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EditorB. C. UMERAH

Associate EditorI. J. Okoye

ZONAL ASSISTANT EDITORSK. B. JUMAH ACCRAL. GORDON HARRIS FREETOWNO. F. KOMOLAFE ILORINR. OGUNSEYINDE IBADANO. B. CAMPELL IBADANV. A ADETILOYE IFEK. SOYEBI LAGOSA. T. AJEKIGBE LAGOSF. A. DUROSINMI ETTI ABUJAA. O. AKANO ABUJAN. C. NWANKWO PORT

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EDITORIAL CORRESPONDENCE: PROF. B. C. UMERAHDepartment of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria. E-mail Address: okoyeij2002@yahoo.co.uk, or unnfacmed@hyperia.comWebsite: www.arawa.org

ISBN: 1115-3474

VOL. 11 NO. 1APRIL 2004

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K. K. AgwuC. OhuegbeI. J. Okoye

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S. O. Mgbor

CONTENTS OF THIS ISSUE

Editor Editorial

Relationship Between Umbilical Vein Diameter (UVD) and Growth Parameters In Nigerian Foetuses

Effect of Delayed Film Processing and Milliamperage Changes On Image Quality

A Rare Case Report Mucopoly-saccharidosis (hurler Syndrome) with Rachitic Changes in a Nigeria

Preliminary Study of the Correlation of S y m p t o m s o f D y s p e p s i a w i t h Radiological Findings

Scintigraphic Analysis of Thyroid Diseases at the Lagos University Teaching Hospital, Lagos, Nigeria.

Intestinal Malrotation In The Older Child: Common Diagnostic Pitfalls.

A Modification of Bowel Preparation Prior To Intravenous Urography

Colonic Diverticulosis In Enugu Nigeria: The Prevalence And Distributional Pattern

ABSTRACT

The intrahepatic diameter of the umbilical vein of 350 normal and singleton fetuses were measured sonographically to establish the relationship between umbilical vein diameter (UVD) and fetal growth parameters.

Foetuses from 17 weeks to 40 weeks were evaluated sonographically in mothers who had no history of chronic illness or abnormal liquor volumes. The least squares method was used to fit mean UVD values against G.A. Pearson Moment Correlation analysis was also performed between the mean UVD and the other established growth parameters (BPD and AC) obtained concurrently.

There was a steady increase in the foetal UVD with gestational age which is expressed by the equation. GA = 2.36 + 4.84 UVD. The fastest growth rate of the UVD occurred in the last 10 weeks of gestation with a maximum mean value of 9.85 + 0.71mm. The UVD correlated strongly and positively with both BPD and AC.

ABSTRAITLe diamètre intrahépatique de la veine ombilicale de 350 foetus normaux et de s i n g l e t o n o n t é t é m e s u r é s sonographically pour établir le rapport entre le diamètre veing ombilical * UVD)

et paramètres foetaux de croissance.

Des foetus de 17 semaines à 40 semaines ont été évalués sonographically dans les mères qui n'ont eu aucune histoire de maladie chronique ou de volumes anormaux de boisson alcoolisée. La méthode des moindres carrés a été employée pour adapter des valeurs moyennes d'UVD contre G.A. L'analyse de corrélation de moment de Pearson a été également exécutée entre l'UVD moyen et les autres paramètres établis de croissance (baril par jour et C.A.) obtenus concurremment.

Il y avait une augmentation régulière de l'UVD foetal avec l'âge de gestational qui est exprimé par l'équation. GA = 2.36 + 4.84 UVD. La vitesse de croissance la plus rapide de l'UVD s'est produite en 10 dernières semaines de la gestation avec une valeur moyenne maximum de 9.85 + de 0.71mm. L'UVD corrélé fortement et franchement avec le baril par jour et le C.A..

INTRODUCTION:The umbilical vein diameter (UVD) has been studied in relation to rhesus isoimunization, umbilical blood flow and

1,2,3pathologies of the cord . Umbilical varix which is a focal dilatation of the umbilical vein has been associated with unexplained high mortality rate in utero and thrombosis within the dilatation has led to foetal death and other

RELATIONSHIP BETWEEN UMBILICAL VEIN DIAMETER (UVD) AND GROWTH PARAMETERS IN NIGERIAN FOETUSES

Authors: *K.K. Agwu, *C. Ohuegbe, **I.J. Okoye *Department of Medical Radiography and Radiological Sciences

University of Nigeria, Enugu Campus**Department of Radiation Medicine

University of Nigeria Teaching HospitalEnugu, Nigeria.

Correspondence: K.K. Agwu, Department of Medical Radiography and Radiological Sciences, Faculty of Health Serious and Technology, University of Nigeria, Enugu

Campus, Enugu Nigeria

complications including hydrops 4foetalis.

Knowledge of population specific normal dimensions of the UVD at various gestational ages would facilitate diagnosis of any haemodynamic compromise to the foetal blood supply and its associated effect on foetal growth.

MATERIALS AND METHODSThis study was conducted at the

Radiology Department of the University of Nigeria Teaching Hospital (UNTH), Enugu. Patients referred for sonography from the ante-natal clinics of the hospital were enlisted. Only subjects who had history of regular menstrual cycle, known last menstrual period (LMP), s i n g l e t o n a n d u n c o m p l i c a t e d

(10)pregnancies were included.During the scan, only those

foetuses whose gestational evaluation met with the criteria of a normal biophysical profile were eventually included.

Out of 500 subjects initially enlisted only 350 met the selection criteria. The UVD was measured ultrasonographically using a real-time sector scanner (Sonoline SL 2) with a transducer frequency of 3.5 MHZ and a caliper calibrated for an assumed

-1ultrasound velocity of 1540ms in soft tissue.

To measure the UVD, the foetus was scanned in the longitudinal plane until the foetal aorta was seen. The

0transducer was then rotated through 90 at the level of the lower foetal ribs. By adjusting the transducer, a section was obtained just above the kidney where the umbilical vein appeared as a perfect circle. The intrahepatic diameter was measured prior to the junction of the

1umbilical vein and the portal sinusMeasurements were taken from

outer to inner margins of the vein at the

widest transverse and sagittal diameters as shown in Fig. 1. Average values were ca l cu la t ed a f t e r a t l eas t f i v e measurements and the mean obtained for each gestational age. Two observers carried out the measurements and the inter observer variation coefficients calculated. The biparietal diameter (BPD) and the abdominal circumference (AC) were also measured for each foetus and the mean for each gestational age calculated. A least mean square method was used to fit UVD against GA and a linear regression equation obtained. Comparison was made between UVD in foetal liver versus BPD and AC.

'Pearson Moment Correlation' was performed between GA and the anthropometric parameters (BPD, AC and UVD) and between UVD, BPD and AC. Only UVD of fetuses from 17 weeks of gestational age (calculated from the last menstrual period) were measured because below this, GA values are unreliable and the UVD is not clearly delineated on the scan.

RESULTSTable 1 shows the mean UVD in

foetal liver and the corresponding menstrual ages at two standard deviation (2 SD). The mean value of the UVD from 17 weeks to 40 weeks was 5.70mm. A steady increase was noticed in the UVD from 17 weeks to 40 weeks. The growth rate for the 20-30 weeks and 30-40 week periods were 0.17mm and 0.34mm respectively. The mean of the maximum UVD at 40 weeks was 9.85+ 0.71mm. The intra observer coefficient of variation was 6.3%.

Table 2 shows the range of G.A. measured and the corresponding values of the anthropometric parameters (BPD and AC). The result of the linear regression analysis yielded the equation G.A. = 2.36 + 4.84 UVD.

T h e ' P e a r s o n M o m e n t Correlation' analysis indicated a high positive relationship between G.A. and BPD (r = 0.99), GA and UVD (r = 0.95), AC

West African Journal of Radiology April 2004 Vol. 11 No. 1

and UVD (r = 0.93) and BPD and UVD (r = 0.94). There is also a significant relationship between UVD and BPD, and between UVD and AC (r = 0.93 and 0.93 respectively)

DISCUSSION

In foetal circulation the umbilical vein (UV) carries blood charged with nutritive material and oxygen from the placenta to the foetal liver. The UV thus contributes signif icantly to the metabolism of the foetus and any haemodynamic compromise may affect the foetus adversely.

It is for these reasons that the umbilical vein has been the subject of much investigation. For example, the

5,6umbilical vein (UV), flow rate , UV pulsation and absolute umbilical blood

6flow rate have all been investigated. The relationship between UV blood flow and foetal growth parameters has also been

3assessed and Babera et al noted a strong correlation between absolute UV blood flow and foetal head and abdominal circumference (AC).

The umbilical vein diameter (UVD) is an estimate of the size of the UV and its value is important in the blood supply to the foetus and consequently will affect foetal growth. A direct re la t ionsh ip has a l ready been established between the UVD and the mean velocity and absolute UV blood flow

3by Babera et alFrom this study, the UVD

increased linearly throughout gestation th thfrom the 17 week of pregnancy to the 40

week with the fastest growth occurring th thbetween the last 10 weeks (30 40 week)

as shown in Table I. This relationship is expressed mathematically by this regression equation. GA = 2.36 + 4.84 UVD for normal, uncomplicated and singletion pregnancies. A strong positive correlation was also noted between UVD

and both BPD and AC.From the regression equation

normal UVD values can be calculated for various GAS and possible cause of growth retardation identified. The positive correlation between the UVD and the growth parameters also present the potential for the use of UVD in dating pregnancy. This is particularly important since the UVD has its fastest growth rate occurring in the last 10 weeks of gestation where the BPD is less reliable in dating pregnancy because its growth rate is fastest within 20-30 weeks of

6pregnancy . UVD can be used therefore in late pregnancy for better accuracy in dating pregnancy and in conditions where BPD i s unre l i ab l e l i ke dolicocephaly and early foetal head engagement.

The normal UVD obtained across the gestational age can also serve as guide in establishing venous constriction and haemodynamic compromise in the absence of a Doppler instrument for measur ing v enous b l ood f l ow parameters. This is because venous blood flow and its pulsation have been noted to be related to the UVD values.

The maximum mean UVD in 7Caucasian population is 10.00+0.12mm

compared to 9.85+0.71mm obtained in this study. However, this difference is not statistically significant (P> 0.05).

Table 1: Mean intrahepatic UVD Values and their corresponding gestational ages

Menstrual No. of Mean Values S.D Age Measurement (mm)

Table 2: Measured Mean UVD, BPD and AC values matched against corresponding gestational ages.

Umbilical Vein at 33wksUmbilical Vein at 33wks

References

1. Mayden, KL. The umbilical vein d i a m e t e r i n r h e s u s isoimunization. Med ultrasound 1980; 119: 125

2. Coulter GB, Scott JM, Jorda MM. Oedema of the cord and respiratory distress in the new born. BJ Obstet Gynaecol 1975; 82:453

3. Barbera A. Galar HL. Ferrazzi E, Rigano S, Jozwik M. Battaglia FC, Parachi G. Relationship of umbilical vein flow to growth parameter in the human fetuses Am J. Obstet Gynaecol 1999; 8: 174 -9

4. Philippe V. Intra abdominal u m b i l i c a l v e i n v a r i x http:www.thefetus.net/ page.php 2001 ; 1- 4

5. Skulstad SM, Kiserad J. Rasmussen S. The effect of vascu la r cons t r i c t i on on

umbilical venous pulsation. Ultrasound Obstet Gynecol 2004 23 (2): 126 - 30

6. Boedcell L, Ovsini I, Rizzo N. Estimation of gestational age during the first trimester by real time measurement of foetal crown rump length and biparietal diameter J Clin Ultrasound 1981 9:71

7. Yagel S, Adom DS, Wax Y, Hochner Celinkier D. A statistical examination of the accuracy of combining femoral length and biparietal diameter as an index of foetal gestational age, Brit. J. Obstet Gynaecol 1986; 93:109 155.

ABSTRACTA study of the effect of delayed clinical processing and milliamperage changes on image quality was carried out at the Radiology Department, University of Calabar, Nigeria, using filmstrips exposed to x-radiation at milliamperage (mA) values of 50, 100, 200, 300, 400 and 500. Exposed film strips were processed over varied post exposure, pre-processing keeping times ranging from 0 hours (control) to the 18th day. Results show progressive decrease in optical densities measured on the film, with prolonged pre-processing keeping time, and this is more marked at low (50) mA procedures, and is less in high (500) mA procedures, at which mA also, the onset was highly delayed (commencing about the 12th hour). The implication of this in a developing economy is discussed.

ABSTRAITUne étude de l'effet des changements cliniques retardés de traitement et de milliamperage sur la qualité d'image a été effectuée au service de radiologie, Université de Calabar, Le Nigéria, employer des filmstrips a exposé au x-r a y o n n e m e n t a u x v a l e u r s d u milliamperage (mA) de 50, 100. 200. 300. 400 et 500. Les bandes exposées de film étaient post-exposition changé par excédent traité, garder de prétraitement chronomètre s'étendre de 0 heures (commande) au 18ème jour. Les résultats montrent la diminution progressive des densités optiques mesurées sur le film, avec le prétraitement prolongé gardant le temps, et ceci davantage est marqué aux procédures du bas (50) mA, et est moins

(des 500) procédures élevées de mA, à quel mA également, le début a été fortement retardé (débutant au sujet de la 12ème heure). L'implication de ceci dans une économie se développante est discutée.

INTRODUCTION:

The radiographic image must contain the required diagnostic information in a form that is easy to extract visually (under suitable conditions). How easily this information is extracted depends on the subjective assessment of the differences in the optical densities. The degree of film blackening on the film is defined by the equation D = Log I / I (1)10 o

where D is the optical density measured on the radiograph or exposed film, Io is the value of the incident intensity of light falling on the film, and I is the value of the transmitted intensity.

The ease with which this information is extracted depends in part, on the magnitude of the measured optical density differences present in the image (contrast) and, the values of the optical densities forming these differences. Optical densities result from exposure and chemical processing of the exposed film, hence, development affects the values of optical densities obtained and therefore the density differences by its influence on the fog (inherent optical density of a film before exposure plus

EFFECT OF DELAYED FILM PROCESSING AND MILLIAMPERAGE CHANGES ON IMAGE QUALITY

*N. O. Egbe; B. F. Olisemeke and D. U. Eduwem.Radiology Department,

College of Medical Sciences,University of Calabar,

P. M. B. 1115,Calabar, Nigeria.

densities produced by development of 1unexposed silver halide) produced.

These effects of development on film characteristics are usually studied with the characteristic curve Fig. 1A and 1B as shown below.

through the subject. The quality and accuracy of resulting radiography

3depends on many factors one of which is the time between exposure and

1development . In the interval between exposure and processing, recombination of silver and bromide has been reported, although this is largely prevented by

1halogen acceptors in the emulsion . 4Carrol (1985) affirms the occurrence of

recombination and attributes it to the delay before processing (development). The result of this recombination is manifest as decrease in optical density recorded on the film. The image is said to undergo fading as a result of silver and bromide recombination, so that density decreases with the timed delay of commencement of film processing, i.e., the time between exposure and

1,4development .In deve l op ing count r i e s ,

inadequacy of amenities like electricity supply often result to the adoption of non-standard or unorthodox procedures to obtain required results. One of these is the increased 'keeping time' of exposed X-ray films before processing due to power outages that make even manual processing (the predominant method of film processing in these parts) a “nightmare”, as electrical ventilation of the darkroom is cut off, and film identification devices cannot be used. During such periods it is impossible to monitor the progress of film development with safe lights. Operators have had to r esor t t o sc ra tch ing pa t i en ts ' identification on radiographs while processing in completely dark and poorly ventilated darkrooms resulting in poor film quality. Unnecessary radiation

5exposures to the patients .so affected have been the result.

It is in an attempt to find a way around this problem that this study was

1,4designed. Considering the reports , would it be of any benefit to the patient and the radiographer if films were delayed post exposure before processing

Fig A.

Longer Dev.

Shorter Dev.

Log. Exposure

Fig B.

Fog Level

Development Time (min)

Fig. 1A: Influence of development on Characteristic Curve

1B: Influence on speed and fog levels of the film.

The film emulsion is made of 2silver bromide in ionic form . When

subjected to development, a chemical reduction process registers visible film blackening which indicates the pattern of transmission of the radiation beam

in these areas? Would this phenomenon occur and to what extent, with mA variation? Milliamperage (mA) has tremendous effect on the intensity of radiation reaching the film to form the image. Milliampere-seconds (mAs) is generally said to affect only the density, however, in radiography of some dense structures, a change in milliampere-seconds affects both density and contrast.

EQUIPMENTAll exposures were made with a

three phase, high frequency, GEC X-ray generator (Roentgen 501) with a maximum output of 150KV, 500mA and 5 seconds, and a minimum output of 40KV, 25mA and 0.01 seconds. Duplitized, fast 18x24 cm X-ray films manufactured by Konica, with fast tungstate GEC medical intensifying screens cassettes emitting blue light were used. Other essential equipment used were the manual processing unit,(which is more commonly used in these parts), processing chemicals (Agfa-Gevaert Dev. G 153 and Agfa-Gevaert Fixer G 353), a dryer unit (Quick dry Film unit Model No. 119DS) having sixty cycles and AC 6Amps. A Sakura densitometer, Model No. PDA-85 was used to determine the optical density of the films. All equipment used were pre-tested for efficiency before use.

PROCEDUREThe X-ray films were made into

appropriate sizes (strips), grouped in six (A-F), and were exposed to X-radiation as shown in table 1.

Mean optical densities, measured with the densitometer are tabulated in Table 3 below. The means were obtained by taking three readings (top, middle and bottom) of each filmstrip, since each exposure covered the entire area of the strip used.

Exposed films were stored in their cassettes and kept in an air-conditioned and humidity free darkroom to avoid

1other causes of film deterioration . Each group of exposed filmstrips, were then processed manually at a temperature of 26 degrees Celsius under thermostatic control. Replenishment of processing solutions was done periodically using the

1.area by volume method The film strips were developed one at a time for three minutes, timed with a stop watch, rinsed for thirty seconds, fixed for forty minutes and then dried for fifteen minutes using the automated drying system.The procedure for processing is as in table 2.

DISCUSSION:

Film processing involves several stages but development being the first has the most profound effects on the quality of the image produced. The beam of x-rays whose intensity is a function of mAs at a given kilovoltage, forms a developable latent image on a film emulsion, which is made visible by the process of chemical reduction of silver and ions to metallic silver and bromine

6atoms . From our results, we note the following;(i) The optical density produced on a

radiograph decreases with the prolonged delay of the exposed film before processing, and

(ii) the onset of this decrease, and the rate of occurrence are functions of the intensity or quantity of radiation (mA) incident on the film.

Milliampere and exposure time are useful in controlling average image density. While the mA is an indication of the number of electrons flowing per second across the X-ray tube during an

7exposure , the exposure time measures the duration of this electron flow. Hence, higher mA exposures produce greater

2beam intensities .

Interaction of X-rays with the imaging device results in formation of the latent image which formation depends, apart from the intensity of the beam, on the average grain size of the film

7emulsion and the speed . It is for this reason that the same make of films, of the same set and date of manufacture, were used for this work. Similarly, to rule out the effects of old or oxidized developer, new developer and fixer solutions were used. The expected effects of storing exposed films with or in close association with intensifying screens (as possibly being the cause of the decreasing optical density with duration of pre-processing

storage), is ignored since this effect occurs in all cases of film-screen contact, and therefore, in all the film strips used.

Increase in mA, (beam intensity) increasingly prevents the onset of image combination as is shown from the results. This result suggests that radiographs of high mA examinations like chest and abdominal radiographs, could be processed about 24hours after exposure, without appreciable loss in image quality. The converse is the case with low mA techniques, in which case

ththe films must be processed before the 8 hour after exposure.

TABLE 1: EXPOSURE FACTORS

Table 3: Mean Optical Densities obtained

REFERENCES1. Jenkins DJ. Radiographic

ndPhotography & Imaging. 2 Ed. MTP Press Ltd. England. 1981; . 130; 190 - 192

2. Meredith WJ, Massey JB The properties of X-ray film In: Fundamen ta l Phys i c s o f

rdRadiology 3 Edition, Wright Publishers, 1977; 175-190

3. Chesney DN, Chesney MO. rdRadiographic Photography, 3

Ed. Blackwell Publication. 1971; 506.

4. Carol QE. Funch's principles of R a d i o g r a p h i c E x p o s u r e , Processing and Quality Control.

rd3 Ed. Charles C. Thomas Publishers, London. 1985; 235

5. C o r r P . I m a g e Q u a l i t y Optimization and Control In: Pattern Recognition in Diagnostic Imaging. WHO. Geneva 2001; pp.3 14.

6. Pizzutiello RJ, Cullinan JE. I n t r o d u c t i o n t o M e d i c a l Radiographic Imaging. Eastman Kodak Company, Rochester, NY. 1992; 1 - 96.

7. Chesney DN, Chesney MO. The X-ray Tube In: X-ray Equipment for Student Radiographers. Blackwell Publication. 1971; 25 26.

8. Eastman Kodak Company Support Services Manual 2001

ABSTRACT A n u n u s u a l p r e s e n t a t i o n o f mucopolysachar idos is (Hur ler ' s syndrome), a connective tissue enzyme deficiency disorder with rickets is presented. It was seen in a 3 year old female child. Though facilities to confirm the metabolite in urine were not available, the radiological changes appeared pathognomonic for Hurler Syndrome. They also showed the features of rickets.

ABSTRAIT Une présentation peu commune de mucopolysachandosis (le syndrome de Hurler), un désordre d'insuffisance d'enzymes de tissu connectif avec le rachitisme est présenté. On l'a vu dans un enfant féminin âgé de 3 ans. Bien que les équipements pour confirmer le métabolite en urine n'aient pas été d i s p o n i b l e s , l e s c h a n g e m e n t s radiologiques ont semblé pathognomonic pour le syndrome de Hurler. Ils ont également montré les dispositifs du rachitisme.

CASE REPORT A 3 year old female presented in an outpatient paediatric clinic with persistent nasal discharge and progressive abdominal enlargement of 2 years and 8 months duration. Other associated problems included delayed s p e e c h d e v e l o p m e n t , h e a r i n g impairment, knock knees. At 6 months of age, her parents observed she did not look normal hence they confined her indoors most of the time. None of her other siblings (four) had similar problems.

On examination she had coarse facies with frontal bossing, bilateral corneal clouding and depressed nasal bridge. She had copious nasal discharge.Her apex beat was at the fifth left intercostal space lateral to the mid clavicular line. Auscultation of the lung fields yielded transmitted sounds. The abdomen was d i s t ended w i th hepatomegaly of 6cm below the costal margin. She also had short sturdy fingers w i th swe l l ing o f bo th wr i s t s , kyphoscoliosis and bilateral genu valgus. A clinical diagnosis of Hurlers s yndrome was made . U r ina ry glycosaminoglycans level could not be obtained but alkaline phophatase level was raised 557iu/l. There were classical radiological features both of Hurlers syndrome and rickets. She had vitamin D replacement therapy but absconded from follow up. A search for this association of Hurlers syndrome with rickets was not easily available in documented literature hence the need to publish it.

Discussion:The mucopolysaccharidoses form a rare group of abnormalities with prominent recognizable radiological features. Incidence is about 1 in 150,000 infants. These inherited disorders consist of 6 major types as follows: Morquio-Brailsford type (MPS-IV), Hurler-Scheie type (MPS1-H), Maroteaux Lamy disease, spondyloepiphyseal dysplasia, Diatrophic dwarfism, metatrophic dwarfism etc. Morquio and Brailsford described this clinical entity (Morquio-Brai ls ford) s imultaneously and

A RARE CASE REPORT: MUCOPOLY-SACCHARIDOSIS (HURLER SYNDROME) WITH RACHITIC CHANGES IN A NIGERIAN

1 2OBIDIKE EGBUNA, NJEZE NGOZI R., UDE A. C., NNANNI O., OSSI G. O.

1 2Department of Paediatrics, Department of Radiation MedicineCollege of Medicine, University of Nigeria, Enugu Campus

independently in 1929 in Montevideo, Uruguay and Birmingham, England

1respectively .Hurler syndrome was first identified by a German paediatrician, Gertrud Hurler (1889 1965) in 1919, Scheie, an ophthalmologist described a mild form of Hurler syndrome called Hurler syndrome

2type V . Hurler syndrome is one of the c o m m o n e s t f o r m s o f mucopo lysacchar idoses and i s autosomal recessive like most other types of MPS. In Hurler syndrome, there is a deficiency in the enzyme, alpha L- iduronidase. Because the body is unable to metabolize the glycosaminoglycans (commonly referred to as GAGs) there is an excessive accumulation of complex c a r b o h y d r a t e s c a l l e d mucopolysaccharides in connective tissue. GAGs are produced by the body and are present in all types of connective tissue. Connective tissue gives structural support to organs. Almost all organs are involved. This results in progressive damage and ultimately to the numerous clinical, radiological and laboratory changes seen in these individuals. This patient manifested grotesque features of Hurler clinically.These children appear normal at birth but the characteristic pathological features begin to appear by the age of 6months to 1 year as was the case with this child. The clinical features include coarse, thick, facial features, prominent dark eye-brows, depressed nasal bridge, full lips, thick large tongue, cloudy corneas, progressive stiffness and obvious mental retardation. The heart and heart valves may be involved and such cardiac effects mostly lead to death during teenage age. Our patient did not have this manifestation though there was no echo study. These patients have short stature (especially short trunk). This may occasionally pose some diagnostic difficulty when differentiating Hurler's syndrome from other forms of dwarfism. Hirsutism, shortness of breath, stiff joints, umbilical hernia, claw hand are

other clinical features that may be visualizedClinical examination may reveal a comb ina t i on o f the f o l l ow ing : Hepatomegaly, as seen in the present case, splenomegaly, inguinal hernia, flared nostrils, enlarged tongue, retinal pigmentation, hip dislocation, kyphosis, heart murmurs etc.Laboratory investigations especially urine show increased amounts of dermatan sulphate and heparin sulphate and is the gold standard for diagnosis of Hurler syndrome. These however were not conducted in this child because of non availability of the reagent. Other advanced tests include detecting the absence of lysosomal alpha L iduronidase in cultured fibroblasts. There is abnormal histologic staining of white blood cells called metachromasia. Prenatal testing involves aminocenthesis for enzyme testing and culture of cells obtained from amniotic fluid. TCG is h e l p f u l i n d e t e c t i n g c a r d i a c abnormal i t ies. 2 Dimensional echocardiography will also show chamber enlargement and valvular lesions.Radiological Investigations form a very important part of diagnosis in mucopolysaccharidoses as seen in this patients case. The radiographs of the skull, vertebrae, long bones, pelvis, hand and chest are usually quite informative. In Hurler's syndrome, a J-shaped sella is seen in the skull. This results because of the shallow elongated sella with a long anterior recess extending underneath the anterior clinoid processes.The ribs show typical widening of the ribs end. There is antero-inferior beaking in the vertebral bodies. The central part of the second lumbar vertebral body is hypoplastic and is displaced somewhat posteriorly resulting in a kyphus deformity. The long bones show swelling of their central aspects due to widening of their medullary canal. Typical Radiological features of mucopolysaccharidoses IH include a

combination of the following features macrocephaly, thickened calvarium, groundglass appearance, wide ribs, short wide clavicles which are poorly modelled. Ovoid hook-shaped vertebral bodies with thoracolumbar kyphus deformity. Odontoid hypoplasia, flaring of iliac wings with basal constriction of the iliac bones. Small irregular femoral capital epiphyses, coxa valga; the long bones are poorly modelled and have thin cortices. Trabecular pattern of the bones are coarse and the phalanges are short and wide. There is characteristic pointing of the proximal ends of the metacarpals. This patients films displayed classical radiological features of hurler as well as healing rickets. The confinement of the patient by her parents' because of her abnormal appearance may well be responsible for the rachitic changes which ensued since she was not exposed to enough sunlight.In Morquio Syndrome, the vertebral bodies show generalized flattening of the vertebral bodies with central anterior beaking. Hypoplasia is quite common and there is posterior displacement of L1 or L2 culminating in sharp angular kyphosis. The long bones taper but this feature is not as marked as in Hurler's s y n d r o m e . T h e r e i s f l a r i n g , fragmentation and flattening of the femoral heads with irregular deformity of the acetabulum. Subluxation of the hip therefore arises. The viscera and central nervous system should be investigated as well. Generally, anterior beaking of the vertebral bodies may well be visualized in Hurler's, Morquios syndrome, cretinism, or dysostosis multiplex group. Hurler's syndrome and the dysostosis multiplex group share similar features than morquio. However again, laboratory analysis especially urine, leucocytes, and fibroblastic cultures aid more specific diagnosis. Neurological changes are best demonstrated by magnetic resonance imaging.The present case report presents a

combination of rachitic features and MPS like the sole report by Gudino et al that had MPS, West syndrome and vitamin D dependent rickets. Rickets is a disorder of bone mineralization in which osteoblastic activity and production of bone matrix continue but mineralization of matrix is delayed. Aetilogy of rickets is divided into two categories: The first category there is diminished or in effective production of active vitamin D. This includes reduced oral intake of vitamin D, limited sunlight, liver disease or vitamin D malabsorption. This patient being discussed seems to fall into the first category possibly because of her parents' reaction due to the fact that she was purposely kept indoors and non of her siblings showed rachitic changes at all. The second category is due to renal abnormalities like fanconi syndrome and renal tubular acidosis Treatment

5includes vitamin D replacement .There is no known definitive treatment for Hurler syndrome. The only attempt at treatment is bone marrow or cord blood transplant. The bone marrow transplant is preferably before the age of 2 years. The patient defaulted to follow up.Generally however, life expectancy if left totally untreated in MPS I-H is only 5-10 years. The oldest Hurler survivor of a bone marrow transplant is in his early twenties. Enzyme replacement therapy could be attempted and has been approved in the USA and Europe. A Study in a Cuban population claimed to offer genetic counselling to affected

5families .

Fig. 1

X-RAY FINDINGS

Macrocephaly with ground glass a p p e a r a n c e ( a l s o s e e n i n Achondroplasia)Calvarium is thickened.Sella is widened in anteroposterior direction tending towards a J-shape.Thinned occiput (relative to the rest of the calvarium).

Second lumbar vertebrae is diminished in size. It is slightly displaced posteriorly resulting in kyphosis at the lumbar region.Antero-inferior beaking of the vertebrae especially lumbar.

HANDS AND FOREARM

Fig. 3

Widened phalanges.Pointing of the proximal ends of the metacarpals.Bevelling of the distal ends of the radius and ulna(both ulna metaphyses)Dense horizontal band at the distal end of the radius and ulna.Cupping of the right ulna.Transverse bands also seen in distal radial shaft (growth arrest lines)Irregularity of shaft of radius in the medial border.

KNEES (mostly rachitic)

Fig. 4Distal femora are widened(flared)(a rachitic feature)Transverse lines in the diaphysio-metaphyseal ends. (growth arrest lines)Some flaying of the medial part of metaphyses of the tibia.Growth arrest lines in the tibiae.Slight anterior bowing of the tibia.

PELVIS ( sma l l and square in achondroplasia)Iliac wings are flared.Elongated femoral neck.Acetabular roofs appear shallow(also seen in achondroplasia)Interpedicular distance is normal unlike in achondroplasia where it progressively narrows down to fifth lumbar.

REFERENCES

1. Grainger RG, Allison DJ, Adam A, Dixon AK. Grainger and Allison's Diagnostic Radiology- A textbook of Medical Imaging. 1978; 4: 2432-2433

2. Muenzer J and Fisher A. Advances in t h e t r e a t m e n t o f Mucopolysaccharidoses type I. H. Engl J Med. 2004; 350:19.

3 Gudino MA, Campistol J, Chavez B, Conill J, Hernandez S, Vilaseca MA. J Child Neurol Hurler syndrome, West's syndrome and Vitamin D dependent rickets. MA. J Child Neurol 2002; 17(2): 149-51.

4. Menendez- Sainz C, Zaldivar-Munoz C,Gonzalez-Quevedo A. Case thirty two rickets. A Mucopolysaccaridoses type I in the Cuban population. Uhrad.com- Pediatric Imaging Teaching files.

ABSTRACTThree hundred and eighty-one (381) barium meal studies were studied. There was low incidence of gastro-esophageal reflux and hiatus hernia and relatively high incidence of achalasia. Our studies revealed rarity of post-bulbar ulcers. There were high incidences of duodeno-gastric ulceration and lymphomas. The occurrence of the latter being higher than gastric ulcers. A high incidence of peptic ulcers was found in 21-30 year age group.

ABSTRAITTrois cents et 381) études de repas de baryum d'eighty-one (ont été étudiés. Il y avait incidence limitée d'hernie gastro-oesophagienne de reflux et de hiatus et i n c i d e n c e r e l a t i v e m e n t é l e v é e d'achalasia. Nos études ont indiqué la rarité des ulcères poteau-bulbaires. Il y avait des incidences élevées d'ulcération et de lymphomas duodeno-gastriques. L'occurrence de dernier être plus hauts que les ulcères gastriques. Une incidence élevée des ulcères peptiques a été trouvée dans la catégorie d'âge de 21 - 30 ans.

INTRODUCTIONSome diseases like appendicitis and peptic ulcer were not usually associated

1with Africans. Apart from notable examples like Crohn's disease and ulcerative colitis which are still recognized to be very rare, most of the other conditions are now regularly found in Africans in contemporary medical

2practice.The aim of this preliminary study is to establish the incidence of positive radiological findings in patients with

dyspepsia and relate these with symptomatology.

METHODRetrospective analysis of our barium meal studies over a 3 year period was conducted on patients referred to the University of Nigeria Teaching Hospital, Enugu.The radiological findings were then reviewed.

RESULTSA total of 381 patients were studied and the age range was 10 to 60 years.There were 198 male and 183 female patients. These findings are tabulated in the tables as shown.

DiscussionThe results confirm some of our clinical impressions. Both symptoms and positive findings at Barium studies show significant differences compared with studies in Western Countries. Table 1 summarizes the relationship between the symptoms and radiological findings.Our results show that pain was the most common symptom (66%) and was the most relevant for peptic ulcer and organic lesions in the upper gastro-intestinal tract. Heartburn was uncommon (about 11%) and confirmed the rarity of gastro-esophageal reflux and hiatus hernia. However, the incidence of duodenal ulcer as well as high gastric acidity was high, the latter is judged by significant amount of resting juice. Our impression is that racial peculiarities

PRELIMINARY STUDY OF THE CORRELATION OF SYMPTOMS OF DYSPEPSIA WITH RADIOLOGICAL FINDINGS

*Prof. B. C Umerah, *Dr. F.I Obioha, **Dr. O. C. Okpala, *Dr. I.J Okoye

*Department of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, **Department of Radiology, Nnamdi Azikiwe University, Nnewi

related to physique and life style are responsible for the low incidence of reflux. A high incidence of cascade contour of the gastric fundus which may be significant in stopping reflux may not be right. Cascade deformity was uncommon in females in whom reflux was also very rare. (see table 3).

Fullness was a common complaint and was associated with a high incidence of spasm or hypotonia and in a few cases gastric outlet obstruction. It was not a reliable pointer of peptic ulcer. We suspect that intolerance, for example, lactose (a long standing impression of a defect in Africans) may account for a proportion of these cases).Further studies will confirm or refute this postulation. using barium meal follow through examination and small bowel biopsy.

In Table 2 and 3, we confirmed that the shape of the female and asthenic male stomach was predominantly J- shaped and in males particularly, the pyknic type is perpendicular/oblique shaped. The significance of cascade deformity in our environment as well as elsewhere remains obscure. Apart from resting gastric juice found predominantly on J shaped stomachs, we found no correlation of peptic ulcers and other organic abnormalities with gastric configuration.

In Table 4 a high incidence of peptic ulcer was found with duodenal to gastric ratio of 54:1.Gastric ulcer is therefore very rare; this pattern is clearly different

4,3,5from those of Western countries . The spicy nature of our diet may be significant in this finding, as gastric ulcers are not associated with hyperacidity.Post bulbar ulcer seen in many tropical regions is rare in our environment and shows interesting geographical variation, compared with other areas even within

5this country .

Clearly, rice as a staple food, is not enough to postulate as a basic aetiology.In this small series, a positive case of carcinoma represents a significant incidence of carcinoma of the esophagus. This is also confirmed by our overall experience in the past 10 years.A case of gastric neoplasm was found in this series and whilst this is significant, this condition is clearly rare compared with Caucasian studies. It is interesting that lymphoma appears to be more common than carcinoma; this reversal has, to our knowledge, not been previously documented.Three patients with gastric outlet obstruction were as a result of long standing duodenal ulcer. Two cases were due to pyloric hypertrophic stenosis-one adult and one infant.Vomiting was common in all the cases. Fullness was a constant complaint in adults whilst pain was a presenting complaint in the two patients with associated chronic ulcer.Rugosity of the stomach and duodenal mucosa was a common finding. It was never limited to the stomach to suggest enteropathy, for example, menitrier's disease. Due to associated pain and discomfort, most of these cases were thought to be due to gastritis but this is a re lat ive s ign. Corrosive gastro oesophagitis is relatively common in three patients. This was accidental in two and due to caustic local medicine in one of them.

Achalasia is surprisingly common in this sub region and the most common positive finding in patients with dysphagia. Apart from the rare

1carcinoma, spondylodysphagia , most patients with this complaint presented with physiological derangement for example globus, dysautonomia, presby-esophagus etc.

In this preliminary study, the incidence of various abnormalities in the upper

gastro intestinal tract have been shown in a small series reflecting the pattern of presentation in this sub-region.No socio-economic class bias was

1,6established for any entity . In Tables 5 & 6. a strong bias in age distribution however, is evident. The highest number of referrals and positive findings were in

1,5the 20-30 year age group . This is a significant finding, since it is relatively a younger preponderance compared with

1Western experience .Compared with immediate war experience, our study confirms a sustained high incidence of duodenal ulcer but with a downward trend in prevalence. This we believe is probably stress related due to prevailing social circumstances. We hasten to add that the economic crisis has not produced more

1peptic ulcers in our series , other factors are clearly operative and may include dietary habits.

CONCLUSIONIn this study, we observed:1 low inc idence o f gastro-esophageal reflux and hiatus hernia.

2 relatively high incidence of achalasia

3 very high incidence of gastric ulceration

4 rarity of post-bulbar ulcers.5 higher incidence of lymphomas

than gastric cancers6 high incidence of peptic ulcers in

21 30 age group.

Emphasis on different conditions have been highlighted and this include the absence of conditions seen elsewhere. For example, in our studies, atrophic gastritis was never seen.

Table:1Radiological Findings

TABLE 2Shapes of Stomach

TABLE 4.Incidence of Lesions within the period of study.

1.Peptic Ulcera) Duodenalb) Gastric2.Gastro-Oesophageal reflux3.Hiatus hernia4.Miscellaneousa) lymphomab) duodenitisc) tertiary contractiond) achalasiae) calculoma carcinoma i) stomach ii) oesophagusf)corrosive gastritis and oesophagitis

54 1 2

- 3 4 7 5 1 1 3

Type of lesions Number of cases Percentage of the Total

REFERENCES

1. Umerah BC, Singarayar J, Ramzan M, Kisumbi S. Incidence of Peptic Ulcer in the Zambian African A radiological Study. Medical Journal of Zambia.1978 12;117 118.

2 Kolawole TM Solanke T. Duodenal Ulcers in Ibadan, Nigeria.

3 Angate Y. Med. Afr. 1971 88: 213.

4 Bohrer S.P, Solanke T., Williams A.O Br. Med. J. 1968; 515

5. Gogler H. Trop. & Geog. Medicine 1973; 25: 335.

6. Silen W. Harrison's Principles of Internal Medicine 1974; 7: 1434

ABSTRACTThis paper presents a retrospective analysis of randomly selected clinical scintigraphic records at the College of Medicine/Lagos University Teaching Hospital, Nigeria. Out of the 436 patients s c a n n e d f o r v a r i o u s t h y r o i d abnormalities, 266 (61.0%) were used for the analysis due to insufficient data and parameters required for the analysis in the clinical records. Among these 266 cases selected, euthyroidism showed the highest incidence of 123 (46.2%). This was followed by hyperthyroidism 103 (38.7%) and hypothyroidism 40 (15.1%). Of the 103 hyperthyroidism studied, thyrotoxicosis was noted in 82 cases (79.6%). Grave's disease was found in 11 (10.7%) and Nodular goitre in 10 (9.7%).

ABSTRAITCet article présente une analyse rétrospective des disques scintigraphic cliniques aléatoirement choisis à l'université de la médecineHôpital D'Enseignement D'Université De Lagos, Le Nigéria. Hors des 436 patients a balayé pour différentes anomalies thyroïde, 266 (61.0%) ont été employés pour l'analyse due aux données insuffisantes et aux paramètres exigés pour l'analyse dans les disques cliniques. Parmi ces 266 cas choisis, l'euthyroidism a montré l'incidence la plus élevée de 123 ( 46 .2%) . Cec i a é t é su i v i d e l'hyperthyroïdisme 103 (38.7%) et de l'hypothyroïdisme 40 (15.1%). De 103 l 'hyperthyroïdisme a étudié, le thyrotoxicosis a été noté dans 82 cas (79.6%). La maladie de la tombe a été trouvée dans 11 (10.7%) et goiter

nodulaire dans 10 (9.7%).INTRODUCTIONThyroid scanning dates back to 1929 when Geiger-Muller counter was invented. The term scan traditionally refers to the imaging of human body in order to portray the anatomy and the physiology, which are essential to the diagnosis and treatment of diseases. There exists a wide spectrum of such d i s e a s e s t y p i c a l l y f o u n d i n cardiovascular, thyroid and parathyroid systems, gastrointestinal track etc. The first point-by-point image of the thyroid gland was obtained in 1948 (1). Scintigraphic scanning has since then become a well-known technique for t h y r o i d u p t a k e s t u d i e s , radioimmunoassay of the gland and the study of other endocrine disorders.The Department of Radiation Biology, Radiotherapy and Radiodiagnosis of the College of Medicine /Lagos University Teaching Hospital in Nigeria has been practicing radioisotopic scanning since 1968 . Th is paper p resents a retrospective analytical study of the thyroid scintigraphs in the laboratory using a rectilinear scanner Scintimat II from Siemens. Treated cases of thyroid diseases over a period of time were randomly selected and analyzed to compare and establish the predominant age group and sex and to define the prevalence, clinical presentation and the outcome of the diagnosis of diseases.

INSTRUMENTATION & METHODSThe Scintimat II from Siemens was used for the scintigraphic procedures. The system is an automatic rectilinear scanner with a detector assembly

SCINTIGRAPHIC ANALYSIS OF THYROID DISEASES AT THE LAGOS UNIVERSITY TEACHING HOSPITAL, LAGOS, NIGERIA.

M. A. Aweda, Department Of Radiation Biology, Radiotherapy And Radiodiagnosis, College Of Medicine/Lagos University Teaching Hospital, P. M. B. 12003, Lagos, Nigeria.

E-Mail: awedama@hotmail.com

consisting of a 7.5mm by 5.0mm NaI(Tl) scintillator, a multihole cylindrical lead collimator which has been tapered to converge at a focal point in order to direct the gamma rays, the photomultiplier tube (PMT) with a preamplifier, are well shielded to minimize the influence of background radiation. The detector and the PMT are so connected to ensure good energy resolution and the best optical conditions. The collimators are of various sizes, each adapted for different types of examination with characteristic focal distance, resolution, sensitivity and focal depth of the photon energy. A maximum resolution, sensitivity of 1530

4counts/min x cm3/3.7 x 10 Bq and 0.13 2counts x mm /quart and a focal distance

of 100mm were used with a fine focus of 86 holed collimator for the thyroid scans. A multicolour dot printer provides the information recording on paper with different colours indicating different concentration distribution of the radionuclide uptake. The system is designed for uptake measurements in 2-D scintigraphic image production of different organs. It is capable of thyroid, liver, bone and total body scanning. Typical scans are presented in figures 1 2.The radiopharmaceutical of choice in 95% of the cases reported was NaI-131 with the characteristic gamma emission of 264KeV and the activity ranging from 1.85 to 3.7MBq. I-123 was not used because of its short T . The product was 1/2

administered orally or intravenously 24 hours prior to scanning. Thyroid function counts were obtained 4 hours, 12 hours and 48 hours after injection.

DATA ANALYSISData were obtained from the clinical records of the patients with thyroid abnormalities. Requests for thyroid radioisotopic scans were received from the managing physician while the final diagnosis was arrived at from a combination of all the clinical findings

from blood and urine tests and radiological investigations. The records were categorized as hypothyroidism, euthyroidism and hyperthyroidism. Patients were also classified according to the clinical diagnosis, sex and age groups. The grouping of ages was as follows: 0 12 years as children, 13 25 years as adolescent and above 25 years as adults. This classification conforms with that of Butterworths Medical

2Dictionary with a slight variation. The classification of diseases adopted is the

3modified form of Werner's . The authors thought it useful to maintain a distinction between childhood, puberty and menopausal stages. This was however impossible because the clinical records simply present the patient ages as either “children” or “adults” in most cases. Only 266 (61.0%) of the 436 clinical cases randomly selected were used for this study. This is because the other records could not provide sufficient parameters and the variables such as age, sex and clinical prognosis required for the analysis.

RESULTS40 (15.0%) patients of the analysed cases belong to this category. 32 (80.0%) were predominantly hypothyroid, 7 (17.0%) were cases of cretinism and 1 (2.5%) was of low Intelligence Quotient (IQ). Fig. 3(a) shows virtually similar incidence of hypothyroidism in 16 (50.0%) adults and in 15(46.9%) children. Tables 1(a) and 2(a) show the overall statistics of the occurrence in different age groups and gender. Hypothyroidism occurs more frequently in childhood but has equal probability of occurrence among males and females.

EUTHYROIDISMThis accounted for 123 (46.2%) of the cases. The high percentage could be attributed to the fact that patients with Grave's disease become euthyroid or hyperthyroid after medical, surgical or

radioiodine therapy (8). Table 1(b) shows the frequency of occurrence with the simple goitre dominating, having 49 (39.0%) cases, thyroid swelling 26 (21.0%), non-toxic goitre 22 (17.9%), thyroid carcinoma 6 (5.0%), thyroiditis 2 (1.6%), thyroglossal cyst 2 (1.6%) and non-classified euthyroid 16 (13%) cases. Out of the 49 simple goitre patients, 44 (90.0%) occurred in adults and the rest 5 (10.0%) in adolescents with no single record in children below 12 years.A total of 104 (85.0%) of the disease conditions were diagnosed among females. As shown in table 1(b) and in fig 4(b), except the thyroglossal cyst and thyroid carcinoma, all others show prevalence in females. Fig 5(b) clearly demonstrates that euthyroidism is a prevalent condition among adult females. Adolescents showing indication of abnormal thyroid in this category are significantly females as could be seen in table 2(b). Although there is a marked similarity in the distribution of thyroid carcinomas between genders (ratio 1:1), it occurs mainly in adulthood.

HYPERTHYROIDISMThis was recorded in 103 (38.7%) cases. Thyrotoxicosis was noted in 82 (79.6%) cases. Grave's disease in 11 (10.7%) and nodular goitre in 10 (9.7%) cases. There was loss of weight in 2 patients. Fig 4(c) show an overriding incidence of thyrotoxicosis among adults 7(70.9%) compared to a rather low 3 (2.9%) cases in childhood and a complementary increase in adolescents 6 (5.8%). This trend is in agreement with the separate

9reports by Perrild et. Al. and Witte et 10al. that thyrotoxicosis in childhood

and adolescent is rare and most frequently due to Grave's disease. It is predominantly expressed in females 66 (80.5%) as seen in fig 4(c). No case of Grave's disease was recorded in children in this study and only one incidence (9.0%) was found in adolescents, and 10 (91.0%) in adults. Grave's disease is

dominant in females 8 (72.7%) which 6agrees with Ghada Haddad , who

attributed the prevalence to other autoimmune diseases. Nodular goitre is predominant among adults 8 (100.0%). Fig 5(c) shows the distribution of hyperthyroidism among classified age groups and in relation to gender. It indicates a sizeable incidence in female adults and slight indications in adolescents and children.

DISCUSSION Hypothyroidism accounts for 15.0% of the cases studied. Generally, primary and secondary hypothyroidisms characteristically produce decreased iodine uptake. Primary hypothyroidism is a failure of the gland to respond to thyroid stimulation hormone (TSH), whereas secondary hypothyroidism is due to insufficient pituitary secretion of the TSH. However because of the recent decrease in the uptake resulting from increased dietary iodide, it is becoming increasingly difficult to use the iodine uptake as indication for hypothyroidism. Ectopic thyroid tissue could be demonstrated only by scintigraphiy where clinical examinations and ultrasonography fail in the diagnosis of

8congenital hypothyroidism . Cretinism is noticeably the sole contributor to hypothyroidism in childhood. Karlson et. al. have suggested thyroxin replacement therapy in hypothyroid children to prevent the development of a

9more severe hypothyroidic state . Low growth rate in prepubertal parents with the disease has also been reported. This agrees with the findings in our study. Within the two genders in fig 3(a), a noticeable difference in the incidence is observed with the female gender dominating 22 (69.0%) over male 10 (31.0%), although cretinism appears to be prevalent in males 5 (71.0%) when compared to females 2 (29.0%). Dent et. al. in their survey of the incidence and the size of endemic goitres in Harare,

claimed that there is no significant 10difference in the incidence with age .

This claim is however contrary to our findings with 5 (10.0%) and 3 (14.0%) of the goitres and non-toxic goitres respectively in adolescents and much as greater percentage in adults. This claim could however be explained by the fact that their studies were restricted to ages between 9 and 15 years, which is insufficient to make such generalised claim. Their results on the incidence among the genders 63.0% male and 80.0% female however compare favourably with ours in table 1(b) and fig 4(b). A critical study of fig 3(b) reveals a unique similarity in the trend followed by the distribution of the incidence of the disease condition i.e. increased incidence from childhood to adolescent, and the highest incidence in adults. The only exception to this trend is the thyroid swelling which affects more children 3 (11.0%) than the adolescents 1 (4.0%), and an upsurge of incidence in adults 22 (85.0%). Marked similarity n the distribution of thyroid carcinomas between genders occurs in adulthood.. This observation agrees totally with

11Danase et al. who declared a prevalence in females with a ratio ranging from 3 to 8:1. They also claimed that childhood accounts for about 13% of all thyroid cases. The difference in our results may be due to the low number of thyroid carcinomas in this study, which in not adequate to draw any valid conclusion on the prevalence of the disease. Hyperthyroidism, which represents 38.7% of studied cases, may be due to diffuse toxic goitre (Grave's disease), toxic nodulal goiter or single toxic nodule (Plimmer's disease). Radioiodine uptake study as an aid to calculating the therapeutic dosage is becoming less frequently practiced

21according to Lazarus . Grave's disease is usually diagnosed clinically by scintigraphy, but where there is doubt, ultrasound may occasionally be used in

confirming that the gland is the seat of a diffuse rather than a nodular process. Scintigraphy reveals homogeneous uptake in an enlarged gland, which differentiates Grave's disease from toxic nodular goitre. Toxic nodular goitre scintigraphy reveals an increased uptake in a single or multiple nodules with partial or complete suppression of the remaining thyroid tissue. The importance of multinodularity is in relation to the risk of malignancy. It has been said that the chance of malignancy arising in a multinodular gland is low, of the order of 1 to 4 %. Whereas the chance in a truely solitary is 10 25% (14, 15). However, the former figure was arrived at using clinical examinations and scintigraphy. It is now known that there are multiple nodules present in the thyroid glands of 20 to 40% of parents presenting with a clinically solitary

16lesion . Solitary nodule is a controversial topic and a common clinical problem. Palpable nodules have been reported in 15% of the population with solitary nodules present in 3.2% of

17women and 0.8% of men . The overall likelihood of malignancy in a solitary thyroid nodule is significant and is about

1810% . Ideally, imaging should enable us to identify 10% of nodules, which are malignant, avoiding the removal of the other 90%. Ultrasound has a limited role in the initial evaluation of thyroid nodules, but it is important in following both benign and malignant lesions, to monitor lymph node spread and thyroid

19bed recurrence .The role of scintigraphy in the investigation of solitary thyroid nodules is changing. Hypofunctioning (cold) nodules are dangerous and should be removed or at least biopsied. Malignancy is rare in nodules showing uptake of radiopharmaceuticals and autonomous functioning nodules are almost never malignant. There could be equivocal results on whether a nodule is truly hot or just warm, (i. e. uptake of the same order as the surrounding normal thyroid

West African Journal of Radiology April 2004 Vol. 11 No. 1West African Journal of Radiology April 2004 Vol. 11 No. 1

tissues). Although this difficulty can be resolved by rescanning the patient after the administration of triiodothyronine to see if the activity of the nodule is suppressed, this is seldom done in practice.

Fig 1 Thyroid Carcinoma involving the left laba

1. Ansell G, Rotblat J. “Radioactive Iodine as a Diagnostic Aid for Intrathoracic Goitre”. Brit. J. Radiol. 1948; 21: 552-558.

2. Butherworths Medical Dictionary. McDonald C. Editor-in-Chief. Butherworths and Co. Pub. Ltd. 1990 Edition.

3. Werner SCJ. “Report of the Committee on Nomenclature: American Thyroid Association” J. Clinc. Endocrinol. 1969; 29:0860-862.

4. Freeman AG “Gross Digital Clubbing and Exophthalmic Ophthalmophegia in Thyroid Disorder”. Lancet. 1958; II: 57-60.

5. Perrild A, Lavard J, Brock-Jacobson B. “Clinical Aspect and Treatment of Juveri Grave's Disease” Exp. Clin. Endocrinol. Diabet. 1997; 105: 4 pp 55-57.

6. Ghada Haddad M. D. “Is it Hyperthyroidism? You Can't Always Tell from the Clinical Picture” Postgrad. Med. J.1998;104: 42-55

7. Klett M. “Epidemiology of Congenital Hypothyroidism” Exp. Clin. Endocrinol. Diabet. Supplem 4 1997; 105: 19-23.

8. Meller J, Zappel H, Conrad M, Roth C, Emirich D, Becker W. “Diagnostic Value of I-123 Scintigraphy and Perchlorate Discharge Test in D i a g n o s i s o f C o n g e n i t a l Hypothyroidism”. Exp. Clin. Endocrinol. Diabet. Suppl. 4 1997; 105: 24-27.

9. Karlsson B, Gustafsson J, Hedov G., Ivorsson S A, Anneren G. “Thyroid Dysfunction in Down's Syndrome. Relation to Age and Thyroid Autoimmuneity “ Arch. Dis. Child. 1998; 79: 242-245.

10. Dent JN, Gasden EL, Furth J. “A Survey of the Incidence and Size of Endemic Goitre in Harare” The Central Afric. J. Medicine. 1965;

REFERENCES 174-185.11. Danase D. “Thyroid Carcinoma in

Children and Adolescents” Euro. J. Paediatri. 1997; 156( 3): 190-194.

12. Lazarus JH. “Guidelines for the Use of Radioiodine in the Management of Hypothyroidism: A Summary” J. Royal College of Physicians of London 1995; 29: 464-469.

13. Price DC. Radioisotopic Evaluation of the Thyroid and Parathyroids” Radiol.Clinic. Of North America 1993; 31: 991-1015.

14. M e s s a r i s G , K y r i a k o u K , Vasilopoulos P. “The Single Thyroid Nodule and Carcinoma” Brit. J. Surgery. 1974; 16: 943-944.

15. Brooks JR. “The Solitary Nodule” Americ. J. Surgery. 1973; 125: 477-481.

16. Scheible W, Leopold GR, Woo V L, Gosink BB. “High Resolution Real Time Ultrasonography of Thyroid Nodules” Radiology 1979;133: 413-417.

17. Tubridge W, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA. “The Spectrum of the Thyroid Diseases in a Community. The W i c k h a m S u r v e y ” C l i n . Endocrinology 1977; 7: 481-493.

18. Rokeski M. T. and Gharib H. “ N o d u l a r T h y r o i d D i s e a s e : Evaluation and Management” New England J. Med. 1985; 313: 428-436.

19. Ross D. S. “Evaluation of the Thyroid Nodules” J. Nucl. Med. 1991; 32: 2181-2192.

ABSTRACT8 children aged 4 to 14yrs (mean age 9yrs) with a clinical diagnosis of intestinal malrotation were studied prospectively over a 4yr period at the University of Nigeria Teaching Hospital Enugu. Despite, the reported normal ba r ium s tud i e s o f t h e uppe r gastrointestinal tract in the children, surgery were done based on strong clinical suspicion, chronic morbidity, and our interpretation of the barium studies. Operative findings were consistent with intestinal malrotation. 7 patients were symptom-free after 3months to 3yrs follow-up. One patient died of gastroenteritis 2 weeks post-operatively. A high index of suspicion and a close co-operation between Radiologists and Paediatric Surgeons are required for prompt and accurate diagnosis of intestinal malrotation in the older child.

ABSTRAIT8 enfants âgés 4 à 14yrs (âge moyen 9yrs) avec un diagnostic clinique de malrotation intestinal ont été étudiés pour l'avenir sur une période 4yr à l'université de l'hôpital d'enseignement Enugu du Nigéria. Outrage, les études normales rapportées de baryum de l'appareil gastro-intestinal supérieur dans les enfants, la chirurgie ont été faites a basé sur le soupçon clinique fort, morb id i té chron ique , e t not re interprétation des études de baryum.

Les résultats effectifs étaient conformés au malrotation intestinal. 7 patients étaient sans symptômes après 3months au suivi 3yrs. Un patient est mort de la gastroentérite pendant 2 semaines postopératoirement. Un index élevé de soupçon et une collaboration étroite entre les radiologistes et les chirurgiens pédiatriques sont exigés pour le diagnostic prompt et précis du malrotation intestinal dans l'enfant plus âgé.

INTRODUCTIONIntestinal malrotation is a spectrum of clinical conditions resulting from anomalies of migration, rotation, and fixation of the midgut during fetal

1 , 2d e v e l o p m e n t . T h e c l i n i c a l manifestation can be acute and severe in neonates and infants as a result of m i d g u t v o l v u l u s o r d u o d e n a l obstruction. In contrast to neonates and infants, the clinical manifestations of intestinal malrotation in older children are chronic, non-specific, and often obscure, leading to delay in diagnosis and treatment. Intermittent, and partial intestinal obstruction give rise to prolonged, atypical and obscure

3,4symptoms. Upper GIT contrast studies regarded as the gold standard for

1,2,5,6diagnosis of this condition are often atypical in these older patients and may be wrongly interpreted. This paper describes the cl inical features,

INTESTINAL MALROTATION IN THE OLDER CHILD:COMMON DIAGNOSTIC PITFALLS.

C.C. Amah, N.E.N. Agugua-Obianyo, S.O. EkenzeSub-Dept of Paediatric Surgery, University of Nigeria Teaching Hospital, Enugu.

Nigeria.

Correspondence: Dr. C.C. Amah, Sub-dept of Paediatric SurgeryUniversity of Nigeria Teaching Hospital, Enugu, Nigeria

E-mail: Tel: 234-803 321 6393

amahcc@hotmail.com

radiological features, operative findings, treatment and outcome of these children and calls for the attention of both clinicians and radiologists to these diagnostic pitfalls that lead to delay in treatment.

PATIENTS AND METHODWe prospectively documented the clinical data of 8 patients aged between 4yrs and 14years seen from January 2000 to December 2003 with intestinal malrotation and whose upper GI barium studies were reported as normal. Collected data included age, sex, clinical features and findings on barium studies (both radiologist report and surgeon's impression). Also included are operative findings, operative treatment and outcome.

RESULTSTable I shows the clinical data of the 8 children with malrotation. None of the radiologist's reports of the barium studies indicated malrotation. Our cl inical diagnosis of intest inal malrotation was based partly on the chronicity of the symptoms (Table 1), our interpretation of the barium films, and partly on experience. This was confirmed by the operative findings which were consistent with malrotation - multiple congenital bands, defects in the mesentery, and chronic volvulus (Table 1). One patient (14 year old) who had had 4 previous admissions came in with intestinal obstruction, and malrotation was diagnosed at laparotomy (Fig 1V). Another patient (6 year old) who was severely malnourished and who had chronic volvulus at operation (Fig 11) died two weeks post-operatively from acute gastroenteritis (14.3% mortality). DISCUSSIONRotational anomalies occur when the proximal (duodeno-jejunal) and distal (coeco-colic) loops of the embryonic midgut fail to complete their required

0 1,7,8270 counter clockwise rotation . This rotations when completed ensures that the base of the small bowel is spread along a diagonal from the ligament of Trietz to the ileocaecal attachments, thereby stabilizing the midgut, and protecting it from volvulus and

1,8,9strangulation . Malrotation results when the duodeno-jejunal loop remains to the right of the spine, but the caeco-

0 colic loop rotates 180 , passing in front of the superior mesenteric artery (SMA), and fails to descend to the right lower quadrant. This leaves the two points of fixation of the small bowel mesentery almost superimposed upon each other at

1,2,8the base of the SMA . The resultant mesenteric attachment is narrow and

1 0predisposes to volvulus . The presentation may be acute and persistent or chronic and intermittent. The latter picture is seen in the older children and is illustrated by the 8 cases reported in this

study.Normal rotation and fixation of the midgut also results in the fixation to the posterior abdominal wall of the right and

1,8left colon and the duodenuim. . Potentially, obstructive aberrant peritoneal bands (Ladd's bands) as well as mesocolic envelops form when the mesentery of these parts fail to become

1,7fixed retroperitonealy . These may restrict small bowel loops to one or other

s ide o f the abdomen. Wrong interpretation of barium studies in this

5condition has been documented . Similar reports in the literature show that the diagnosis of malrotation was not clear

6,11until exploration was performed . Our 1,12,13findings are similar to other reports

CONCLUSIONThe common diagnostic pitfalls of intestinal malrotation syndrome in the older child arise from the fact that symptoms are usually chronic, non-specific, and obscure. Physical signs are often absent or unremarkable, and upper GI barium studies are often reported as normal. We therefore recommend that

Table I: Clinical Data, Upper GI barium & Operative findings, in 8 children with intestinal malrotation syndrome

the older child with recurrent attacks of abdominal colic should have a comprehensive evaluation. Their upper GI contrast studies should, preferably, be jointly reviewed by an experienced Paediatric Radiologist and the Paediatric Surgeon.

volvulus has been resected and the ileo-colonic anastomosis is shown.

Fig 1: Operative finding showing D-J flexure (arrow) to the right of the midline

Fig 2: Operative finding showing showing volvulus of the midgut

Fig 3: Barium meal and follow through X-ray showing hugely dilated stomach

Fig 4: Operative finding showing the defect in the mesentery. The perforated

REFERENCES1. Filston HC, Kirks DR. Malrotation-

the ubiquitous anomaly. J Pediatr Surg. 1981;16:614-20

2. Bill AH. Malrotation of the Intestine. In: Ravitch MM,Welch KJ, Benson CD, editors. Pediatric Surgery Chicago: Year Book Medical. 1979; 912-23

3. Schey WL, Donaldson JS Sty JR. Malrotation of the bowel: variable patterns with different surgical considerations. J. Pediatr Surg. 1993; 28:96-101

4. Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. J. Pediatr Surg. 1989; 24:777-80

5 Anjali Parish, Rolyn Hatley. Intestinal Malrotation.E-medicine World MedicalLibrary. 2002; 27 (Medline)

6. Brandt ML, Pokorny WJ, McGill CW, Harberg FJ. Late presentation of midgut Malrotation in children.Am J Surg. 1985; 150:767-71

7. Janik JS, Ein SH. Normal intestinal

rotation with non-fixation: a cause of chronic abdominal pain. J Pediatr Surg. 1979; 14(6): 670-4

8. Lister J, Rickham PP. Malrotation and volvulus of the intestine. In: Lister J, Rickham PP, Irving IM,

ndeditors. Neonatal Surgery. 2 ed. London: Butterworth; 1980; 371-80

9. Torres AM, Ziegler MM. Malrotation of the Intestine. World J Surg. 1993;17: 326-1

10. Kamal IM. Defusing the intra-abdominal ticking bomb: Intestinal malrotation in children. CMAJ, 2000; 162(9); 1315-7

11. Spigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg. 1990; Nov; 25(11) 1139-42

12.Ameh EA, Chirdan LB. Intestinal Malrotation: Experience in Zaria, Nigeria. WAJM 2001; 20(3), 227-30.

13. Van Roye S, Vandelanotte M, Proot L, Lanckneus M. Chronic Small bowel obstruction due to intestinal malrotation in the older child: an often missed diagnosis. Acta Chir Belg. 1993; 93:262-4.

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ABSTRACTOne hundred (100) adult patients booked to have out patient intravenous urogram in the University of Calabar Teaching Hospital, Nigeria were allocated into one of two groups taking into cognizance their bowel habits.

Group 'A' patients had very sluggish bowel habit (opened bowel once in three or more days) while Group 'B' patients opened bowel at least once in 48 hours. Both groups received the same instructions for bowel preparation except for the laxative Dulcolax (Bisacodyl) which was excluded in Group 'B'.The effectiveness of the bowel preparation in both groups was assessed by awarding scores to their “Control film”. The result showed no significant difference in the degree of faecal shadowing between the groups. Meanwhile 35(70%) of patients in group 'A' experienced some inconveniences as side effects from the laxative. There was no reduction in the number of radiographs taken in either groups therefore the use of a laxative did not decrease radiation dose.

In conclusion, the routine use of a laxative for every patient booked for IVU is not justified, a modification of bowel preparation to suit bowel habit is

therefore recommended.

ABSTRAITCent (100) patients d'adulte ont réservé pour avo i r hors de l 'urogram intraveineux patient à l'université de Calabar enseignant l'hôpital, Le Nigéria ont été assignés dans un de deux groupes prenant dans la connaissance leurs habitudes d'entrailles.

Groupez le ` A les 'patients ont eu l'habitude très que lente d'entrailles (entrailles ouvertes une fois en trois jours ou plus) tandis que le groupe les patients de ` B 'ouvraient des entrailles au moins par le passé en 48 heures. Les deux groupes ont reçu les mêmes instructions pour la préparation d'entrailles excepté le Dulcolax laxatif (Bisacodyl) qui a été exclu dans le ` B de groupe '. L'efficacité de la préparation d'entrailles dans les deux groupes a été évaluée en attribuant des points à leur "film de commande".

Le résultat n'a montré aucune différence significative dans le degré d'ombrager fécal entre les groupes. En attendant 35(70%) de patients dans le ̀ A de groupe 'a éprouvé quelques dérangements en tant qu'effets secondaires du laxatif. Il n'y avait aucune réduction du nombre de radiographies prises dans l'un ou l'autre groupes donc que l'utilisation d'un laxatif n'a pas

A MODIFICATION OF BOWEL PREPARATION PRIOR TO INTRAVENOUS UROGRAPHY

*Bassey D. E; *Eduwem D., *Udoaka A., **Awosanya G.O.G., *** Okoye I.J. *Department Of Radiology, University Of Calabar Teaching Hospital,

**Lagos University Teaching Hospital***University of Nigeria Teaching Hospital, Enug,. Nigeria.

Correspondence:Dr. D. E. Bassey

Department Of Radiology University Of Calabar Teaching Hospital Calabar,

Cross River State, Nigeria.

diminué la dose de rayonnement.

En conclusion, l'utilisation courante d'un laxatif pour chaque patient réservé pour IVU n'est pas justifiée, une modification de préparation d'entrailles à l'habitude d'entrailles de costume est donc recommandée.

INTRODUCTIONWhether or not bowel preparation should be used before Intravenous Urography

1(IVU) remains a controversial issue . Some studies have concluded that the routine administration of a bowel preparation is unlikely to improve the diagnostic quality of out-patient

2intravenous urogram but many Radiology departments still continue

3with it and departmental practice varies . 1George and Vinnicombe concluded that

purgation does reduce faecal residue but due to the increase in bowel gas there was no significant difference in renal tract visibility on the urograms between prepared and unprepared groups. This method can also be very unpleasant for the patient.

The aim of this study is to modify our standard bowel preparation prior to IVU such that urograms produced are of better diagnostic quality.

PATIENTS AND METHOD100 patients, 18years and above booked to have outpatient Intravenous Urogram were allocated into one of two groups (A or B). Group A patients opened bowel once in three or more days. They received instructions for our standard bowel preparation of: two 5mg Dulcolax (Bisacodyl) tablets stat at night 48 hours before examination. Low residue e.g rice and pepper soup or stock diet for 24 hours, fasting and restricted fluid intake 6 hours prior to the procedure.

Group B patients opened bowel at least once in 48hrs. Instructions given were

the same as for group A only the Dulcolax tablets were excluded. Patients were excluded from this study if they were not sure of their bowel habit, had colostomies, abdominal malignances, specific contraindications to laxatives or habitual enema or cathartic users. On the day of examination patients were questioned to ensure that instructions were properly followed and any unpleasant effects from the preparations were noted.

The radiologist supervising the I. V. U. was blinded from the preparation received by the patient. The control films were assessed independently by two radiologists who had no knowledge of the grouping. The effectiveness of the bowel preparation determined by the quantity of faecal residue visible was scored on a one to ten scale. A score of one indicated severe faecal loading and ten absolutely none.

RESULTSThe two patient groups contained similar age and sex distribution (Table 1.).(Fig. 1) illustrates the distribution of scores awarded by each radiologist.On comparing the mean scores given to each group (Table 2.) it shows that patients in group A who received the standard bowel preparation scored higher. However, when the highest mean score from group A (6.14) and the lowest from Group B (5.94) are statistically compared by applying student's t-test; the difference does not quite achieve statistical significance at the 5% level.All patients claimed to have carried out the preparation as described. In Group A where patients took the laxative Dulcolax, 26(52%) complained of abdominal cramps, 9(18%) of weakness while 15(30%) had no complaints.In Group B, 9(18%) complained of hunger, 2(4%) of weakness while 39(78%) had no complaints.

DISCUSSIONThe routine administration of a bowel preparation to patients undergoing out-patient intravenous urography (IVU) is still common despite recent studies questioning its value. Cochrane Shanks

4and Johnstone as far back as 1950 had questioned its usefulness but a number of texts including recent ones still recommend bowel preparation. Bowel preparation has long been considered necessary in order to improve the diagnostic quality of the examination and varying doses of laxatives such as Senna tablets, Sodium picosulphate (Picolax,

2Nordic) were the most frequently used .

In this study, the laxative Dulcolax was administered to group A patients since it is expected that they would have a high faecal load in the colon when compared with group B who moved bowel more frequently. Although group A scored higher indicating less faecal residue, there was no significant difference in the faecal shadowing between the two groups. Habitual enema or cathartic users were excluded from this study.

5Bassey DE noted that the use of herbal, water and soap enema (enema saponis) is habitual and indeed a ritual among the people of South-Eastern Nigeria particularly the Efiks, the indigenes of Calabar. This form of “medication” is aimed at cleaning out the gut and thereby improve bowel habit. Patients in this study moved bowel without any form of colonic stimulation.

6Roberge-wade et al had concluded that the administration of a laxative did not significantly improve the diagnostic quality of the urogram. Many hospitals routinely use purgative all in a bid to improve the visibility of the renal tract and to reduce the need for tomography

3with its higher radiation dose . There was no reduction in the number of radiographs taken in either groups,

Table 1Age Range And Sex Distribution In Each Group

Age Range (yrs)

Mean Age (yrs)

Females

Total patients

Group A Group B

18 – 80 18 – 76

57.2 56.7

Table 2Mean Score Awarded To Each Group

RADIOLOGIST 1 RADIOLOGIST 2

Group A 6.12 6.14

Group B 5.58 5.94

therefore the use of a laxative did not decrease radiation dose and 70% of patients in group A experienced some inconvenience as side effects of the laxative.

In conclusion, bowel preparation is still necessary prior to an I.V.U. to reduce faecal residue but the routine use of a laxative cannot be justi f ied, a modification in bowel preparation to suit patients' bowel habit is recommended.

REFERENCE

1. George CD, Vinnicombe SJ, Bowel Preparation Before Intravenous Urography: Is it necessary? Br. J. Radiol 1993; 66(781): 17-9.

2. Bailey SR, Tyrrell PN, Hale M. A. A Trial To Assess The Effectiveness Of Bowe l Prepara t ion Pr io r to Intraveness Urography? C l i n Radiol 1991; 44(5) 335-7.

3. Bradley AJ, Taylor PM. Does Bowel Preparation Improve The Quality of Intravenous Urography? Br. J. Radiol 1996; 69(826) : 906-9

4. Cochrane Shanks S and Johnstone AS (1950). A textbook of X-Ray Diagnosis, 2edn, Cochrane Shanks S & Kerley. P.p 105. H. K. Lewis, London.

5. Bassey DE. Radiological Observation in The Colon Of Nigerians with Enema Abuse. East Afr. Med. J. 1993 70(7), 452-4.

6. Roberge-wade AP, Hosking DW, MacEwen DH & Ramsey, EW. The E x c r e t o r y U r o g r a m B o w e l Preparation is it necessary? Journal of Urology 1988, 140, 1473-74.

1 2 3 4 5 6 7 8 9 10

Radiologist 2

GROUP BRadiologist 1

1 2 3 4 5 6 7 8 9 10

Radiologist 2

1 2 3 4 5 6 7 8 9 10

Fig 1Distribution of Scores Awarded by each Radiologist in each Group

GROUP A

Radiologist 1

1 2 3 4 5 6 7 8 9 10

ABSTRACTA retrospective study on the pattern and prevalence of colonic diverticulosis of inhibitory in Enugu, Nigeria was carried out.

Radiographs and reports of past Barium Enema examinations done over a 10 year period were reviewed and analysed.

The prevalence of this disease entity in our community is 6.52% with no significant difference between both sexes. This figure is lower than those of Countries of industrialized West but higher than those of Middle East, India, Ghana. This is 3 times the figure recorded in Nigerians of another city, 15 to 30 years ago. The peak age incidence is the 40- 60 age groups.

A right sided predominance was observed. This is similar to the observation in Orientals but contrasts sharply with the findings in Caucasians. The disease coexists with colonic, malignancy in 25% of cases, thus buttressing previous suspicions that both diseases share common aetiological basis. No symptoms were found to be pathognomonic of the disease.

Colonic diverticulosis is no longer a rare disease in Nigerians as its incidence appears to be rising. The disease entity has no recognizable predilection for any sex. It occurs predominantly on the right, shows no pathognomonic symptom and may coexist with colonic malignancy in a quarter of the cases.

ABSTRAITUne étude rétrospective sur le modèle et la prédominance du diverticulosis du côlon d'inhibiteur dans Enugu, Le Nigéria a été effectué.

Des radiographies et les rapports des examens passés d'enema de baryum faits sur une période de 10 ans ont été passés en revue et analysés.

La prédominance de cette entité de la maladie dans notre communauté est 6.52% sans la différence significative entre les deux sexes. Ce chiffre est plus bas que ceux des pays de l'ouest industrialisé mais plus haut que ceux de l'Moyen-est, L'Inde, Le Ghana. C'est 3 fois où la figure a enregistré dans les nigériens d'une autre ville, il y a 15 à 30 ans. L'incidence maximale d'âge est les 40 - 60 catégories d'âge.

On a observé une bonne prédominance dégrossie . C 'est semblable à l'observation dedans - Orientaux mais aux contrastes brusquement avec les résultats dans les Caucasiens. La maladie coexiste avec du côlon, malignité dans 25% de cas, de ce fait soupçons précédents étayants que les deux maladies partagent la base étiologique commune. Aucun symptôme n'est avéré pathognomonic de la maladie.Le diverticulosis du côlon n'est plus une maladie rare dans les nigériens car son incidence semble monter. L'entité de la maladie n'a aucune prédilection reconnaissable pour n'importe quel sexe. Il se produit principalement du côté

COLONIC DIVERTICULOSIS IN ENUGU NIGERIA: THE PREVALENCE AND DISTRIBUTIONAL PATTERN

Author: Dr. Samuel O. Mgbor, M.B, BS, EDR; FA (Radiologie) FWACS

Department of Radiation Medicine, College of Medicine University of Nigeria Teaching Hospital, Enugu Nigeria

Correspondence: Dr. Samuel O. Mgbor, Dept of Radiation Medicine, Box 2633, UNTH Enugu, Nigeria, E-mail: mgborsam@yahoo.com

droit, ne montre aucun symptôme pathognomonic et peut coexister avec la malignité du côlon dans un quart des caisses.

INTRODUCTIONColonic Diverticulosis (CD) is defined as the presence of one or more diverticula in the colon. It is common in the Caucasians and rare in Asians and

1Africans.Compelling epidemiological

evidence has been presented to show that diverticular disease of the colon is

2endemic where fibre in diet is low .The incidence of this disease is

known to vary with the state of the economic development of each country vis a viz the extent of westernization of the diet of its inhabitants.

It has also been postulated that this disease would not be expected to manifest in a population until the community in question has departed from its traditional diet for at least half a

2,3.lifetime, that is, about forty years.Only two previous studies on the

prevalence of CD in Nigeria are available on search. Both studies were conducted 30 years and 15 years ago in Ibadan. S.W. Nigeria. The results confirmed the rarity of this disease entity. They showed a prevalence of 1.15% and 1.85%

4,5 respectively. The present retrospective study on the prevalence of diverticular disease as detected by Barium Enema Examinations (BEE), was undertaken in Enugu in the South East Region, an area with similar climatic, socioeconomic and dietary background. The aim of the study is to find out if any alteration in prevalence or trend has occurred in view of the rapid urbanizat ion and industrialization and by extension dietary changes that have accompanied over four decades of Nigeria's political and economic independence.

MATERIALS AND METHODS The study is based on the results of 407 c o n s e c u t i v e B a r i u m E n e m a Examinations performed on adult patients referred to the Radio- diagnostic Department of a private hospital, HANSA CLINICS Enugu metropolis in South Eastern Region of Nigeria over a ten-year period 1993 to 2003. The clinical data of these patients were retrieved and analysed.

The referrals came from private clinics and hospitals in Enugu and environs. Most of the patients were urbanized. Excluded from the analysis are the following categories of patients: Those under the age of 20 as this disease is known to be virtually non-existent in this age group; Those who have had previous bowel resections; those who had incomplete or inadequate examinations.

Based on these criteria, 24 cases were excluded, leaving a total of 383 for the study.

Each examination was conducted in double contrast technique. The request forms and films were reviewed by at least 2 radiologists, who were blinded to the identity of the patients and the clinical history. The site and size of the diverticula were recorded. The splenic flexure is taken as the dividing point

6between the right and left colons.Right-s ided d ivert iculos is

therefore referred to diverticular disease involving the appendix, caecum, ascending colon and transverse colon either singly or in combination.

The major indications for requesting the Barium Enema in all the patients with and without diverticulosis are shown in table 1.

RESULTSColonic Diverticulosis was found in 25 of 383 patients examined with Barium Enema giving a prevalence rate of 6.52%. Of this number, 17 were males and 8 females. Their ages ranged from 40 to 80 with a mean age of 61 years. Table 2

shows the age and sex distribution of CD while table 3 shows the summary of all the radiological findings and other relevant clinical data.

It shows that the disease was encountered nearly as frequently in males as in females. Frequency in males = 6.51%, Frequency in females =6.56%

In males, CD started to appear in ththe 4 decade. The prevalence rate rose

rapidly and early, reaching a peak in the th th6 decade and then diminishing in the 7

thand 8 decades. In females, diverticula thwere not seen until the 5 decade. Its

thprevalence rose steeply in the 6 decade threaching a peak in the 7 and

thdiminishing a little thereafter at the 8 decade.

DISCUSSIONColonic Diverticula are small mucosal hernias which develop at points of weakness in the muscular wall of the colon. These points of weakness are usually synonymous with the points of entry of the intestinal arteries. Diverticula are situated between the Taenia Coli. Because they do not carry any mucosal coat, these outpouchings are usually considered to be false

7,8diverticula The etiopathogensis of these

outpouchings has been the subject of much controversy. It is however sufficient to observe that the causes are at best multifactorial. Low fibre diet which gives rise to constipation, hypersegmenta t ion and ra i sed intraluminal pressure which in turn induces herniation of the mucosal coat at the weak points in the intestinal wall offers a good explanation for a certain form of colonic diverticulosis noted mainly in Caucasians namely the segmental long-necked diverticula of the sigmoid. The above sequence of events would not however entirely explain the etiogenesis of the solitary diverticula or the diffuse diverticula associated with

old age. The former has been thought to be congenital or hereditary in origin while the latter are thought to result predominantly from a predisposing sen i l e a t rophy o f the co lon ic

9musculature.Determining the prevalence of

colonic diverticulosis in any population is considered difficult as mass surveys are hardly feasible or realizable. Diverticula are also visualized with some difficulty at colonoscopy and autopsy but are more clearly visible at Barium

10Enema examinations. Using the results o f consecut ive Bar ium Enema Examinations done in hospitals or diagnostic centers, remains therefore the best option in estimating the prevalence of the disease to date.

The result from such a study is however not absolutely representative of the true picture as it is based on a highly selective population.

Two earlier reports based on B.E.E. done 15 years and 30 years ago in Ibadan, S.W. Nigeria had shown that colonic diverticulosis was rare in Nigerians. The prevalences then were

(4,5)1.85% and 1.15% respectively. The present study however shows that C.D is beginning to occur more frequently in our population. It was found in 6.5% of our adult patients who underwent Barium Enema Examination for various reasons. This figure is lower than those of most Western Countries but higher than those of the other African and Asian communities e.g Ghana and South

11, 12, 13, 14African (Blacks). It is tempting to postulate that this change in trend is traceable to westernization of the Nigerian diet and reduction of its dietary fibre.

While there was no significant difference in prevalence between the male and female subjects examined, a striking discrepancy exists in the age of onset of the disease. Diverticular disease began to appear in males between the

thages of 30 and 39 (4 decade) while it first

thoccurred in females in the 5 decade. Also while there were clusters of affected individuals, male and female alike in the

th th6 and 7 decades, fewer patients with thdiverticulosis were observed in the 8

thand 9 decades. Bearing in mind the role low life expectancy could play in this assessment, one could be tempted to postulate that this distributional pattern, similar to what obtained in Hong Kong Chinese might mean our older citizens have not accepted western diet

10as readily as the younger generation didIn this study, the right colon was

found to be the site of predilection of all forms of diverticulosis including the solitary type which was exclusively observed in the caecum in four patients. This finding is similar to the distribution of diverticula in oriental populations but contrasts strongly with that of the western populations and even South African Blacks. Right Colonic Diverticulosis is common in the Japanese, Thais, Chinese in Hawaii and Chinese, Malays and Indians in Singapore, whereas the most common site of diverticula in western societies is

10,13the sigmoid colon . The reason for this racial difference is still conjectural. It is however pertinent in this regard to mention that blacks have been found to have relatively much longer and wider

15,16sigmoid colons than Caucasians . These factors while leading to a more even distribution of intraluminal pressure along the colon are believed to mitigate against hypersegmentation and by extension diverticular formation in the sigmoid colon.

The preponderance of right-sided diverticulosis in our population implies that clinicians working in this sub-region have to be extra-vigilant with patients who present with right iliac fossa pain or mass and a high index of suspicion for diverticulitis and its complications need be cultivated. In consonance, with the findings of previous authors, no symptoms could

be said to be pathognomonic of colonic diverticulosis per se. Although, abdominal pain, constipation and hematochezia were the commonest symptoms encountered amongst patients with this condition, these same complaints were equally present in those without. This finding buttresses the long held notion that uncomplicated diverticulosis is generally asymptomatic 18, 19

Again this series showed a high degree o f coex istence between radiologically proven cancer and diverticulosis coli. Although the study population is relatively small, this latter finding would seem to lend weight to earlier suggestions that both entities might have similar etiological basis. A larger detailed prospective study would definitely help clarify this relationship.

In conclusion, diverticulosis coli was viewed as a rare entity about 15 to 30 years ago in Nigeria. Now this disease has begun to emerge as a factor to be considered when confronted by patients with signs and symptoms of colonic disease. Its incidence has increased more than three fold that is from 1, 8% in 1989 to 6, 5% in 2003.These findings are in agreement with the predictions of Burkitt and Painter that diverticulosis of colon would start to appear in developing countries of the world within half a lifetime if these populations constantly adopt a

1,2,3westernized dietary lifestyle .

Table 1Clinical Indications for Barium Enema in Patients

Table 2

Age and Sex Distribution of Colonic Diverticula.

Table 3 shows a summary of all demographic, clinical and radiological data as well as sites and types of diverticula.

Table 4Site Distribution of Colonic Diverticula

Table 4 shows the site and subsite distribution of colonic diverticula, in all the patients with diverticulosis in single and multiple colonic segments.

The entire colon with the exception of the appendix and caecum was affected by diverticulosis. The ascending colon was the most frequently involved segment either singly or in combination with other segments (24%). This was followed by the left colon and then the sigmoid. When considered anatomically as earlier defined, the entire right colon comprising the caecum, ascending and transverse colon accounted for about 60% of the diverticula seen in the entire study.

The most prevalent subsite combination was (Ascending + Descending) colon combination. The caecum constituted the only site of solitary diverticulosis and

this occurred in four male subjects.

As regards symptoms, pain was the commonest symptom being present in at least 18 patients. 7 patients complained of constipation, 6 of diarrhoea, 5 of rectal bleeding or melena, weight loss occurred in two, and a palpable abdominal mass was elicited in 3 patients.

Regarding concurrent disease, there was coexistence of diverticulosis and cancer of colon in 6 of patients in this series. Four of these were located in the right colon, 1 in the rectum and the other in the splenic flexure.

REFERENCES

1. Painter N.S Diverticular disease of the colon: a disease of this century. Lancet 1969; 2:586 8.

2. Painter NS, Burkitt DP, Diverticular disease of the Colon: a deficiency disease of Western Civilization. Br. Med. J. 1971; 2: 450 4.

3. Painter NS, Burikitt DP. Diverticular thdisease of the Colon: a 20 Century

Problem. Chin. Castrenterology. 1975; 1 : 3 21.

4. Bohrer SP, Lewis EA. Diverticular disease of the colon in Ibadan, Nigeria. Tropical and Geographical Medicine 1974; 26:9 14.

5. Ogunbiyi O.A Diverticular Disease of Colon In Ibadan, Nigeria. African Journal of Medical Science 1989; 18: 241 244.

6. Williams PL, Warwick R, eds. Gray's Anatomy. Philadelphia: W B Sanders, 1980: 1350 1356.

7. Pemberton JH, Armstrong DN, Dietzen C.D. Diverticulitis. In: Yamada Ted . Textbook o f

n dG a s t r o e n t e r o l o g y 2 e d N Philadelphia JB Lipincott. 1995; 1876 1890.

8. Sugihara K. Diverticular Disease of the Colon in Japan. Annals of Academic Medicine in Singapore 1978; 15 : 504 508.

9. Paulinof, Roselli; A and Martins U, Surgery 1971; 69: 63.

10. Chan Lo. KKL, Chung ECH, LO SSTTON TYW, Colonic Diverticulosis in Hong Kong: Distribution Pattern and Clinical Significance. Clinical

Radiology 1998; 53; 842 844

11. Archampong EQ, Christain, F, Badoe EA Diverticular disease in an indigenous African Community. Ann R Coll Surg. Engl. 1978; 60: 464 70.

12. Isidor Segal, Alexander R.P. WalkerDiverticular disease in urban Africans in South Africa. Digestion 1982 24: 42 46.

13. Lee YS, Diverticular disease of the large Bowel in Singapore: An Autopsy Survey. Dis Colon Rectum 1986; 29: 330 335.

14. Kochhar R, Goenka MK, Nagi B Bhasin DK, Mehta SK, The Emergence of Colonic Diverticulosis in Urbanised Indians. A report of 23 cases Trop. Geogr. Med. 1989, 41: 254 256.

15. Teubes MN: Volvulus of the sigmoid colon in relation to the anatomy of the pelvic colon. S Afr. Med. J. (1963) 37: 1151 1157.

16. Segal I, Solomon A, Hunt JA Emergence of Diverticular Disease in the Urban South African Black. Gastroenterology 1977; 72 : 215 - 219

17. Lewis JH: The biology of the Negro, Chicago. The University of Chicago Press 1942.

18. Thompson WG, Patel DG, Tao H et al. Does uncomplicated diverticular d isease produce symptoms? Digestive disease and Science 1982: 27: 605 608.

19. Thompson WG, Patel DG. Clinical picture of diverticular disease of the colon clinical Gastroenterology 1986: 15: 903 916.

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