Inflammatory Bowel Disease in Adults - Experience and Challenges in Gastroenterology Practices in Calabar, South-South Nigeria.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract that is reported to be rare in Africans. The objective of this study is to share the experience of our Gastroenterology practice in Calabar, Cross River State on IBD. METHODS: This is a ten-year review of the records of patients visiting the Gastroenterology clinic of the University of Calabar Teaching Hospital and two private gastroenterology clinics in Calabar Municipality. The diagnosis of IBD was made based on clinical, laboratory, endoscopic, and histological data obtained. RESULTS: Eight patients presented with features consistent with IBD. Six had ulcerative colitis while 2 had Crohn's disease. Seven patients had moderate disease with the main clinical features being recurrent mucoid bloody diarrhoea. All the patients had treatments with either sulphasalazine or mesalazine as well as azathioprine, steroids and antibiotics with variable response. One patient had strictures requiring a colostomy, while another developed colorectal cancer as complications of IBD. CONCLUSION: Although IBD is uncommon in Nigeria, a high index of suspicion is important, especially in patients presenting with the recurrent passage of mucoid bloody stools. Hence, the role of colonoscopy and histology are invaluable in establishing the diagnosis.

FONDEMENT: La maladie inflammatoire de l'intestin (MII) est un trouble inflammatoire chronique du tractus gastro-intestinal qui est rapporté comme étant rare chez les Africains. L'objectif de cette étude est de partager l'expérience de notre pratique en gastroentérologie à Calabar, dans l'État de Cross River, sur la MII. MÉTHODES: Il s'agit d'une revue de dix ans des dossiers des patients fréquentant la clinique de gastro-entérologie de l'Hôpital universitaire de Calabar et de deux cliniques privées de gastroentérologie dans la municipalité de Calabar. Le diagnostic de MII a été posé sur la base de données cliniques, biologiques, endoscopiques et histologiques obtenues. RÉSULTATS: Huit patients présentaient des caractéristiques compatibles avec la MII. Six présentaient une colite ulcéreuse tandis que 2 présentaient une maladie de Crohn. Sept patients avaient une maladie modérée avec comme principale caractéristique clinique des diarrhées muqueuses sanglantes récurrentes. Tous les patients ont été traités soit avec de la sulfasalazine soit avec de la mésalazine ainsi que de l'azathioprine, des stéroïdes et des antibiotiques avec une réponse variable. Un patient avait des sténoses nécessitant une colostomie, tandis qu'un autre développait un cancer colorectal comme complications de la MII. CONCLUSION: Bien que la MII soit rare au Nigeria, un indice de suspicion élevé est important, surtout chez les patients présentant un passage récurrent de selles muqueuses sanglantes. Ainsi, le rôle de la coloscopie et de l'histologie est inestimable pour établir le diagnostic. MOTS-CLÉS: Adultes, Maladie de Crohn, Maladie inflammatoire de l'intestin, Colite ulcéreuse.

Oestrogen and progesterone receptors in Nigerian breast cancer: relationship to tumour histopathology and survival of patients.

BACKGROUND: Expression of oestrogen receptors (ER) and progesterone receptors (PR) in breast carcinomas identifies patients that are more likely to respond to adjuvant therapy. OBJECTIVES: Our aim was to evaluate the prevalence and prognostic value of histologically confirmed ER and PR immunoreactivity in breast carcinoma seen at Calabar, Nigeria. DESIGN: Cross sectional study. SETTING: University of Calabar Teaching Hospital, Nigeria. SUBJECT: Sections of formalin-fixed, paraffin-embedded samples from 129 breast carcinomas were immunostained for ER and PR. RESULTS: ER and PR were immunohistochemically detected in 24.0% and 13.9%, respectively, of the breast carcinomas. The staining results were significantly associated, though negatively, with the axillary lymph node status, clinical stage, and histological grade. In survival analysis of the whole material, neither ER nor PR positivity showed any prognostic value. In the premenopausal group, both ER and PR showed a prognostic potential. However, they had no independent prognostic value. CONCLUSION: Further studies to assess the frequency and prognostic values of these hormone receptors in breast cancers, after standardized processing and a longer follow up period may be necessary to validate these findings. Furthermore, a consensus must be developed for scoring and reporting ER/PR in Nigerian material.

Functional disturbances in children after ano-rectal surgery.

OBJECTIVE: To determine the prevalence, clinical presentation, highlight management methods and outcome of treatment modalities in children who presented at the University of Calabar Teaching Hospital, Calabar with complications from previous ano-rectal operations. DESIGN: Prospective study of ano-rectal complications from previous ano-rectal surgery in children over a seven year period. SETTING: University of Calabar Teaching Hospital, Calabar, a referral and teaching hospital. SUBJECTS: All cases of complications from previous ano-rectal surgery in children that presented at the paediatric surgical clinic of the University of Calabar Teaching Hospital (UCTH), Calabar, between January 1994 and December 2000. INTERVENTION: Conservative measures were commenced in all cases and involved diet manipulation, enema and physiotherapeutic training. RESULTS: The age of maximum presentation was within the 6-10 year age bracket. The main presenting complain was faecal soilage and poor bowel habit. The children notably presented late and was as a result of societal embarrassment at school. Before then the child was within the home environment hence parents may not bother. Complications from anal agenesis operation accounted for the majority of patients 45(54%) while aganglionic megacolon accounted for 39 patients (46%). Treatment in all cases started conservatively with diet manipulation, cleansing enema and physiotherapeutic training. However, with non improvement in faecal soilage, a simple repair involving a narrowing at the ano-rectal junction was carried out. In a follow-up period of between 6-12 months, 45 children had satisfactory clinical status while in 27 children their general conditions had improved. CONCLUSION: Perseverance and tolerance from the surgeon, the parents and the patient-child is required in these conditions. The late presentation may have helped as the fibres of the external sphincter muscles perhaps have further developed. At this period the child is also psychologically aware of his problem.

Tubular differentiation in African breast cancer.

In an effort to determine numerical thresholds for histological breast cancer grading, we evaluated the fraction of fields with tubular differentiation (FTD) in Nigerian breast cancers (n=300). Analyses were based on Kaplan-Meier survival curves, and univariate and multivariate analyses by Cox's regression. The mean (SD) value of FTD in Nigeria, 16.7 (19.3)%, was much lower than reported in European breast cancer. Decreasing FTD was associated with increasing histological grades (p < 0.0001) and clinical stage (p = 0.0190). The most significant cut-point for FTD in predicting outcome was 15.0%. In univariate analysis, FTD 15% was a significant prognosticator in the whole material, in larger than 5cm tumours, among postmenopausal and premenopausal patients, and LN+ patients. After multivariate analysis with mitotic count, FTD was an independent prognosticator among tumours larger than 5cm, but not in other groups. We conclude that the rational grading of breast cancers need be optimised according to diagnostic and therapeutic environment. We propose FTD 15% as a cut-point to grade breast cancer in Nigerian material.

Influence of age and prognosis of breast cancer in Nigeria.

OBJECTIVE: To determine the relationship between the age at diagnosis and established prognostic factors of breast cancers in Calabar, Nigeria. Attempts made to assess the prognostic value of age at presentation. DESIGN: Retrospective study of invasive breast cancer seen in Calabar over a seventeen-year period. Pearson's correlation, univariate and multivariate Cox's regression were used. SETTING: University of Calabar Teaching Hospital, Calabar, Nigeria, a referral and teaching hospital. SUBJECTS: Three hundred cases of invasive breast cancer diagnosed between 1983 and 1999 in Calabar, Nigeria. The necessary follow-up data was available for 129 patients. RESULTS: The mean age at diagnosis of breast cancer in Nigeria was 42.7 years (SD 12.2, range 18-85 years). Patients less than 40 years accounted for 39.8% of the total number of patients with infiltrating breast carcinoma. In the whole material (n=300), there was a positive association between age and tumour size (r=0.44, p=<0.0001), stage (r=0.47, p=<0.0001), the degree of necrosis (r=0.21, p=0.0002), histological grade (r=0.11, p=0.0476), MAI (mitotic activity index, r=0.12, p=0.0338), and MNA (mean nuclear area, r=0.17, p=0.0033). The correlation between age and SMI (standardized mitotic index), AI (apoptotic index), SMI/AI ratio, and FTD (fraction of fields showing tubular differentiation) were not statistically significant. The optimal decisive prognostic cut point for age was 33 years (p=0.0064). Age was also a significant prognosticator when used as a continuous variable (p=0.0240). Survival was better in the younger patients. However, in the Cox's multivariate analysis involving SMI, tumour size and age (both as a continuous variable and using the determined cut point of 33 years), the age at diagnosis lacked an independent prognostic value. CONCLUSION: The more advanced nature of breast cancers and the possible more aggressive tumours (reflected by the higher MNA values) in the older patients may explain the poorer survival seen in patients diagnosed at 40 years or above. It is also probable that the lifestyle differences between the two studied age groups may influence the early detection and prompt commencement of therapy. Screening and treatment approaches between the two age groups may differ in view of the differences.

Breast cancer in Nigeria and Finland: epidemiological, clinical and histological comparison.

BACKGROUND: We compared the histology and patterns of occurrence of breast cancers in Nigeria (n = 297) and Finland (n = 285). PATIENTS AND METHODS: The histology of invasive ductal carcinoma (IDC) was re-evaluated using similar criteria. The clinical data were extracted from medical records. RESULTS: The mean age at presentation was 42.7 (12.2) years in Nigeria vs. 58.7 (12.5) years in Finland. In both populations there was an association between reproductive factors and the occurrence of breast cancer. In Nigeria, 53.2% of cases belonged to stages 3 and 4 (vs. 6.7% in Finland). In Finland there were higher frequencies of lobular, tubular and mucinous types than in Nigeria. The Nigerian material had more medullary type (2.7% vs. 0.7% in Finland), extensive necrosis, nuclear atypia and pleomorphism, with coexisting pleomorphic ductal carcinoma in situ. At 2 years after treatment, the survival figures for Nigeria and Finland were 72.8% and 96.4%, respectively. CONCLUSION: The histology of Nigerian and Finnish cancers clearly differ. Nigerian cancers appear more advanced with higher grade. The atypical in situ component is clearly more common in Nigeria. Part of the differences can be explained by diagnostic and treatment delays associated with misguided socio-cultural beliefs, poor health care access and impaired immunity.