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   2020| January-June  | Volume 12 | Issue 1  
    Online since May 23, 2020

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Cirrhotic ascites: A review of pathophysiology and management
Shettima Kagu Mustapha
January-June 2020, 12(1):3-12
Ascites describes the condition of pathologic fluid accumulation in the peritoneal cavity. Cirrhosis is the most common cause of ascites worldwide, with a half of cirrhotic patients developing ascites within 10 years of diagnosis. The “underfill” and “overflow” theories have traditionally been used to explain the pathogenesis of ascites in cirrhosis. However, with advances in hemodynamic and neurohumoral studies, it has been shown that neither of these theories fully explains the pathophysiologic mechanisms involved. The key roles of portal hypertension and vasodilators such as nitric oxide (NO) in the process of ascites formation have now been recognized. This led to the proposal of the peripheral arterial vasodilatation theory which includes components of both the “underfill” and “overflow” theories. Recently, the role of gut bacteria in the pathogenesis of ascites has been demonstrated. Bacterial translocation is now known to be a key event preceding the onset of ascites. Bacterial DNA and endotoxin have been shown to stimulate NO synthesis. This led to the proposal of a modified version of the vasodilatation hypothesis, “the systemic inflammation hypothesis,” which proposes that translocated bacteria or their products stimulate the release of proinflammatory cytokines which in turn stimulate NO synthesis. Cardiac dysfunction (cirrhotic cardiomyopathy) has also been described in cirrhosis and is believed to contribute to the reduction in effective circulating volume which stimulates renal sodium and water retention. Initial treatment measures include salt restriction and diuretics. Drugs known to reduce glomerular perfusion or directly toxic to the kidneys must be stopped. Initial therapeutic paracentesis should be done in those presenting with tense ascites. There is no need for albumin infusion if the amount of fluid removed is less than 5 liters. For those with refractory ascites, beta-blockers should be stopped. Treatment options include aquaretics; serial large-volume paracentesis with albumin infusion or midodrine in place of albumin; transjugular intrahepatic portosystemic shunt; peritoneovenous shunt; low-flow ascites pump; and liver transplantation.
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Coronavirus and gastroenterology practice
Nwokediuko Sylvester Chuks
January-June 2020, 12(1):1-2
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Percutaneous endoscopic gastrostomy: The Benin experience
Omorodion Omoruyi Irowa, Nnamdi Jude Nwashilli
January-June 2020, 12(1):13-17
Background: Percutaneous endoscopic gastrostomy (PEG), a gastrointestinal access, is one of the means of ensuring the sustenance of enteral feeding in patients who cannot swallow or eat. The procedure of PEG in the University of Benin Teaching Hospital (UBTH) is new with increasing acceptance by the clinicians and patients as it reduces morbidity and fosters early discharge home. Aims/Objectives: The aim of this study is to identify the need and usefulness for PEG, audit the process in its initial introduction, and document patient outcomes. Patients and Methods: This was a prospective study done over a 4-year period (2015-2018) and included all consecutive patient referred for PEG in the endoscopic suite of UBTH. Patient demographics, indication for PEG, outcome of the procedure, and complications were entered into a pro forma and the data analyzed. Results: A total of 17 patients had PEG over a period of the study. The male-to-female ratio was 2:1. The age range was 35–94 years, with a mean age of 68.6 years. Cardiovascular accident was the most common indication for PEG (64%; 10 patients), whereas intracranial tumors were 12% (2 patients), and other indications, namely severe head injury, dementia, and sepsis were 6% (1 patient) each. All patients had a successful procedure. Surgical site infection occurred in one patient, whereas another patient had extrusion of the PEG tube 1 month after the procedure. Conclusion: PEG is a safe procedure. The authors advocate the routine use of PEG in patient who cannot eat, especially in a subset of cardiovascular accident patients to sustain adequate nutrition while reducing the morbidity associated with nasogastric intubation and hospitalization.
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A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission
Olusegun Adekanle, Oluwasegun Ijarotimi, Emmanuel Obasi, Nnenna Grace Anthony-Nwojo, Dennis A Ndububa
January-June 2020, 12(1):18-23
Background: Liver disease is a major cause of morbidity and mortality globally. Its pattern varies with different geographical locations and these variations are determined by lifestyle, environmental, and genetic factors. This study determined the pattern, clinical presentations, risk factors, and determinants of morbidity and mortality in patients with liver disease admitted into a tertiary hospital in Ile-Ife, Nigeria, over a 5-year period; 2013–2017. Methods: Case records of patients admitted into the medical wards of Obafemi Awolowo University Teaching Hospital, Ile-Ife, with a diagnosis of liver disease were retrieved and information relating to demographics, risk factors, and types of liver disease as well as the results of relevant investigations, duration, and outcome of admission was extracted. Data were entered into SPSS version 20 and analyzed using frequencies and percentages which are presented in tabular form. Results: A total of 5,155 patients were admitted, liver diseases accounted for 324 (6.3%) of medical admissions within the period, with hepatocellular carcinoma (HCC) accounting for 52.8%, liver cirrhosis (LC) – 27.2%, acute hepatitis – 10.38%, metastatic liver disease – 4.1%, autoimmune hepatitis – 1.7%, DILI – 0.7%, liver abscess – 1%, abdominal tuberculosis – 1.4%, and unclassified etiology – 1.76%. A total of 139 cases were HBsAg positive, 64 took alcohol, 67 took herbs, while 57 took self-prescribed medications. Mortality among all patients admitted through the emergency compared with the medical clinic was 81.9% versus 18.1%. Elevated creatinine, coagulation disorder, hypoalbuminemia, and hypokalemia contributed to mortality. Conclusion: HCC and LC accounted for the majority of liver diseases in hospitalized patients with high mortality among all patients admitted through the emergency department and those with elevated creatinine, coagulopathy, and low potassium and albumin. Major etiologic factors were hepatitis B virus infection, alcohol, and self-prescribed medications.
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Hepatocellular carcinoma with initial presentation as metastatic spinal cord compression
Belonwu Onyenekwe, Uche Unigwe
January-June 2020, 12(1):24-27
Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. The burden of HCC is highest in the sub-Saharan Africa, South-East Asia and China. The recognized risk factors for HCC are chronic hepatitis B virus and hepatitis C virus infection, dietary aflatoxin, and alcoholic liver disease among others. HCC typically presents with symptoms related to the primary tumor; abdominal pain, weight loss, and abdominal swelling. Extrahepatic spread is present in up to 15% of patients with HCC at the time of diagnosis and may be the primary presentation. The most common site of extrahepatic metastasis by several authors is the lungs. Bone metastases in HCC are not as rare as previously reported and the most frequent site is the spine. Bone metastasis is mainly osteolytic and may result in pathologic fractures, hypercalcemia, and reduced quality of life. Spinal metastasis of HCC is recognized as a terminal stage of the disease and considerably worsens the prognosis. Presented is a case of a 35-year old man who came to the hospital primarily with metastatic spinal cord compression syndrome with paraplegia and was found to have advanced HCC. He succumbed to the disease within one month of presentation. While Pott's disease of the spine and metastatic prostatic tumor are the most common causes of nontraumatic myelopathy in sub-Saharan Africa, HCC should always be considered in the differential diagnosis of any patient with vertebral disease of uncertain origin.
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AIDS-associated Kaposi sarcoma mimicking bleeding peptic ulcer disease
Ayanfe Omololu, Barka Kwaghe, Pantong Mark, Simji Gomerep, Nathan Shehu
January-June 2020, 12(1):28-30
Kaposi sarcoma (KS) was the first AIDS defining malignancy described, and it commonly involves the skin, although visceral lesions exist. Visceral KS lesions are easy to miss, especially when symptoms are atypical or suggestive of another condition. This is a case of KS of the stomach in an HIV/AIDS patient presenting with symptoms, suggestive of bleeding peptic ulcer disease.
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