Nuhu Ali

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

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

One-Stage Urethroplasty for Strictures in Maiduguri, North Eastern Nigeria

Background. Urethral stricture is a frequent cause of lower urinary tract obstruction worldwide. The aim of this study is to present our experience with one-stage urethroplasty. Methods. All males that underwent one-stage urethroplasty between January 2001 and December 2010 were retrospectively reviewed. Details of their biodata, clinical presentation, diagnostic investigations, operative treatment, postoperative complications, and other outcome of surgery were extracted and analyzed. Results. Ninety-one patients aged 8–76 years, (mean; 45.6 ± 19.7) with urethral stricture were studied. Postinfective strictures accounted for 58.2% and postprostatectomy strictures for 3.3%. Twenty-six (27.9%) of the strictures were in the posterior urethra of which 18 (59.2%) were posttraumatic. Fifty-seven strictures (61.3%) were in the anterior urethra of which 51 (54.8%) were postinfective. Thirty-nine (42.9%) patients had end to end anastomosis, 29 (31.9%) flap augmentation and 17 (18.7%) tabularized flap substitution, and 6 (6.6%) dorsal onlay grafts (5 with buccal mucosa and 1 with penile skin). There were 18 (19.8%) cases of wound infection, 12 (13.2%) of restricture and 6 (6.6%) cases of urethrocutaneous fistula. Satisfactory urinary stream was found in 77 (84.6%) patients. There was no mortality. Conclusion. Infection is the commonest cause of urethral stricture followed by trauma, and one-stage urethroplasty give excellent results.

Causes and treatment outcome of perforation peritonitis in north eastern Nigeria

Background:  Intestinal perforations cause generalized peritonitis and overwhelming sepsis resulting in high morbidity and mortality. The purpose of the present study was to review the causes and treatment outcome of non‐traumatic perforation peritonitis in a government referral hospital in north‐eastern Nigeria.

Bilateral pelvi.ureteric junction obstruction: Our experience in a developing country

BACKGROUND Bilateral pelvi-ureteric junction (PUJ) obstruction is rare and causes high morbidity and mortality. Recent advances have led to its diagnosis and management in the perinatal period. However, open surgery is still the mainstay of treatment in less endowed nations where late presentation is the norm. MATERIALS AND METHODS All patients with PUJ obstruction diagnosed and managed at the University of Maiduguri Teaching Hospital between January 2006 and December 2011 were retrospectively reviewed. All had open surgery and all repairs were stented with double J stents or appropriate size feeding tube. RESULTS A total of 18 patients were analyzed, 11 males and 7 females with a ratio of 1.57:1 and mean age of 27.5 years (age range 2-38). The main clinical features were loin pain (72.22%) and fever (72.22%); while the main complications at presentation were hydronephrosis (55.56%), impaired renal function (61.11%) and pyelonephritis (50%). The causes of obstruction were mainly congenital (50.0%) and due to schistosomal fibrosis/stricture (22.2%). Preliminary double J stents, tube nephrostomies and hemodialysis were used to recover renal function before surgery. Anderson-Hynes (41.7%) and Heineke-Mirhulicz (19.4%) pyeloplasty were the main procedures performed. The main post-operative complications were urinary tract infections (67.67%) and leakage (11.11%). The mean duration of symptoms was 23.72 months and the mean hospital stay was 13 days. The mortality rate was 5.56%. CONCLUSION Bilateral PUJ obstruction is uncommon in Maiduguri, with congenital causes and schistosomal fibrosis as the most common etiologies. Aggressive treatment aimed at recovering renal function is necessary before open pyeloplasty if morbidity and mortality is to be reduced. Open pyeloplasty remained the best treatment option with favorable outcome.

Isolated gallbladder rupture following blunt abdominal trauma

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

Fistula‑in‑Ano Complicated by Fournier's Gangrene Our Experience in North‑Eastern Region of Nigeria

Background: Fistula-in-ano when complicated by Fournier′s gangrene is an unusual finding and always carries high morbidity. This study details our experience in managing 10 cases. Methods of Study: Case files of all patients managed in University of Maiduguri Teaching Hospital and Federal Medical Center of Yola and Gombe from January, 2007 to December, 2011 were retrieved from Medical Record Departments and other Hospital Records. These were analyzed for demographic, clinical and pathological variables, the type of treatment and follow-up. Results: A total of 10 men with a mean age of 50.5 years (35-60) were managed in the period of study. Nearly, 50% of the patients were farmers, 30% businessmen and 20% were civil servant. 7 (70%) of these patients presented with Fournier′s gangrene within 4 weeks of development of fistula-in-ano and the rest within 8 weeks. 4 (40%) of these patients had inadequate drainage of their perianal abscess and 2 (20%) had incision and drainage. Another 4 (40%) had spontaneously rupture of the perianal abscess. 6 (60%) of the fistula-in-ano was submuscular, 30% subcutaneous and 10% were complex or recurrent. Nearly, 20% of patients had fistulotomy and seton application for adequate drainage. Mucosal advancement flap was performed in 5 (50%) and fistulotomy in 3 (30%) patients. Another 30% had fistulotomy and continuing sitz bath. Conclusion: Cryptoglandular infection is an important cause of perianal abscesses and fistula-in-ano and if poorly managed results in Fournier′s gangrene. Early broad spectrum parenteral antibiotic therapy and primary surgical treatment can prevent Fournier′s gangrene.

Bleeding prostate: A 10-year experience in the University of Maiduguri Teaching Hospital (Umth), Nigeria

Background: Bleeding from an enlarged prostate gland is a major complication of benign prostatic enlargement (BPH). This review details our management over a 10-year period. Materials and Methods: A retrospective review of patients who presented with bleeding BPH between January 2001 and December 2010 was carried out to determine the outcome of management. Results: Forty-two patients with bleeding prostates treated by open prostatectomy were analyzed. The peak incidence was in the age group of 60-69 years. The main associated co-morbidities were hypertension in 17 (40.48%) and diabetes in seven (16.67) patients. Urine culture was positive in 24 (57.14%) patients, with E. coli in 13 (54.17%) and Pseudomonas in four (16.67%) patients as the main isolates. Most patients (37; 88.08%) received blood transfusions ranging from two to four units. Operative techniques were transvesical in 30 (76.92%) and retropubic in nine (23.08%) patients. Isolated median lobe enlargement of the prostate was seen in 18 (46.15%) and whole organ enlargement in 21 (53.85%) patients. The weight of the prostates ranged from 47 to 403 g (mean, 127 g). Incidental carcinoma was seen in one patient (2.56%). The mean hospital stay was 11 days (range 9-21), and the mean follow-up was 21 months (range 3-26). There was one (2.38%) mortality. Conclusion: BPH with massive hematuria invariably has an enlarged median lobe and is managed by open prostatectomy, without risk of re-bleeding.

Results of delayed repair of posterior urethral disruption injuries in Maiduguri

Posterior urethral disruption injuries (PUDI) are common and on the increase because of vehicular accidents and civil conflicts. The operative management of PUDI continues to pose a challenge to the urologist because of erectile dysfunction and incontinence from the injury or following repair. The aim of the present study was to review the outcome of delayed repair of PUDI.

Fournier's Gangrene as Seen in University of Maiduguri Teaching Hospital

Background. Fourniers gangrene is uncommon but increasingly being seen over the last two decades probably due to increasing socioeconomic problems including an upsurge in HIV infection especially in the tropics. Patients and Methods. The study retrospectively reviewed all patients with Fourniers gangrene managed in UMTH between January 2007 and December 2012. Results. Thirty-eight males aged 2 weeks to 80 years (mean 37.82) were reviewed, with most aged 30–39 years (13 (34.21%)). Clinical features were scrotal pain and swelling, 36 (94.74%), fever, 19 (50.00%), and discharging scrotal wound, 19 (50.00%). The predisposing conditions were UTI secondary to obstructive uropathy in 11 (28.95%), perianal suppuration, and HIV, in 8 (21.05%) patients each. Wound biopsy culture revealed mixed organisms in 27 (71.05%). Twenty-six (68.42%) had blood transfusions. Thirty-seven (97.37%) patients had wound debridement. Twenty (52.63%) had flap rotation for skin cover. There were 6 (15.79%) mortalities, of which 4 (10.53%) were HIV positive, 1 (2.63%) was diabetic, and 1 (2.63%) was both diabetic and HIV positive. Conclusion. Fourniers gangrene is a fulminant synergistic necrotising fasciitis of the perineum and genitalia with poor prognosis especially when associated with HIV and diabetes, requiringprompt and aggressive management for good outcome.

Primary volvulus of the small intestine

Small bowel volvulus is an occasional cause of mechanical intestinal obstruction in our practice causing diagnostic problems. We report a case of primary small bowel volvulus with gangrene. A 30-year-old farmer who presented with features of acute intestinal obstruction, which at laparotomy revealed a primary small bowel volvulus with a gangrenous loop of ileum. The patient was resuscitated and had exploratory laparotomy; with operative findings of a twisted loop of gangrenous ileum adjoining the ileocecal valve. This was resected and an end to end ileotransverse anastomosis effected. The patient made an uneventful recovery and was discharged on the 7 th postoperative day. Primary small bowel volvulus should be suspected in acute intestinal obstruction. It presents as an acute abdomen due to occlusion of bowel lumen alone or with obstruction of its blood supply leading to gangrene. Treatment includes resection and end to end anastomosis, which can help to reduce mortality and morbidity.