Isolated gallbladder rupture following blunt abdominal trauma.

The gallbladder is a relatively well-protected organ; consequently its rupture following blunt abdominal injury is rare and usually associated with other visceral injuries. Isolated gallbladder rupture is extremely rare. We report a healthy Nigerian adult male who sustained isolated gallbladder rupture following blunt abdominal injury from riding a motor cycle (Okada). A high index of suspicion with positive bile aspirate might lead to early diagnosis. Open cholecystectomy is a safe option of treatment in a resource poor centre especially in delayed presentation and has a good outcome.

Outcome of surgery for toxic goitres in Maiduguri: a single teaching hospital's perspective.

BACKGROUND: Thyrotoxicosis a common endocrine disorder of the thyroid gland in Nigeria is commonly treated surgically. The outcome of thyroidectomy for toxic goiters in Maiduguri Nigeria is evaluated. MATERIALS AND METHODS: Over the last 5 years (Jan 2005-July 2010) , in a prospective review, the demographic, and clinical data of patients operated for toxic goiters in our department was entered, into a predesigned proforma and analyzed. The objective of the study is to review our experience with subtotal and near-total thyroidectomy as treatment for benign toxic goiters. RESULTS: Seventy-eight patients, 11 males (14.1%) and 67 females (85.9%), with male: female ratio of 1:6.1 and the mean age of 30 ± 10.9 (range, 17-65 years), underwent thyroidectomy for toxic goiters. The mean duration of symptoms was 41.9 (range 3-126 months). There were 53 patients with toxic diffuse goiters (Grave's disease) with their mean age of 27.6 ± 6.93 (range 17-38 years), 23 with toxic multinodular goiters, the mean age of 43.7 ± 15.68 (range 17-65 years) and two with toxic nodule. There was no case of permanent recurrent laryngeal nerve palsy or permanent hypocalcemia. Transient hypocalcemia occurred in 9 (11.5%) patients and hemorrhage with hematoma, requiring exploration in 4 (5.1%). There were two cases of wound infection and no postoperative mortality. The mean hospital stay was 7.6 ± 2.34 (range 5-15 days). There was no disease recurrence over a mean follow-up of 20.7 (range 2-48) months. CONCLUSION: Subtotal thyroidectomy is an effective procedure for the treatment of thyrotoxicosis with few postoperative complications and majority of patients being euthyroid after long follow-up.

Perforated peptic ulcer (PPU) in pregnancy during Ramadan fasting.

BACKGROUND: Perforated Peptic Ulcer (PPU) is extremely rare in pregnancy. We report a case of perforated peptic ulcer in pregnancy during Ramadan fasting. PATIENT AND METHODS: The patient is a 16 years old primigravida who presented with features of peritonitis at 28weeks of gestation while fasting during Ramadan. Ultrasound scan reported a singleton live fetus at 28 weeks gestation. At laparotomy via upper midline incision; a 1 cm roundish perforation located on the duodenum anteriorly was found with about a litre of gastric juice mixed with blood and food particles in the peritoneal cavity. The perforation was close transversely with omental patch (Modified Graham's patch) and peritoneal lavage done with warm saline. She had a preterm delivery of a 1 kg baby 3 days post-operatively by a spontaneous vaginal delivery, but the baby died 3 days later. CONCLUSIONS: Perforated Peptic Ulcer(PPU) though rare in pregnancy can occur and fasting can be a risk factor.

Gallbladder perforation complicating typhoid fever: report of two cases.

BACKGROUND: Gallbladder perforation (GBP) is rare and as a complication of typhoid fever is extremely rare. We present two consecutive patients with GBP diagnosed incidentally at laparotomy. METHOD: Information on the management of two patients with gallbladder perforation seen at Federal Medical Centre Azare in June and October 2008 was extracted from their case records. RESULTS: The two patients were both males aged 13 years and 16 years. They both presented with high fever of more than 2 weeks duration; and abdominal pain and distension. Both patients had features of generalised peritonitis. Pre-operative diagnoses of typhoid enteric perforation were made based on a positive Widal test. Intra-operative findings however, were that of bile peritonitis and gallbladder perforation. Both had cholecystectomy. Culture of the bile aspirate yielded Salmonella typhi. CONCLUSION: Gallbladder perforation secondary to typhoid fever should be considered as a differential diagnosis in patients with suspected typhoid enteric perforation in typhoid fever endemic region.

Congenital aganglionic megacolon in Nigerian adults: two case reports and review of the literature.

Congenital aganglionic mega colon (Hirschsprung's disease) is a motor disorder in the gut, due to a defect in the craniocaudal migration of the neuroblast originating from the neural crest that occurs during the first twelve weeks of gestation, causing a functional intestinal obstruction, with its attendant complications, in infants. Despite modern pediatric practice, with emphasis on early diagnosis, Hirschsprung's disease is seen in adults in regions where perinatal care is limited. We report two cases of Nigerian adults with longstanding, recurrent constipation, getting relieved by laxatives and herbal enemata, and then presented to our Emergency Department with a history of progressive abdominal distention, colicky pain, occasional vomiting, and weight loss. Per rectal examination revealed a gripping sensation in the rectum, 10 cm from the anal verge, with rectal fecal load. Barium enema showed a grossly distended proximal large colon, with high fecal retention, with the transition zone at the middle one-third of the rectum. Due to difficulty in bowel preparation of these patients, emergency laparotomy was done. The first case had a diverting sigmoid colostomy and later had a low anterior resection. The second case had a one-stage procedure. Histology of both the cases showed aganglionosis of the stenotic segment and a normal distal rectum. Both patients had complete resolution of the symptoms, without complications, in a three-year follow-up. The related literatures were reviewed. Hirschsprung's disease should be considered in adults patient presenting with chronic constipation. Low anterior resection of the rectum would be a surgical option for the treatment of short and zonal segment of adult Hirschsprung's disease.

Urethral calculi in young-adult Nigerian males: a case series.

BACKGROUND: Urethral calculi are rare and usually encountered in males with urethral pathology. OBJECTIVE: To present our experience managing urethral calculi in a resource limited centre and review the literature. METHODS: We did a chart review of management of patients with urethral calculi between January and April 2009, at Federal Medical Centre (FMC) Azare, Nigeria. We also reviewed the literature on this rare condition. RESULTS: Four young adult male Nigerians between the ages of 17 and 27 years presented with varying degrees of urethral pain and palpable calculi in the anterior urethra. Two presented with acute retention of urine, but none had haematuria. The calculi were radio-opaque, located in the anterior urethra with no associated urethral pathology. Three were solitary and one multiple. The composition of the urethral calculi was a mixture of calcium oxalate calcium carbonate, magnesium phosphate, one has additional cystine but none had struvite or uric acid. Their sizes ranged between 1cm ×1.5cm and 1.5cm × 5.5cm. External urethrotomy was the method of treatment. CONCLUSION: Urethral calculi are rare in our setting, with no clear identifiable aetiological factors which suggests urinary schistosomiasisbeing associsted. The occurrence of urethral calculi appears to have a relationship with childhood urinary schistosomasis.

Giant ureteric and staghorn calculi in a young adult Nigerian male: a case report.

BACKGROUND: Ureteric calculi are usually small and solitary.The term giant has been applied to ureteric calculi that aremore than five cms in length and/or 50g or more in weight. These are uncommon and may present with few or no urological symptoms and might be ignored or be missed. OBJECTIVE: To present a rare case of a giant left ureteric calculus associated with an ipsilateral staghorn calculus. METHODS: A 31-year-old Nigerian male presented with recurrent left abdominal pain, dysuria, urinary frequency, and fever which had been on for 10 years. Patient was clinically evaluated. He had plain abdominal X-rays, abdominal ultrasonography and intravenous urography. He had to undergo nephrouterorectomy. RESULTS: Patient took analgesics and antibiotics purchased from patent chemist shops for relief of symptoms by himself. He was fit except for a hard cylindrical mass felt arising from the pelvis. Abdomino-pelvic ultrasound scan, plain abdominal X-ray and Intravenous urogram showed a giant ureteric calculus with an ipsilateral staghorn calculus in a nonfunctioning hydronephrotic left kidney. There was no evidence of underlying anatomic or metabolic abnormalities. He had left nephroureterectomy. The ureteric calculus measured 10.5 x 3.0cm and weighed 20.1gm. CONCLUSION: Giant ureteric calculi are rare. The association giant ureteric calculus with an ipsilateral staghorn renal calculus without underlying anatomic abnormalities appear not have been reported earlier.

Acute perforated duodenal ulcer in Maiduguri: experience with simple closure and Helicobacter pylori eradication.

BACKGROUND: Effective medical management of peptic ulcer disease (PUD) has reduced the incidence of gastric outlet obstruction (GOO) as a complication, but perforation especially in the elderly remains unchanged and is in fact on the increase. There is a changing trend in emergency surgery for perforated duodenal ulcer (PDU) from definitive anti ulcer surgery to simple closure followed by Helicobacter pylori eradication. OBJECTIVE: To present our experience in managing PDU with simple closure followed by Helicobacter pylori eradication. METHODS: This was a chart review of patients managed for PDU over a nine year period (Jan 1999 to Dec 2007) using information obtained from ward admission registers, theatre operation registers, and patients case files from the medical records department. The patients biodata, clinical, and operative findings as well as treatment outcome were extracted for analysis. RESULTS: Of 55 patients eligible for analysis, 44 (80%) were males and 11(20%) females (M to F, 4:1). Their ages ranged between 18 and 65 years with a mean(SD) of 39.9 (13.5) years. Most of the patients, 34 (61.8%), were below 40 years of age and majority 39(71.0%) had a history suggestive of chronic peptic ulcer disease. Twenty six (47.3%) patients presented within 24 hours of perforation, while nine (16.4%) presented more than 72 hours afterwards. The latter group accounted for most, five(55.6%), of the mortality. All the perforations were anterior pyloroduodenal and all except one had simple closure with omental patch followed by a course of a proton pump inhibitor and Helicobacter pylori eradication therapy. CONCLUSION: Simple closure with omental patch followed by Helicobacter pylori eradication is effective in managing PDU with low morbidity and mortality despite patients late presentation in our center. This technique is recommended in place of a definitive ulcer surgery.

Tuberculous ileal perforation in a HIV positive patient: a case report and review of literature.

BACKGROUND: Tuberculosis is prevalent worldwide. Even in developed countries there is a resurgence of tuberculosis mainly due to increasing HIV infection. Tuberculous ileal perforation is uncommon. It is, however, a potentially fatal complication of intestinal tuberculosis especially in HIV/AIDS patient. AIM: To highlight tuberculous ileal perforation as an underestimated complication of intestinal tuberculosis in an HIV patient presenting with acute abdomen. METHOD: A 42-year-old HIV positive long distance truck driver with tuberculous ileal perforation is presented and related literatures reviewed. CONCLUSION: Intestinal perforation due to abdominal tuberculosis is an aetiological factor in acute HIV abdomen. High index of suspicion remains the key to diagnosis.

Management of adult incisional hernias at the University of Maiduguri Teaching Hospital.

BACKGROUND: Incisional hernias (IH) represent a breakdown or loss of continuity of a fascial closure. They are thus unique as the only external wall hernias that are iatrogenic in aetiology. Incisional hernias are not uncommon complications of laparotomy closure with reported incidence of 2 to 11%. OBJECTIVES: To review our experience,with incisional hernaia identify possible risk factors and proffer preventable strategies. PATIENTS AND METHODS: All case records of adult patients managed with IH at the University of Maiduguri Teaching Hospital between January 1995 and December 2004 were retrieved from the Medical Records Department. Relevant data on age, sex, type and institution of index surgery (General Hospital or Private Hospital), premorbid factors, type of repair, post-operative complications were extracted. Case records with inadequate information were excluded. RESULTS: Between January 1995 and December 2004 a total of 440 patients with external abdominal hernias were treated at UMTH. Out of these: 38 (11.6%) were Incisional hernias and form the basis of this study. Their ages ranged between 18 and 80 years, with peak age range of 40-49 years. There were 6 males and 32 females giving a male to female ratio of 1:5.3. The commonest index surgeries were caesarean section in 12 patients (31.6%) and appendicectomy 10 patients (26.3%). Of the index surgeries 26 (68.4) and 10 (26.3) were performed in general and private hospitals respectively. Only 2(5.3%) were done at UMTH. Wound sepsis, in 18 patients (47.4%), postoperative cough, 8 (21.1%) and obesity 6 (15.8%) were the commonest risk factors. Poor surgical technique was found in 36 patients (94.7%) Most of the patients presented late; 8(21.1%) with recurrence and 6(15.8%) were giant in size. All but one were successfully repaired. Only one (2.3%) had recurrence. There was no mortality. CONCLUSIONS: Incisional hernias are not uncommon constituting 11.6% of all adult external abdominal wall hernias repaired at UMTH. Most of the causes are preventable with 94.7% of the index surgery done at peripheral hospitals where poor surgical technique was common to all. There is urgent need to re-train our general duty doctors on proper surgical techniques of abdominal wound closure.

Aetiology, management and outcome of entero-cutaneous fistula in Maiduguri, Nigeria.

BACKGROUND: Enterocutaneous fistula (ECF) remains an important surgical problem with significant morbidity and mortality. This study aims to review the aetiology and management outcome in a depressed economy like ours. METHODS: A retrospective review of 54 patients with ECF admitted into the surgical wards of the University of Maiduguri Teaching Hospital (UMTH) between January 1994 and December 2004 (11 year period). RESULTS: Thirty two (59.3%) were males and 22 (40.7%) were females giving a male/female ratio of 1.5 to 1. The age ranged from 1 to 58 years with two peak incidents of 20-29 years and 40-49 years. Eighteen cases (33%) occurred following appendicectomy, 12 (22%) following laparotomy for intestinal obstruction, 10 (18.5%) following laparotomy for abdominal malignancies, 7 (13%) followed laparotomy for penetrating abdominal injuries, 3 (5.5%) followed laparotomy for perforated typhoid enteritis, 2 (3.7%) cases were due to spontaneous rupture of strangulated and neglected inguinal hernia, 1 (1.9%) case followed chest tube insertion for pleural effusion in a PTB patient and 1 (1.9%) case followed a native healer's incision on a lumber hernia. Altogether,45 (83.3%) were referred cases from peripheral hospitals. Fourty one (76%) were high output type, while 13 (24%) were low output type. Most patients 32 (59.3%) healed spontaneously on conservative management. Eighteen (33%) had surgical intervention. Eight patients demised giving a mortality rate of 15%. The average hospital stay was 56 days. CONCLUSION: The main cause of ECF in our environment is postoperative (94.4%) with post appendicectomy cases alone accounting for 33%. Majority of our patients (66.7%) were managed conservatively.

Correlation between histopathologic and fine needle aspiration cytology diagnosis of palpable breast lesions: a five-year review.

Fine needle aspiration cytology (FNAC) of the breast has been used as an initial investigative procedure of palpable breast lesions. The purpose of this study is to evaluate our experience with Fine Needle Aspiration Cytology (FNAC) and to correlate between histopathologic and FNAC diagnoses of palpable breast lesions. A 5-year retrospective study was performed using records of all patients who had had both FNAC and histopathologic results of breast lumps. This is a retrospective study of 220 diagnosed cases of breast lesion at the University of Maiduguri Teaching Hospital (UMTH), Nigeria between the periods of January 2001 and December 2005. The results of the FNAC were interpreted as inflammatory, benign, suspicious or malignant. A total of 220 patients had both cytopathologic and histopathologic diagnoses and therefore fulfilled the criteria for this study. There were 11 (5%) cases of inflammatory, 140 (63.6%) cases of benign and 69 (31.4%) cases of malignancy. There were two cases that were suspicious of malignancy and for the purpose of this study were considered as malignant. There were five (5) cases of cytologically interpreted errors which were three cases of false negative and two cases of false positive. The diagnostic accuracy was 97.7%, sensitivity was 95.7%: and specificity was 98.7%. The false negative and false positive rates were 2.9% and 1.9% respectively. FNAC of breast lesions is sensitive, specific, and highly accurate as the initial investigation of palpable breast lesions in our tertiary hospital. We therefore implore clinicians to embrace this procedure in the management of patients.

Schistosomiasis of the appendix in Maiduguri.

We retrospectively studied 27 histologically diagnosed cases of schistosomiasis of the appendix at the University of Maiduguri Teaching Hospital between January 1994 and December 2003. Of 1183 cases of appendices histologically examined, schistosomiasis was seen in 27 (2.3%).

Male breast cancer in north eastern Nigeria.

BACKGROUND: Carcinoma of the male breast is generally rare and constitutes 1% of all breast cancers. They often present late in developing countries and therefore has poor prognosis. The aim of this paper is to highlight the pattern of presentation and problems associated with management of this disease in Maiduguri, North Eastern Nigeria. PATIENTS AND METHOD: Case records of eleven (11) histologically diagnosed male breast cancers out of a total of two hundred and ninety-five (295) cases of breast cancer managed at the University of Maiduguri Teaching Hospital between 1989-2003 were retrospectively studied and analysed. RESULTS: Male breast cancer constitutes 3.7% of all cases of breast cancers seen in this hospital during the study period under review. The male to female ratio was 1:26. The peak age range at presentation was 40-49 years and all were advanced at presentation. The time interval between onset of symptoms and presentation were all over 12 months. All the patients either had toilet mastectomy or modified radical mastectomy. In addition, two patients had sub capsular orchidectomy while nine had Tamoxifen. Four patients had additional cytotoxic chemotherapy. Two patients died in the course of follow-up while the rest were lost to follow-up shortly after discharge. Only one patient was followed-up for more than two years. CONCLUSION: Male breast cancer though rare, is a serious clinical problem associated with late presentation. It is hoped that increased public awareness will improve the outcome of management.

Post-thyroidectomy metastatic thyroid cancer.

BACKGROUND: The objective of this paper is to highlight the importance of tissue biopsy for histopathological diagnosis. METHOD: A report of a 46-year-old farmer with post-thyroidectomy metastatic thyroid cancer. RESULT: A post-thyroidectomy patient presenting with extensive skull and lumbar spine metastasis, paraparesis, huge occipital swelling and good healed scar without tumour residue. The thyroidectomy specimen was not subjected to histopathological diagnosis. Fine needle aspiration cytology of the occipital swelling revealed metastatic follicular carcinoma. Patient was placed on thyroxine 0.5mg daily with great improvement of lower limb muscle power. CONCLUSION: These bony metastases could have been reduced if proper investigation was done. There is need for continuous medical education for all clinical medical personnel.

Chemical composition of urinary calculi in Maiduguri, Nigeria.

Urolithiasis is a common disorder in Maiduguri and constitutes a significant proportion of surgical diseases in Nigerian Hospitals today. Although, the analysis of the stones is an integral part of the assessment of stone formers, earlier report in Maiduguri did not dwell well on it. We therefore, carry out this study to report on the composition of urinary tract calculi removed during surgery at the University of Maiduguri Teaching Hospital and to find out if stone composition in the area changes with time. Fourty-nine urinary tract calculi removed in the surgery unit of the Hospital in 2003 were chemically analyzed in the Department of Chemical Pathology of the same Hospital. We also retrieved results of stones analyzed in 1989 (41) and 1999 (21) and compared the results with the 49 analyzed in 2003. The results showed a male preponderance with male: female ratio 12:1, and the calculi occurred more in the upper part of the tract (70.9%) than the lower part of the tract (29.1%). Calcium containing stones constituted the majority; 76.9%, uric acid/urate was associated with 16.3% of the stones while struvite constitutes 4.3%, xanthine 1.7% and cystine 0.9%. There was subsequent reduction of struvite stones with time. Urinary tract stone is common in Maiduguri. There is need for identification of risk factors of calculi formation in the environment to enable the health care providers plan preventive measures in order to reduce the high incidence in the area.

The status of patients with negative appendicectomies in Maiduguri.

This study was conducted to verify the status of patients with negative appendicectomies in our practice and thus assess possible ways of reducing it. Of a total of 554 appendicectomies done in UMTH from January 1997 to December 2001, 27 (4.9 %) of these appendices were reported at histology as normal. 21 (77.8 %) were females and 6 (22.2 %) were males giving a female to male ratio of 3.5 to 1. The age range of the female patients was between 18 and 47 years with a mean 28.8 (SD) of (8.2) years. The age range of the male patients was between 11 and 47 years with a mean 31.5 (SD) of (12.6) years. The diagnostic alternatives depict the common scenario: Gynaecological conditions, urinary problems, peptic ulcer disease and non specific abdominal pain which are some of the major known differential diagnosis of acute appendicitis. Therefore careful clinical assessment of the patient should be depended upon for the diagnosis of appendicitis especially in our environment where sophisticated aids to diagnosis remains scarce.

Suicide attempts in HIV/AIDS patients: report of two cases presenting with penetrating abdominal injuries.

BACKGROUND: We present two patients to highlight an emerging trend of suicide attempts presenting to the surgeons with penetrating abdominal injuries found to be HIV/AIDS related. METHODS: The two patients were managed at the University of Maiduguri Teaching Hospital in the year 2003. Both patients presented as emergencies with penetrating abdominal injuries and were resuscitated followed by clinical evaluation and laparotomy. RESULTS: Both patients had visceral injuries that were repaired at laparotomy and were both confirmed HIV positive. CONCLUSION: There is an emerging trend of suicide attempts in HIV/AIDS patients and the need to determine the suicide pattern that will enable all stakeholders workout a formidable HIV/AIDS and suicide prevention programmes.

Epidemiology of childhood burns in Maiduguri north-eastern Nigeria.

BACKGROUND: Burns is a global problem and has its toll especially in a developing region like ours where poverty and ignorance are still rife. Previous studies in the sub-region have lumped children and adults together. We retrospectively studied the factors that lead to burns in children and the peculiarities in managing them. METHODS: All case notes of burns injury in children managed at the University of Maiduguri Teaching Hospital between 1991-2000 were retrospectively studied. RESULTS: A total of 219 children were studied. Children of age below 5 years were affected more than children above 5 years (168 vs. 51) with toddlers 1-2 years constituting a significant proportion of those below 5 years (71 vs. 168). The male to female ratio was 1.6:1 with a preponderance of male children below 10 years and the females between 11-15 years of age. The commonest cause of burns was scald (64.4%) in the household, which is usually accidental, but 3 were suicide attempts by teenage pregnant females 11-15 years protesting forced marriages, a cultural problem in our environment. Flame burns ranked second (27.4%) and results mainly from careless storage, adulteration and hawking of petroleum products. More than 50% of the patients sustained major burns resulting in high morbidity and mortality rate of 16%. CONCLUSION: Burn is a major public health problem and will require public/school health education campaign on childhood household safety. Appropriate legislation and enforcement on the sale of petroleum products would help to reduce the scourge.