A clinico-pathological study of Cushing's syndrome at the University Hospital of the West Indies and a review of literature

Cushing's syndrome is an uncommon but important disease. Twenty-one confirmed cases of spontaneous Cuching's syndrome were documented at the University Hospital of the West Indies over a 21-year period. They were predominantly young females (F:M ratio of 17:4; mean age 25 years and three months). The commonest presenting symptoms were amenorrhoea (41 percent) and obesity (19 percent). Common clinical features were cushingnoid features (95 percent), hypertension (76 percent) and hirsutism (82 percent). Twenty-nine per cent had frank hyperglycaemia. Cushing's syndrome was due to Cushing's disease in 10 cases, adrenal adenoma in 3 and adrenal carcinoma in 2 cases. In 4 cases with presumed adrenal hyperplasia, the histology was either unavailable or was not consistent with the diagnosis. Two cases appear now to have had ectopic ACTH syndrome. Adrenalectomy was the commonest treatment offered. There were no intra-operative or post-operative deaths but recurrence was common after subtotal adrenalectomy in Cushing's disease. Twenty-seven per cent of the patients developed Nelson's syndrome, which was fatal in 50 per cent. Long-term hormone replacement therapy was unnecessary after surgery for adrenal adenomas. Treatment of Cushing's syndrome was well tolerated by the patients. (AU)

Colorectal cancer in Jamaica - Poster abstract

OBJECTIVE: This review was designed as a pilot study to collect data on colorectal cancer surgery which would provide the basis for conducting formal prospective data collection on the patterns of this disease and its clinical presentation. DESIGN AND METHOD: A comprehensive audit of all patients with a diagnosis of colorectal carcinoma was undertaken over a 2 year period (January 1996 to December 1997). RESULTS: A total of seventy-nine patients were studied. There were 47 females and 32 males. The median age was 64.5 years (range 19 to 91 years). The predominant presenting symptoms were abdominal pain in 44 patients (55.7 percent), change in bowel habit in 38 patients (48.1 percent) and rectal bleeding in 37 patients (46.8 percent). The presence of an abdominal mass in 18 patients was the most frequently detected sign. Rectal examination detected the presence of a mass in 14 (17.7 percent) patients. Forty-seven percent of patients present with anaemia. The most common location was the right colon in 21 patients (26.5 percent) followed by sigmoid colon in 15 (18.9 percent) and rectum in 14 (17.7 percent). Left and transverse colon accounted for 7 and 5 cases, respectively. Resection with restorative anastomosis was the most common procedure for primary disease with colostomy being performed infrequently (in 3 cases). Seventeen patients presented with advanced disease. There were 14 deaths, 10 due to metastatic disease and 4 from postoperative complications. Our findings indicate an increased incidence of right-sided colonic carcinomas which has also been reported by other recent series. Although this colorectal audit provides some information about the patterns of disease seen in our unit, further study of a larger group of patients will be necessary before accurate conclusion can be made. CONCLUSION: The detection of early colorectal carcinoma will require screening at a stage when the disease is asymptomatic in order to improve the chance for cure. The data presented here indicate that the majority of patients presented with advanced right sided lesions that could have been detected earlier with an established screening programme.(AU)

Treatment of low rectal carcinoma by transanal electrocoagulation

This study reports the first 13 cases of biopsy-proven low rectal carcinoma treated by transanal electrocoagulation using a locally manufactured instrument. At the University Hospital of the West Indies, over a 16-year period, 9 patients were treated for cure, six of whom have no clinical evidence of recurrence for one to 12 years. Four cases who were offered this procedure for palliation defaulted after a single treatment. Transanal electrocoagulation provides an additional option for treating patients with small, mobile low rectal cancers, following careful screening for evidence of nodal or distant spread. The procedure can also be used in the local control of disease in patients with distant spread or in whom a major operation is not feasible (AU)

Trauma aetiology and cost in the Accident and Emergency Unit of the University of the West Indies

Trauma accounted for 37 percent of 22,311 patients seen in the Accident and Emergency Unit (A&E) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine percent of injuries were intentional and 18 percent were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75 percent of the injuries compared with 5 percent for gunshot wounds. Passengers were injured in about 40 percent of motor vehicle accidents and pedestrians in 19 percent. The admission rate was 16 percent and the orthopaedic clinic received 75 percent of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24 percent) than those of unintentional violence (13 percent). The average cost of caring for each patient in the A&E Unit was US$70 resulting in an annual cost of US$578,000.(AU)

Breast cancer in young women

Breast cancer is now the commonest malignancy among females in Jamaica. In 1985 a Breast Cancer clinic was established at the University Hospital of the West Indies (UHWI) and, because young age has been suggested to be an adverse prognostic factor, data collected during the first five years were analysed to establish the pattern of this disease in young women. Thirty of the 227 female patients seen at the clinic during this period were under age 40. Information was insufficient in one case and the remaining 29 formed the study group. Only three patients were less than 30 years of age, 15 being aged 35 to 39 years. Family history was negative in 16 of 24 cases. In 28 patients presentation was related to the finding of a mass. Treatment was by surgery with or without adjunctive therapy. Eight patients were assessed as stage I, eleven were stage II and nine were stage III. Of the 20 patients for less than five years, there were three deaths and eight were distant metastases. Two of the other nine patients had distant metastases. There may be several reasons including difficulty in accessing health care, attitudes to health care that delay diagnosis, and race, why in so many of the study group the presenting disease was advanced, but no information was available to suggest what role these factors might have played in our patients.(AU)

Cholecystectomy in sickle-cell disease: the Jamaican experience

Fifty-eight patients with homozygous sickle-cell disease had cholecystectomy for symptomatic gallstones between January 1986 and September 1995 at the University Hospital of the West Indies and the Bustamante Hospital for Children, Jamaica. Top-up blood transfusion was administered to 7 patients with haemoglobin levels > lgm/dl below their steady state values. Complications related to the presence of biliary calculi were cholecystitis (58), common bile duct (CBD) dilatation (20), gallbladder empyema (2), and gallstone ileus (1). Nine developed the acute chest syndrome post-operatively leading to death in two patients. Three had retained CBD stones, which passed into the duodenum after a trial of saline irrigation via an in-situ t-tube. Because pre-operative ultrasonography is an unrelialbe modality for detecting CBD stones and also because of the high presence of CBD stones in sickle-cell disease, routine operative cholangiography is recommended at the time of surgery (AU)

Chemical burns as assault injuries in Jamaica

A three-fold greater incidence of chemical burn injuries in Jamaican hospitals, compared to burn centers in other industrial countries, underscores the problem of the use of common chemicals for assault weapons in this country. With the increased availability of guns for personal use, many Jamaicans learned the value of carrying household chemicals such as sulphuric acid from batteries or sodium hydroxide obtained from cleaning supplies. Chemical carried in a container, such as one might carry mace, afforded a means of defence among the lower socioeconomic groups who could not afford handguns. The use of dangerous chemicals for defensive weapons has extended to the use of chemicals for assault. The pattern of chemical injury differs significantly from most reports in the literature in both prevalence and aetiology. This review was prepared to examine these injuries with a view to planning strategies for prevention. (AU)

Primary aortoenteric fistula

One hundred and thirty-eight patients with abdominal aortic aneurysms were treated by aneurysmorrhaphy over an eleven-year period. Six patients, all male and aged 60 - 74 years, were found to have developed primary aorteonteric fistulae. Four patients presented with bleeding into the gastrointestinal tract in association with a tender abdominal swelling. In the other two cases, the aneurysm was discovered at emergency laparatomy for gastrointestinal haemorrhage. The presence of the fistula was confirmed at operation in five patients and at autopsy in one. Two patients died, one from a massive gastrointestinal haemorrhage to surgery, the other from sepsis complicated by adult respiratory distress syndrome and renal failure following operation (AU)

Primary aortoenteric fistula

One hundred and thirty-eight patients with abdominal aortic aneurysms were treated by aneurysmorrhaphy over an eleven-year period. Six patients, all male and aged 60 - 74 years, were found to have developed primary aorteonteric fistulae. Four patients presented with bleeding into the gastrointestinal tract in association with a tender abdominal swelling. In the other two cases, the aneurysm was discovered at emergency laparatomy for gastrointestinal haemorrhage. The presence of the fistula was confirmed at operation in five patients and at autopsy in one. Two patients died, one from a massive gastrointestinal haemorrhage to surgery, the other from sepsis complicated by adult respiratory distress syndrome and renal failure following operation

Benign colovesical fistulae

Two successfully treated cases of benign colovesical fistula are presented. The condition should be suspected whenever patients with colorectal disease develop urinary symptoms. Fllexible colonoscopy and lateral abdominal X-ray should be the initial investigations; but barium enema, cystoscopy and, rarely, CT scan may be necessary to confirm the presence of a colovesical fistula. Patients should be managed conservatively during the acute phase, and then be treated definitively by a single-stage bowel resection. Simple closure or resection and closure is used for the bladder defect. (AU)

Benign colovesical fistulae

Two successfully treated cases of benign colovesical fistula are presented. The condition should be suspected whenever patients with colorectal disease develop urinary symptoms. Fllexible colonoscopy and lateral abdominal X-ray should be the initial investigations; but barium enema, cystoscopy and, rarely, CT scan may be necessary to confirm the presence of a colovesical fistula. Patients should be managed conservatively during the acute phase, and then be treated definitively by a single-stage bowel resection. Simple closure or resection and closure is used for the bladder defect.

Colo-mucosal proctectomy with ileo-anal anastomosis: the Jamaican experience

A total colectomy and a mucosal proctectomy with ileo-anal anastomosis (c-mp-iaa) effectively removes all debilitating, potentially malignant colonic mucosa. Preservation of the anorectal sphincter predictably results in good to excellent anal continence with a low mortality and acceptable morbidity. Since 1983 at the University Hospital of the West Indies (U.H.W.I.), Jamaica, five (5) patients have undergone c-mp-iaa for colonic mucosal disease. All have good to excellent anal continence with an average of 2-6 continent, formed stools per day. There were no operative deaths. The five (5) cases are described and a plea is made for the earlier use of this definitive surgical procedure where indicated. (AU)

Appendicectomy at the University Hospital of the West Indies (1984-1988): A retrospective review

The pathological records of appendicectomy specimens from patients with suspected acute appendicitis at the University Hospital of the West Indies during the 5-year period 1984-1988 were studied. The numbers of cases, their ages, sex and seasonal incidence were similar to those of other studies. The over-all false positive diagnosis rate was 25 percent (16 percent in males, 38 percent in females). The main diagnostic difficulty was in young females in whom surgery for suspected appendicitis often proved unnecessary. (AU)

Pancolo-mucosal proctectomy with ileo-anal anastomosis - abstract

Preservation of the ano-rectal spinchter and lower rectal muscle cuff following total colectomy and a mucosal protectomy with ileo-anal anastomosis (CMP - IAA) effectively removes all the debilitating, potentially malignant colonic mucosa and results in good to excellent continence. Since 1983 at U.H.W.I., Mona, five (5) patients have undergone CMP - IAA for colonic mucosal dysplasia and multicentric adenocarcinoma (1), familial polyposis coli (1), juvenile polyposis coli (1) and ulcerative colitis (2). Four out of five have had clousure of their temporary diverting ileostomy and all have good to excellent anal continence, with an average of 2 - 6 stools/day. There were no deaths and an unremarkable post-operative course was noted in all except one patient with over a 20-year history of steriod-controlled ulcerative colitis. She had a prolonged stormy post-operative course, rectal cuff abscess and resulting ileo-anal stricturing. Not withstanding this, she has good anal continence, but requires digital dilation. This initial experience of the U.H.W.I. group compares favourably with over 2,500 cases in the current literature and establishes CMP - IAA as the procedure of choice in this group of young, active patients (AU)

Spontaneous rupture of the normal colon

A case of spontaneous rupture of the colon in a previously asymptomatic patient is herein reported. At laparotomy, apart from the tear in the sigmoid colon, no other pathological problem was present. An awareness of the existence of this condition will lead to early diagnosis and management with improved morbidity and mortality. (AU)

Ruptured rectal prolapse

Rectal prolapse is not a common surgical disorder. The complication reported here, of evisceration of small bowel through a prolapsed rectum, is extremely rare and is the first case reported in the West Indies. Some of the features of rectal prolapse are described, and the surgical management of this particular complication is discussed (AU)

Fine needle aspiration biopsy in the diagnosis of breast cancer

A prospective study if 176 fine needle aspiration biopsy (FNAB) in 172 patients was carried out to assess the accuracy of FNAB in diagnosing breast cancer at the University Hospital of the West Indies. The results showed 99 per cent and 97 per cent accuracy and sensitivity rates, respectively. There were no false positives and a one per cent false negative rate. FNAB provides a rapid, safe and cheap method of accurately diagnosing breast cancer (AU)