspepsia seen over a 27-month period in two gastrointestinal endoscopy facilities in Enugu, South-East Nigeria were further evaluated with upper gastrointestinal endoscopy and duodenal mucosal biopsies if no lesion was found in the upper gastrointestinal tract. Patients with heartburn and/or regurgitation who did not have any dyspeptic symptoms and did not have any lesion in the upper gastrointestinal tract on endoscopy were presumed to have non-erosive reflux disease (NERD) and they served as controls. The control subjects also had duodenal biopsies. The histopathological findings in the cases and controls were compared. RESULTS: There were 68 patients with FD and 52 patients with NERD. The total inflammatory score was 242 in FD and 66 in NERD (Mann-Whitney U =1168, P=0.0011). Similarly, the scores for chronic inflammation, gastric metaplasia, neutrophilic activity, eosinophilic infiltration, and Helicobacter pylori were significantly higher in FD than NERD. CONCLUSION: Functional dyspepsia is associated with a high degree of inflammation in the duodenal mucosa. This may reflect the high prevalence of gastrointestinal infections in a tropical environment such as Nigeria. These findings may have therapeutic potential that further studies might elucidate.

Functional dyspepsia: subtypes, risk factors, and overlap with irritable bowel syndrome in a population of african patients.

Background. Functional dyspepsia is the prototype functional gastrointestinal disorder. This study was designed to determine its prevalence, subtypes, and risk factors associated with the subtypes. Method. Patients with upper gastrointestinal symptoms who presented for endoscopy were administered a questionnaire containing the functional dyspepsia and irritable bowel syndrome modules of the Rome III diagnostic criteria. Results. Of 192 patients who had functional dyspepsia, epigastric pain syndrome, postprandial distress syndrome, and combination of the two subtypes accounted for 79.2%, 62.5%, and 50%, respectively. Multivariate analysis of the risk factors showed that independent predictors of postprandial distress syndrome were alcohol and irritable bowel syndrome while irritable bowel syndrome was independent predictor of epigastric pain syndrome. Alcohol, smoking, and use of nonsteroidal anti-inflammatory drugs were independent predictors of cooccurrence of postprandial distress syndrome and epigastric pain syndrome. Conclusion. Functional dyspepsia accounts for 62.5% of dyspepsia in a population of black African patients. Regarding symptomatology, epigastric pain syndrome, postprandial distress syndrome, and combination of the two subtypes account for 79.2%, 62.5%, and 50%, respectively. Risk factors for functional dyspepsia are irritable bowel syndrome, alcohol, smoking, and use of nonsteroidal anti-inflammatory drugs.

Current trends in the management of gastroesophageal reflux disease: a review.

Gastroesophageal reflux disease (GERD) is a chronic disorder of the upper gastrointestinal tract with global distribution. The incidence is on the increase in different parts of the world. In the last 30 to 40 years, research findings have given rise to a more robust understanding of its pathophysiology, clinical presentation, and management. The current definition of GERD (The Montreal definition, 2006) is not only symptom-based and patient-driven, but also encompasses esophageal and extraesophageal manifestations of the disease. The implication is that the disease can be confidently diagnosed based on symptoms alone. Nonerosive reflux disease (NERD) remains the predominant form of GERD. Current thinking is that NERD and erosive reflux disease (ERD) are distinct phenotypes of GERD rather than the old concept which regarded them as components of a disease spectrum. Non erosive reflux disease is a very heterogeneous group with significant overlap with other functional gastrointestinal disorders. There is no gold standard for the diagnosis of GERD. Esophageal pH monitoring and intraluminal impedance monitoring have thrown some light on the heterogeneity of NERD. A substantial proportion of GERD patients continue to have symptoms despite optimal PPI therapy, and this has necessitated research into the development of new drugs. Several safety concerns have been raised about chronic use of proton pump inhibitors but these are yet to be substantiated in controlled studies. The debate about efficacy of long-term medical treatment compared to surgery continues, however, recent data indicate that modern surgical techniques and long-term PPI therapy have comparable efficacy. These and other issues are subjects of further research.

Sedation practices for routine diagnostic upper gastrointestinal endoscopy in Nigeria.

AIM: To determine the sedation practices and preferences of Nigerian endoscopists for routine diagnostic upper gastrointestinal endoscopy. METHODS: A structured questionnaire containing questions related to sedation practices and safety procedures was administered to Nigerian gastrointestinal endoscopists at the 2011 annual conference of the Society for Gastroenterology and Hepatology in Nigeria which was held at Ibadan, June 23-35, 2011. RESULTS: Of 35 endoscopists who responded, 17 (48.6%) used sedation for less than 25% of procedures, while 14 (40.0%) used sedation for more than 75% of upper gastrointestinal endoscopies. The majority of respondents (22/35 or 62.9%) had less than 5 years experience in gastrointestinal endoscopy. The sedative of choice was benzodiazepine alone in the majority of respondents (85.7%). Opioid use (alone or in combination with benzodiazepines) was reported by only 5 respondents (14.3%). None of the respondents had had any experience with propofol. Non-anaesthesiologist-directed sedation was practiced by 91.4% of endoscopists. Monitoring of oxygen saturation during sedation was practiced by only 57.1% of respondents. Over half of the respondents (18/35 or 51.4%) never used supplemental oxygen for diagnostic upper gastrointestinal endoscopy. CONCLUSION: Sedation for routine diagnostic upper gastrointestinal endoscopy in Nigeria is characterized by lack of guidelines, and differs markedly from that in developed countries.

Time trends of upper gastrointestinal diseases in Nigeria.

BACKGROUND: The changing epidemiology of a disease often provides valuable insight into possible etiopathogenic mechanisms. There have been significant changes over the last several decades in disease manifestations of the foregut in Western Europe, North America and Asia. This time trend analysis was carried out to determine if any changes have occurred in the prevalence of diseases of the upper gastrointestinal tract in Nigeria. METHOD: Records of patients who underwent upper gastrointestinal endoscopy during two time periods (1995 to 1999 and 2006 to 2010) in Enugu, South-East Nigeria were analyzed with regard to biodata of patients, indications for upper gastrointestinal endoscopy and endoscopic findings. RESULTS: During the two time periods, 1,365 patients had upper gastrointestinal endoscopy (575 patients in the period 1995-1999 and 790 in the period 2006-2010). Dyspepsia was the commonest indication for upper gastrointestinal endoscopy for both periods (81.9% and 72.9%, respectively; p= 0.9052). Heartburn and dysphagia were more frequent during the second time period (p<0.0001). Duodenal ulcer was more common in the first time period (p<0.0001), while esophagitis, gastric ulcer and bile reflux were significantly more common in the second period (p<0.0001, p=0.0007 and p=0.0019, respectively). CONCLUSION: Over the 15-year period, the prevalence of duodenal ulcer has declined while that of gastric ulcer has increased. There has also been an increase in the prevalence of gastroesophageal reflux disease. Putative explanations for this trend may include widespread availability and use of very potent acid suppressant drugs, increasing use of non steroidal anti-inflammatory drugs, change towards western diet and increasing obesity.

Risk factors for hepatitis C virus transmission obscure in nigerian patients.

Aim. To determine the prevalence of anti-HCV and risk factors associated with HCV infection in Nigerians. Materials and Method. Patients attending a general outpatient clinic were administered a structured questionnaire on the risk factors for HCV infection. They were also tested for anti-HCV using a third generation enzyme-linked immunosorbent assay. Result. The seroprevalence of anti-HCV was 4.7%. Among the risk factors evaluated, none was found to be significantly associated with anti-HCV seropositivity. Conclusion. The risk factors associated with HCV infection in Nigerian patients are obscure. This warrants further studies on the epidemiology of this important cause of liver disease.

Esophageal Intraepithelial Neutrophil Infiltration is Common in Nigerian Patients With Non-Erosive Reflux Disease.

BACKGROUND: Non-erosive reflux disease (NERD) is a variant of gastroesophageal reflux disease (GERD) in which patients with typical reflux symptoms have no evidence of erosive esophagitis at endoscopy. An objective diagnostic tool for NERD remains an unmet need for clinicians and researchers. This study was designed to determine the types of histological alterations seen in Nigerian patients with NERD. METHODS: This was a prospective cross-sectional study in which mucosal biopsy was taken from the lower esophagus in patients with NERD. Similar biopsy was also taken from patients with nonulcer dyspepsia who served as controls. The materials were processed and examined histologically. RESULTS: There were 68 patients with NERD and 60 patients with nonulcer dyspepsia. Intraepithelial neutrophil infiltration was significantly more frequent in patients with NERD compared to those with nonulcer dyspepsia (47.1% vs 13.3%, P = 0.0326). Epithelial proliferative chnges in the form of basal cell hyperplasia and papilla elongation were minimal (11.8% and 3.3% respectively). CONCLUSIONS: Nigerian patients with NERD have a high degree of esophageal intraepithelial neutrophil infiltration and a low prevalence of epithelial proliferative changes. This may be related to the relative rarity of Barrett's esophagus in Nigerians.

Chronic hepatitis B: management challenges in resource-poor countries.

Sylvester Chuks Nwokediuko, Department of Medicine, University of Nigeria Teaching Hospital, Ituku OzallaChronic infection with hepatitis B virus (HBV) is a global public health problem because of its worldwide distribution and its potential to cause sequelae. HBV is most prevalent in China, South East Asia, sub-Saharan Africa, and the Amazon basin of South America where health care resources are most limited. Numerous challenges exist for effective management of chronic HBV infection, particularly in resource-limited regions. These challenges include lack of accurate prevalence data, absence of a surveillance program, and poor political will of governments in resource-poor countries to enforce effective measures to control the disease. There is a lack of understanding regarding HBV infec-tion by both the general public and health care providers. A better understanding of the pathogenesis and treatment of this condition is necessary. The acute shortage of trained medical manpower necessary for accurate diagnosis and treatment of chronic hepati-tis B (CHB) in resource-poor countries is a formidable challenge. The condition is com-plicated by the continuing efflux of medical graduates from low-income economies to richer countries. The most critical problem in the management of CHB is the high cost of laboratory tests and drugs. Drugs are also not readily available. Other challenges in the manage-ment of CHB include stigmatization of patients, co-infection with other viruses, lack of management guidelines, and absence of an effective patient referral system. To address these challenges, governments of resource-poor nations must be committed to budg-etary allocation for the implementation of health programs. It is necessary to provide awareness campaigns, health education, proper screening of blood and blood products for transfusion, active screening, intensification of existing childhood immunization, technical and financial assistance from wealthier nations, and implementation of the recommendations outlined in the Global Hepatitis Policy (2010).

Selected biochemical and hematological abnormalities in Nigerians with human immunodeficiency virus and hepatitis C virus coinfection.

BACKGROUND: Liver disease has emerged as a major cause of morbidity and mortality in patients with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection, now that antiretroviral therapy has become more effective and has prolonged life expectancy in HIV-infected patients. The main objectives of this study were to determine the prevalence of HIV/HCV coinfection and the pattern of hematological and biochemical abnormalities associated with such dual infection. METHODS: In this study, patients with HIV infection (cases) were tested for anti-HCV antibodies. There was a control group made up of apparently healthy individuals who came to hospital for medical examination for various reasons. They also had an anti-HCV antibody test. Those who tested positive for anti-HCV antibodies among the cases and control subjects were further evaluated for hemoglobin concentration, total white cell count, platelet count, and liver function. RESULTS: One hundred and eighty HIV-infected patients and 180 control subjects participated in the study. The seroprevalence of anti-HCV antibodies in the HIV-infected patients and control subjects were 6.7% and 4.4%, respectively (P = 0.57). Serum total bilirubin, conjugated bilirubin, and alkaline phosphatase were significantly higher in the HIV/HCV coinfected patients compared with their HCV monoinfected counterparts (P = 0.0396, 0.0001, and 0.0016, respectively). The mean hemoglobin, white cell count, platelet count, and CD4+ T lymphocyte count were significantly lower in the HIV/HCV coinfected patients than the HCV monoinfected control group (P = 0.0082, 0.0133, 0.0031, and 0.0001, respectively). CONCLUSION: The seroprevalence of anti-HCV antibodies in HIV-infected Nigerian patients is 6.7%. Patients with HIV/HCV coinfection have lower blood counts, higher serum bilirubin, and higher serum alkaline phosphatase compared with patients having HCV monoinfection.

Platelet Function and Other Indices of Hemostasis in Chronic Liver Disease.

BACKGROUND: Bleeding time has been used for a long time as a global test of platelet function. Due to a number of pitfalls the test has been losing popularity. This study was designed to determine the prevalence of prolonged bleeding time in Nigerians with chronic liver disease in relation to other indices of hemostasis. METHODS: Bleeding time, platelet count, prothrombin time (PT) and activated partial thromboplastin time (aPTT) were determined in patients with chronic liver disease seen over a twenty-eight-month period. Liver disease severity was graded using Child's score. RESULTS: Only 14 of 164 (8.5%) patients with chronic liver disease had prolonged bleeding time while 60 patients (36.6%) had significantly prolonged PT. Thirty seven patients (22.6%) had prolonged aPTT. Bleeding time showed positive correlation with PT and aPTT but negative correlation with platelet count. CONCLUSIONS: Bleeding time is not sensitive in detecting disorders of hemostasis in patients with chronic liver disease although it correlates significantly with other indices of hemostasis.

Relatively Long Survival in Hepatocellular Carcinoma Presenting With Carcinoid Syndrome.

Hepatocelluar carcinoma is one of the commonest cancers in Nigeria. Some patients may manifest a variety of paraneoplastic syndromes. Carcinoid syndrome is an extremely rare presentation of hepatocellular carcinoma. A 57-year old man presented with recurrent facial flushing and diarrhea, tricuspid regurgitation, and very high level of urinary hydroxyindoleacetic acid (HIAA) as the first manifestation of a multicentric hepatic lesion which proved histologically to be hepatocellular carcinoma. The lesions also exhibited arterial hypervascularization on contrast enhanced computerized tomography. The patient is still alive after 6 years of symptoms.

Gastroesophageal Reflux Disease: A Population Based Study.

BACKGROUND: The prevalence of gastroesophageal reflux disease varies in different parts of the world. There are no population based studies in Nigeria. The main objectives of this study were to determine the prevalence and risk factors for gastroesophageal reflux disease in a population of Nigerian medical students. METHODS: The Carlsson-Dent questionnaire was administered to medical students in the clinical phase of their training at the University of Nigeria, Enugu Campus. Some putative risk factors for gastroesophageal reflux disease were also included in the questionnaire. RESULTS: The prevalence of gastroesophageal reflux disease was 26.34%. There was an association between the use of caffeine-containing substances (coffee and kolanuts) and the prevalence of gastroesophageal reflux disease (odds ratio = 2.2 and 2.015, respectively). CONCLUSIONS: Gastroesophageal reflux disease is common among Nigerian medical students. The use of caffeine-containing substances (coffee and kolanuts) by students may have a role in the high prevalence.

Quantitative Platelet Abnormalities in Patients With Hepatitis B Virus-Related Liver Disease.

BACKGROUND: Platelets play a central role in primary hemostasis. Quantitative abnormalities of platelets are known to occur in chronic liver disease. The study was carried out to determine the abnormalities of platelet count in various forms of Hepatitis B virus-related liver disease. METHODS: Platelet count was carried out on consecutive chronic liver disease patients seen at the gastroenterology unit of the University of Nigeria Teaching Hospital Ituku/Ozalla who tested positive for Hepatitis B surface antigen (HBsAg) from January 2007 to June 2009. Dyspeptic patients undergoing upper gastrointestinal endoscopy who were HBsAg negative were used as controls. RESULTS: There were 142 patients with various forms of HBV-related liver disease (asymptomatic infection 29.6%, chronic hepatitis 8.4%, cirrhosis 27.5%, and hepatocellular carcinoma 34.5%). There was no statistically significant difference between the mean platelet count in the patients with Hepatitis B virus (HBV) related liver disease as a whole and control subjects (p = 0.4655). However patients with cirrhosis had a statistically significant lower platelet count than control subjects (p < 0.0001). Conversely, patients with hepatocellular carcinoma (HCC) had a higher platelet count than control subjects (p < 0.0001), and cirrhotic patients (p < 0.0001). CONCLUSIONS: Abnormalities of platelet count occur in HBV-related liver disease. Patients with liver cirrhosis tend to have lower platelet count while patients with HCC tend to have higher counts. Thrombocytosis may be a paraneoplastic manifestation of HCC.

Intestinal Helminths in relationship to Chronic Diarrhoea in Human Immunodeficiency Virus-Seropositive Adults in Enugu.

Human immunodeficiency virus (HIV) infection and intestinal helminthiasis are common conditions in Nigeria. Chronic diarrhoea is a common manifestation of acquired immune deficiency syndrome ( AIDS). Helminths such as Strongyloides stercoralis and Trichuris trichiura may cause chronic diarrhoea especially in immunocompromised individuals. In order to determine whether any relationship exists between HIV infection and intestinal helminthiasis, stool samples from all HIV seropositive adults (with or without diarrhoea) admitted to the medical wards of the University of Nigeria Teaching Hospital, Enugu from August 1996 to October 1998 were examined microscopically for helminths. Out of 383 HIV-seropositive patients studied, 181 (47.26%) presented with chronic diarrhoea whereas 202 (52.74%) had no diarrhoea. The overall prevalence rate of gut helminths was 17.74%. The prevalence rate in the patients with chronic diarrhoea was 19.34% and that of those without chronic diarrhoea was 16.34%. The difference was not statistically significant. The helminths identified were Ascaris lumbricoides, Hookworm, Strongyloides stercoralis and Trichuris trichiura but there was no statistically significant difference in the two groups of patients. The study showed that there may be no clearcut relationship between gut helminths and HIV infection.