Browsing by Author "Archampong, E.Q."
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Item The "A" Level Aggregate and Medical School Examination Performance.(Ghana Medical Journal, 1989-06) Woolhouse, N.M.; Archampong, E.Q.The value of A level results as predicted indices of likely performance in the various professional examinations taken by Undergraduate medical students has been investigated. Performance in the MB II, MB III and Part II examinations was found to correlate closely with the Aggregate attained. Students with the best A level aggregates achieved significantly better results in these examinations than those with weaker aggregates. (p < 001, p < 0.001 and p < 0.01) respectively. In contrast. no significant correlation was found with the Part I examination resultsItem "A" Level Subject Performance and Sex in relation to Medical School Examination performance(Ghana Medical Journal, 1989-06) Woolhouse, N.M.; Archampong, E.Q.The Relative performance of students admitted to the medical school with an A level pass in either biology or mathematics and of male and female students has been studied. The influence of the A level grade in chemistry on the subsequent performance in bio chemistry has also been investigated A significant difference (p<0.001) was found in the distribution of examination results covering all subjects examined among mathematicians and biologists. In general; mathematicians performed significantly better overall than did biologists. In particular mathematicians performed significantly better (p<0.01) in anatomy. Whilst there is no significant difference between the performance of male and female students taken overall, females appear to perform significantly better (p<0.001) than males in the clinical subject areas, The quality of the A level grade in chemistry has a major influence on performance in biochemistry at the MB II examinationItem Acute Upper Gastro-Intestinal Haernorrhage in Ghanaians - An Endoscopic Review at Korle-Bu Teaching Hospital.(Ghana Medical Journal, 1994) Nkrumah, K.N.; Archampong, E.Q.; Quartey-Papafio, I.B.; Ofori-Adjei, D.; Nakajima, A.Upper gastro-intestinal (UGI) endoscopy was per· formed at the Korle-Bu Teaching Hospital. between 1981·83, on patients with history of acute upper gastro-intestinal haemorrhage. Eighty six (86) such patients were endoscoped and results have been rei· respectively analysed to establish the major symptomatology, the underlying lesions, and any other relevant contributory factors. The role of endoscopy in the management of acute upper gastro-intestinal haemorrhage as well as its potential cost effective· ness are discussed. The term endoscopy, in the text, refers to oesophago-gastro-duodenoscopy, and GI bleed refers to upper gastrointestinal haemorrhage.Item Changing pattern of intestinal obstruction in Accra, Ghana.(Hepato-Gastroenterology, 2000) Archampong, E.Q.; Naaeder, S.B.; Darko, R.BACKGROUND/AIMS: Over the past 50 years acute intestinal obstruction has remained among the commonest causes of the acute abdomen, along with peritonitis, appendicitis and gastrointestinal perforations. However several observers have noticed over the past 2 decades a shift in the etiological spectrum. The study aims at ascertaining the precise nature of the change. METHODOLOGY: Published data on intestinal obstruction from the Korle Bu Teaching Hospital over the past 50 years were reviewed, as the consistent report format permitted ready comparison of the series. Emphasis was placed on clinical features, established cause and resulting complications. RESULTS: The case load of intestinal obstruction has dwindled over the past 3 decades, accounting for 0.7% of all hospital admissions compared with 1.4% 30 years earlier. External hernias together with adhesive bands still constitute the bulk of presenting cases, but the proportions have changed with strangulated hernias accounting for 59.8% instead of 77.6%. The change has paralleled a rise in elective hernia day case surgery. The incidence of intussusception has almost doubled (7.4% from 4.0%) and it still afflicts the very young. Colonic neoplasms have been commoner over the past 2 decades although the incidence (3.3%) falls short of Western figures. Overall mortality has remained unchanged at 9.4% and this has been associated with a rise in resection rates to 18.3%. CONCLUSIONS: The patterns of intestinal obstruction have been much influenced by changing attitudes regarding elective hernia surgery and evolving financial policies.Item Conclusion(2013) Archampong, E.Q.In lieu of an abstract, here is a brief excerpt of the content: •212• Chapter 18 Conclusion E.Q. Archampong The revelation that has emerged from the exercise of preparing this manual is the tremendous information base and the fount of technical expertise currently available in the Department of Surgery. However, the concern that strikes any observer must be the challenges of access to these assets. It is evident that with the exception of the paper on the elimination of childhood blindness, which is the product of an on-going project, most of the contributions have emanated from retrospectively collected data in respect of ad hoc stand-alone studies, without clear evidence of continuity in the immediate future. This can not be a dependable means of building the knowledge base of the Department or the institution as a whole. The situation is the result of the paucity of sustainable research projects with appropriate funding. Clearly, if periodic audit studies can yield so much information, it is exciting to imagine how much could be produced through systematic and comprehensive studies based in the Department. The outcome of the project on elimination of childhood blindness in Ghana is precise information on the causes (bilateral and unilateral) of childhood blindness in the target populations in the Greater Accra and Eastern regions, and what has been achieved, using the team approach strategy, by way of prevention through scientific presentations , public lectures including radio and television interviews and interventions through drug therapies and operations by surgical teams. The project is now in Phase 2 with collaboration between WHO/Lions Club International and the Ghana government, future interventions are expected to be extended to the rest of the country. The study has emphasized the need for continued advocacy nationally and internationally to ensure availability of funding which is the prerequisite for sustainability. The two papers on breast lesions are timely, given that breast cancer is the commonest female cancer in Ghana and Africa as a whole. •213• Noise Pollution at Work Place and Health Implications Evidence has been adduced that global developments in management of breast cancer have led to better patient management in Ghana. These include the use of multidisciplinary teams (MDT’s) in the formulation of plans. This constitutes the basis for best practice in the management of the disease. There is evidence for the extent to which these practices are being incorporated in breast cancer management in the two main treatment centres in Ghana. Unfortunately, mammographic screening has not yet taken root in Ghana because of resource limitation; however, the proposal for clinical breast examination, breast self-examination and opportunistic screening has been strongly recommended. Tripple assessment, i.e. clinical examination, imaging procedures and tissue sampling, remains the basis for diagnosis. The challenge for Ghanaian surgeons currently, is the development of methods for taking a biopsy of non-palpable breast lesions. Advances have been noted in all the treatment modalities i.e. surgery, radiotherapy, chemotherapy and hormone therapy. Biological therapy in the treatment of patients with HER2 receptor over-expression is available but the outcome is often hindered by the high cost of treatment. It is reassuring that breast cancer management in Ghana has kept pace with global developments. The young age of the breast cancer patient in Ghana, attendant socio-cultural differences and prevailing financial limitations indicate significant modifications in the approach to management of the condition in the country. The study of benign and pre-malignant breast disease has also revealed significant increase in ductal carcinoma in situ and this carries a higher risk of invasive carcinoma. It should therefore be treated appropriately to prevent this progression to the disease. There is an urgent need for investment in the work of the Breast Cancer Clinic and activities of the MDTs in response to the apparent increased breast cancer incidence in the country. The papers on acute appendicitis, peptic ulcer disease (and complications ), gastrointestinal tumours and obstructive biliary disease all point to the rising incidence of these lifestyle related diseases in the Ghanaian population, and call attention to the need for health education on healthy eating habits, regular exercise and need for stress •214• Chapter 18 control in socio-cultural activities. The striking observation from these studies is the close resemblance of the natural history, diagnosis and management of these conditions and their complications to the presentation in Western countries. The principal difference is the poorer outcome of management, which stems from delays in presentation and the prevailing resource limitation in the developing world. There would never be enough resources for...Item Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader(Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader, 2013) Archampong, E.Q.; Essuman, V.A.; Dakubo, J.C.B.; Clegg-Lamptey, J.N.Worldwide, there is a plethora of study materials in the form of authoritative review articles on disease entities afflicting the Western world but relatively few publications exploring similar problems confronting the developing countries, where resource limitation adds an extra dimension to the challenges facing the clinician. The contributions in this Reader address common surgical challenges and what measures have evolved to countenance these problems. This therefore addresses �Current Surgical Practice�, placing emphasis on the principles underlying the consensus opinions prevailing in surgical management. The approach is practical, avoiding the minutiae of procedures for which appropriate references detailing such information are provided. The contributions have come from a broad suave of critical management problems in the salient fi elds of surgery. Regrettably some urgent areas of public interest are not covered but it is clear that this volume represents the beginning of a process, yea, the initiation of an epoch of Recent Advances in Surgical Practice; we are confi dent that such yawning gaps in coverage would soon be made good by subsequent developments, stimulated by issuance of this publication.Item Fibreoptic Gastro-Intestinal Endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana: A Historical Perspective(Ghana medical journal, 2017-12) Nkrumah, K.N.; Archampong, E.Q.Fibreoptic (or Flexible) endoscopy has revolutionized and completely transformed practice of gastroenterology, and many other medical specialties, over the past half century or so. At the Korle Bu Teaching Hospital, Accra the development of this facility has evolved gradually, especially involving specialists from the Departments of Medicine and Surgery since the 1970s. This article is an attempt to trace and record this journey and to highlight some of the problems and challenges yet to be overcome. It is an anecdotal account based on the authors' recollection with attempts at verification of important dates.Item How often are Ghanaian gallbladder stones cholesterol-rich(West African Journal of Medicine, 2002) Darko, R.; Archampong, E.Q.; Qureshi, Y.; Muphy, G.M.; Dowling, R.H.BACKGROUND: Although the prevalence of symptomatic gallbladder stone disease in Ghana increased almost four-fold between 1966 and 1991, little is known about the composition of and aetiopathogenesis of these stones, nor about their suitability for non-surgical (dissolution) treatments. METHODS: To study this, gallstones from 67 out of 90 patients coming to cholecystectomy were retrieved and, based on their external appearance, classified provisionally as cholesterol(chol) (n = 8), black pigment (n = 28) and brown pigment (n = 31) stones. The gallstones were then homogenised, their cholesterol(chol) content measured chemically and the stones re-classified as cholesterol-poor (< 10% chol by weight), intermediate (10-75% chol) and cholesterol-rich (> 75% chol). The relationship between the initial and the definitive classifications was then examined and the biliary bacteriology (carried out on fresh samples of gallbladder(GB) bile obtained by fine needle aspiration) on gallstone composition, analysed. RESULTS: The external appearance correctly predicted stone composition in the 28 thought, initially, to have black pigment stones (all of whom had stones containing < 10% chol by weight, on chemical analysis) and the eight believed, originally to have "cholesterol" stones (all of whom had stones with > 75% chol) but it proved unreliable in the 31 considered, at the time of surgery, to have brown pigment stones (mean chol content 58+ SEM 35%; range 0-98%. By chemical analysis, more than half the patients 35 of 67 or 52% had cholesterol-poor stones, nine (13% of the total) had intermediate stones, while 23 (34%) had cholesterol-rich stones. Cholesterol-rich gallstones were also more frequent in women than in men (p < 0.03). Only nine of 43 patients (21%) whose GB bile was aspirated, had positive bacterial cultures. There was no obvious difference in stone composition between those with positive, and those with negative, cultures. CONCLUSION: Since the majority of Ghanaian patients with cholecystolithiasis have gallbladder stones with < 75% chol by weight, when active treatment is indicated surgery is more appropriate than dissolution therapy. However contrary to common belief, cholesterol-rich gallstones do occur in West Africa: 34% of the present series had stones with > 70% chol by weight.Item Lower gastrointestinal bleeding(Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader, 2013) Archampong, E.Q.In lieu of an abstract, here is a brief excerpt of the content: •117• Chapter 11 Lower Gastrointestinal Bleeding E. Q. Archampong Introduction Historically two categories of gastrointestinal bleeding have been recognized, namely “upper” and “lower”, in relation to origins proximal and distal respectively to the ligament of Treitz. However, recent advances in endoscopic procedures, in particular increasing use of capsule endoscopy, have prompted a rethinking of this classification with a proposal for “upper” “mid” and “lower” categories”.1,2 In this system, upper GI Bleeding (UGIB) is recognised as occurring proximal to the ampulla of Vater, within reach of the oesophagogastro -duodenoscope; mid-GI bleeding (MGIB) is defined as occurring between the ampulla and the terminal ileum, best assessed by capsule endoscopy or double balloon endoscopy (DBE), while lower GI bleeding (LGIB) is newly recognized as occurring within the colon and best evaluated by colonoscopy. In most parts of the world, mid and lower source of bleeding account for 25-30 percent of all GI bleeding.3,4 In developing countries the presentation may be chronic, as longstanding anaemia, but many also present acutely with much haemodynamic instability5,6 demanding urgent resuscitation and management. Although the more sophisticated investigative procedures are not consistently available in developing countries, it is important that whenever possible the new concept of classification be used in patient management. This article reviews recent experience of mid and lower GI bleeding at our centre, with emphasis on initial evaluation, diagnostic procedures and definitive management. Materials and Methods For this review the records of 675 patients who were referred from the surgical and medical outpatients and general services to the •118• Chapter 11 Endoscopy Unit from October 2010 to end of September 2012 were analysed retrospectively. The aetiological distribution of these patients and the symptoms they presented with are depicted in Tables 11.1 and 11.2. Clearly the vast majority of patients complaining of rectal bleeding had haemorrhoids but it is significant that 7.0 percent had colorectal cancer. Nearly 6 percent had significant bleeding from diverticular disease and only a few (1.9 percent) suffered from fissure in ano. Clearly vascular lesions such as angiodysplasias are difficult to identify; only 3 were diagnosed in the two years reviewed. It is note worthy that 2.2 percent of undiagnosed iron deficiency anaemias were traceable to colorectal lesions. Patients with negative findings were separately documented. The demographic and epidemiological distribution of patients seen at the Endoscopy Unit is currently uncertain; it is certainly not representative of the population in the Greater Accra Region. The incidence figures arrived at in this study are therefore only approximations of the true position in the population as a whole. Table 11.1 Aetiological Factors in LGIB FACTOR NUMBER % Haemorrhoids 474 70.2 Diverticular Disease 40 5.9 Colorectal Carcinoma 47 7.0 Polyps (Single) (Multiple) 30 35 5 5.2 Colitis (Practitis) 14 13 2.0 1.9 Angiodysplasia 3 0.4 Granuloma (Amoebic) 2 0.3 Normal mucosa 47 7.0 Total 675 100.0 •119• Lower Gastrointestinal Bleeding Table 11.2 Symptomatology in LGIB NUMBER % Bleeding P.R. 547 18.1 LGIB 91 13.5 Melaena 9 1.3 Anaemia (Occuit Blood) 15 2.2 Not Recroded 13 1.9 Total 675 100 Initial Management and Resuscitation Some 80 percent of patients with acute mid and lower GI bleeding experiencespontaneouscessationofbleedingwithin24hoursofadmission. Patients with continued bleeding—as occurs in diverticular disease, inflammatory diseases or amoebiasis—may however rapidly deteriorate and present in a haemodynamically unstable state, demanding urgent diagnosis and treatment. The principles involving implementation of “ABC” apply, securing the airway and obtaining adequate venous access for appropriate volume resuscitation. The attainment of a reasonable clinical stability is the signal for a thorough history focusing on intake of anticoagulants and antiplatelet agents, and physical examination that would lead on to the diagnosis. Appropriate laboratory tests, in particular haemoglobin, haematocrit grouping and cross matching, and coagulation profile, are conducted. Where haemorrhagic shock threatens on account of continued active bleeding, resuscitation and evaluation are carried out concurrently. In these severely ill patients, especially in the elderly, it is crucial to apply the principles of “damage control” resuscitation, ensuring early exhibition of blood and blood products, and oxygen therapy to help to correct the lethal triad of coagulopathy, metabolic acidosis and hypothermia, and thus influence the outcome is crucial.7 Diagnosis, Localisation, and Interventional Therapies It has been established that in any situation that presents as lower GI bleeding, the source may indeed lie in the...Item Lower Gastrointestinal Bleeding(2013-12-09) Archampong, E.Q.The management of gastrointestinal bleeding poses the principal challenge of location of source of the bleeding, since some upper gastrointestinal (UGIB) sources occasionally present with features indistinguishable from lower gastrointestinal bleeding (LGIB).1,2 Recent advances in endoscopic procedures, in particular, increasing use of capsule endoscopy, have prompted some rethinking of the dichotomous classification with a proposal for upper, mid and lower catagories.1,2 In most parts of the world mid and lower source of bleeding account for 25-30 percent of GI bleeding 3,4 and since 80 percent of these forms of GI bleeding settle spontaneously within 24 hours, it seemed essential to ascertain the features of LGIB in our practice and determine how these affect management. Six hundred and seventy-five patients who were referred from the surgical and medical out patients and general services for endoscopy for the two year period October 2010 to September 2012 were analysed retrospectively. The findings indicate that LGIB is not only less frequently encountered but also presents a less dramatic picture than UGIB. Haemorrhoids are the commonest cause (70.2 per cent), but increasingly significant are amoebic granulomas (7.0 percent) Diverticular disease (5.9 per cent) and Colo-rectal carcinoma (7.0 per cent).Item MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING(2013-12-09) Archampong, E.Q.While the recent emphasis on conservative measures in the management of peptic ulcer disease has facilitated control of the disease in the community, this has not reflected in commensurate decline in complications of the disease, such as bleeding or perforation. Indeed, recent reports from Ghana indicate that perforation and bleeding incidents are on the increase and do result in significant morbidity and mortality posing serious challenges in management. This chapter sets out to ascertain the magnitude of the problem posed by upper gastrointestinal bleeding at the Korle-Bu Teaching Hospital, exploring the dominant causes and the current protocol for management. This has been done through a retrospective analysis of some 552 cases of haematemesis and melaena referred to the endoscopy centre at the hospital over a two year period. The study has revealed that peptic ulcer disease is responsible for 27.5 percent (Duodenal Ulcer: 15.9 and Gastric Ulcer: 11.6) and that contrary to perception, oesophageal and grastric varices together account for 31.3 percent (oesophageal 30-6, and gastric 0.7). Negative findings were made in 14.1% of cases. Management has emphasized importance of initial management (resuscitation) and early diagnosis by endoscopy in a stable patient.Item Management of upper gastrointestinal bleeding(Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader, 2013) Archampong, E.Q.In lieu of an abstract, here is a brief excerpt of the content: •88• Chapter 9 Management of Upper Gastrointestinal Bleeding E. Q. Archampong. Introduction Upper gastrointestinal bleeding (UGIB) is usually an acute emergency which is defined as bleeding originating from the gastro-intestinal tract, proximal to the ligament of Treitz and made manifest by the symptoms of haematemesis and or melaena. Presentation is however not always clear cut and the bleeding may take unusual forms that may not be readily distinguishable from haemorrhage from lower reaches of the bowel. The approach to the control of the latter category of bleeding differs in several significant respects, and is therefore tackled in a subsequent paper; its consideration is nonetheless less essential in the initial assessment of all forms of gastrointestinal haemorrhage. This presentation focuses on the current management of the principal causes of upper gastrointestinal haemorrhage in our practice emphasizing the need for urgent accurate assessment, patient triage and resuscitation, diagnosis and concerted action to influence outcome. Epidemiology The relative frequency of causes of upper GI bleeding varies in different regions of the world. In most parts of Africa, chronic peptic ulceration1 (chronic duodenal and gastric ulcer (Du/Gv: 60/10) accounts for 50-90 per cent of cases. Notable exceptions to this are some East and Central African countries - Tanzania, Zimbabwe, Kenya - where oesophageal varices constitute a more common cause of bleeding than chronic peptic ulceration8 . In Accra over a period of two years, some 552 cases of haematemesis and melaena referred to the endoscopy centre showed the following aetiological spread and symptomatology (Tables 9.1 and 9.2). •89• Management of Upper Gastrointestinal Bleeding Clearly these are not population-based figures; the availability of the endoscopic expertise may have attracted to the centre a disproportionate number of bleeding cases. There is also a preponderance of bleeding from oesophageal and gastric varices, amounting to 30 percent, almost equal to the figures for combined gastric and duodenal ulcers, and almost approaching the pattern in East and Central Africa. Whether this is a reflection of latent high prevalence of subacute hepatic disease in the population or a selection phenomenon, occasioned by the location of the endoscopy centre, needs to be established by a purpose-designed and appropriately powered prospective study. Notwithstanding the geographical variation in the causes of UGIB, in terms of frequency, in West Africa, as elsewhere, three categories are discernable.1 The common or major causes: duodenal/gastric ulcers and stress ulcers (including gastritis mucosal erosions) and oesophageal varices. The less common: oesophagitis (GORD) Mallory-Weiss Syndrome, benign and malignant tumours of the oesophagus, stomach and duodenum, and the rare group: invading pancreatic tumours aortoenteric fistulae, blood dyscrasias hereditary telangiectasias angiodysplasias and anticoagulant therapy, and Dieulafoy’s lesion. The real incidence of these latter lesions is difficult to assess in the context of our practice, because even when endoscopic facilities are available at the appropriate point in time, these lesions are more often than not missed, even when they have been responsible for massive UGI bleeding. Table 9.I Causes of Upper GI Haemorrhage in Accra Causes Number Percentage (%) DU 88 15.9 Prepyloric GU Lesser Curve (Type 1) 36 28 64 6.5 5.1 11.6 Gastric Erosions 2 0.4 Duodenal Erosions 7 1.3 Oesophagitis 15 2.7 Gastritis 10 1.8 •90• Chapter 9 Gastric Polyps 4 0.7 Duodenal Polyps 2 0.4 Oesphageal Polyps 1 0.2 Oesophageal Varices 169 30.6 Gastric Varices 4 0.7 Negative Findings 78 14.1 Total 552 100 Clinical Presentation UGIB is announced by haematemesis (vomiting of bright red or dark blood – coffee grounds) and/or melaena (passage of black, tarry stools) or frankly bloody stools. Usually, haematemesis is generally indicative of oesophageal and gastric bleeding while melaena suggests duodenal haemorrhage; nonetheless duodenal episodes may manifest as haematemesis while gastric and oesophageal bleeding may manifest as melaena only. Since the bleeding is usually acute and the loss significant in many cases, even in the mild cases, the presentation rapidly builds up into a resuscitation and risk assessment, even before diagnosis of presumptive origin is made. Table 9.2 Symptoms on Presentation Symptoms Number Percent (%) Haematemesis 360 65.2 Melaena 96 17.4 Bleeding P.R. 22 4.0 Haematemesis and Melaena 31 5.6 Not indicated 43 7.8 Total 552 100.0 Initial Management Appropriate haemodynamic assessment involves careful measurements of pulse, blood pressure, estimates of intravascular volume status, to Contd. from pg. 89:Table 9.I Causes of Upper Gi Haemorrhage...Item Medical Research and the Practice of Medicine in West Africa(University of Ghana, 1981-12-17) Archampong, E.Q.Item The microflora of bile in Ghanaians(African Journal of Medicine, 1994) Darko, R.; Archampong, E.Q.Bile was obtained from the gall bladder of 104 patients undergoing cholecystectomy for gall stone disease. Bile was also obtained from the common bile duct and T-tube of 17 patients who also had exploration of common bile duct. During the same period, 148 cholecystectomies were performed. The specimens were sent for culture and sensitivity and 32.7% of the specimens grew bacteria. The factors that were associated with positive culture were emergency cholecystectomy for acute cholecystitis and empyema of gall bladder, carcinoma of gall bladder and obstructive jaundice. The commonest organisms were E. Coli (28.2%) and Klebsiella (17.9%). Pseudomonas surprisingly formed 10.2% of the cultured organisms. Salmonella that causes typhoid, which is an endemic disease in Ghana, formed only 7.7% of the isolates. Most of the organisms were resistant to Ampicillin and tetracyclines. The antibiotics that most were sensitive to were Gentamicin and Cefuroxime. Therefore the antibiotics that are recommended for use as prophylaxis in biliary tract surgery are Gentamicin or Cefuroxime.Item Peptic ulcer disease(Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader, 2013) Archampong, E.Q.In lieu of an abstract, here is a brief excerpt of the content: •62• Chapter 6 Peptic Ulcer Disease E. Q. Archampong Introduction Nothing short of a revolution has characterized our understanding of the aetiology, pathogenesis and management of peptic ulcer disease over the past century and the burning issue that arises is how far this has influenced the outcome of current management of the disease. The decline of the acid dogma,1,2 “no acid, no ulcer”, which had given rise to decades of dominance of surgical interventions (partial gastrectomies, various forms of vagotomy), was succeeded by short term antibiotic regimes aimed at elimination of helicobacter pylori infection; this ensued following the demonstration that H. pylori is a primary factor in the pathogenesis of peptic ulcer disease by Warren and Marshall3,4, for which they were awarded the Nobel Prize for Medicine and Physiology in 2005. Furthermore non-steroidal anti-inflammatory drugs (NSAIDS) and low-dose asprin are currently increasingly associated with peptic ulcer disease in H. pylori negative individuals. This article attempts to review the current practice in West Africa in the management of the various forms of peptic ulcer disease, i.e. duodenal, gastric ulcers, gastro-esophageal reflux (GOERD), and its outcome. Pathogenesis of Peptic Ulcer Disease This remains complex but basically, there is imbalance of aggressive gastric luminal agents, mainly acid and the digestive enzyme pepsin, and the defensive mucosal barrier function; so acid secretion still plays an important role. However a whole range of environmental and host factors contribute to ulcerogenesis by increasing acid or pepsin secretion or through impairment of gastric mucosal barrier function.2,5,6 •63• Peptic Ulcer Disease Among the former, tobacco use and alcoholism and drug agents have been cited but apart from NSAID use, none of these have been specifically backed by research data.2 Although emotional stress is frequently blamed for ulcerogenesis, there is more objective support for severe organic stress from sepsis, burns and head or cerebral injuries.7,8 The Influence of H. Pylori Although there is a very strong epidemiological association between H. pylori infection and duodenal and gastric ulceration, the ultimate confirmation of H. pylori as the main cause has been the demonstration of permanent cure of peptic ulcers by the eradication of H. pylori infection.9,10 The fact is that while more that 50 percent of the world’s population is chronically infected with H. pylori (and the figure reaches 75 percent in developing countries), only 5-10 per cent of those so infected develop ulcers. It seems the pattern of histological gastritis induced is one of the main determining factors. Thus in patients with duodenal ulcer, density and severity of infection are greatest in the distal and antral region, sparing the acid-secreting body mucosa, while in gastric ulcer the inflammation affects the body and antral mucosa to a similar degree, leading to much reduced gastric acid secretion, because of the more severe involvement of the acid secreting mucosa of the body of the stomach. There are also factors such as ulcerogenic strains of H. pylori and genetic factors and their influence on gastric and duodenal metaplasia. H. pylori infection impairs the negative feed-back regulation of gastrin release. Through its capacity for high urease activity, it not only protects the organism from the low gastric pH, but also prevents the D cells in the gastric mucosa from sensing the true level of gastric acidity, thus stimulating an inappropriate release of stematostatin (decrease) resulting in an increase in gastrin release, leading to excessive acid secretion.11 One of the effects of excessive gastric acid secretion is development of metaplasia in the duodenal bulb, leading to islands of colonization of the duodenal mucosa, a phenomenon more often seen in gastric •64• Chapter 6 than duodenal mucosa. The inflamed metaplasic duodenal mucosa is more susceptible to ulceration with further acid exposure. The mucosal inflammation generated in the gastric mucosa appears more severe, with induction of epithelium-derived cytokines, particularly interleukin,8 interleukin 112 producing an influx of neutrophils , macrophages with release of lysosomal enzymes, leucotrines and reactive oxygen free radicals, which impair mucosal resistance, releasing a process of immunopathogenic ulcerogenesis. In this scenario, even the reduced acid environment in the gastric mucosa, vitiated by body and antral gastritis, succumbs readily to gastric ulcer. The NSAID Factor in Ulcerogenesis This was earlier attributed to topical injury through ion trapping and reduction of mucosa gel protective activity;13 subsequently this was shown to be more likely through...Item PEPTIC ULCER DISEASE(2013-12-09) Archampong, E.Q.Nothing short of a revolution has transpired in our understanding of the aetiology, pathogenesis and the management of peptic ulcer disease over the past century, and the burning issue is how far this has influenced the outcome of management. Dominance of treatment by surgical intervention based on the acid dogma “no-acid, no ulcer” has given way to conservative measures aimed at elimination of helicobactor pylori using short term antibiotic regimes. This chapter represents a descriptive study through review of the literature on the outcome of these interventions over the past half century. The study is supplemented with the outcome of interviews with colleagues on their practice as physicians and surgeons in the Korle-Bu Teaching Hospital. It is evident that in the local practice as elsewhere the management of peptic ulcer disease has become increasingly conservative; surgical interventions are virtually confined to complications – perforations, bleeding and cicatrisation. Control of the disease within the communities has been effective, but for problems of compliance on account of access to the necessary drugs in the community.Item Preface(Current Challenges with their Evolving Solutions in Surgical Practice in West Africa: A Reader, 2013) Archampong, E.Q.In lieu of an abstract, here is a brief excerpt of the content: •ix• Preface E.Q. Archampong TheViceChancellor’scalltothevarioussectionsoftheUniversityforthe publication of Readers resonates very well with the desires and aspirations of many senior members of the diverse sections of the College of Health Sciences. Some see this as an opportunity for dissemination of non-technical information on topical issues of general interest to the public, i.e. reinforcement of the public health education mission in the health sciences. Others, feeling that much has already transpired in this area, for example through the publication of books such as The Layman’s Guide to Good Health1 etc are inclined to explore the development of learning materials within their particular disciplines. In the Department of Surgery several senior members were attracted to the latter idea, targeting learning materials for the ever increasing number of residents in the postgraduate programmes in the Department. Worldwide, there is a plethora of study materials in the form of authoritative review articles on disease entities afflicting the Western world but relatively few publications exploring similar problems confronting the developing countries, where resource limitation adds an extra dimension to the challenges facing the clinician. The contributions received aim therefore to address common surgical challenges and what measures have evolved to overcome these problems. This Reader therefore addresses “Current Surgical Practice”, placing emphasis on the principles underlying the consensus opinions prevailing in surgical management. The approach is practical, avoiding the minutiae of procedures by providing appropriate references detailing such information. The contributions address a broad swathe of critical management problems in the salient fields of surgery. Regrettably some urgent areas of public interest are not covered but it is clear that this volume represents the beginning of a process, indeed, the initiation of an epoch of Recent Advances in Surgical Practice. We are confident that this publication will stimulate further efforts to fill the yawning gaps in coverage. •x• Preface This publication highlights developments in the prevention of childhood blindness in the country; global developments in premalignant and malignant disease of the breast are widely reviewed. The challenges in management of common disease entities such as acute appendicitis, peptic ulcer, and its complications, colorectal and gastric carcinoma, and emerging new patterns of neoplasia such as gastrointestinal stromal tumours (GIST). Some refreshing thoughts are expressed on old problems such as biliary tract and urinary tract obstruction. Departmental experience on fairly common challenges in infant care such as club foot and oesophageal atresia are reviewed. The development of one of the centres of excellence in the Department of Surgery, namely the National Cardiothoracic Centre is also highlighted. References 1. Health and Disease: A Layman’s Guide to Good Health. (Eds). E.A. Badoe and S.K. Owusu. University of Ghana Medical / Smart Line Limited, Accra. 2011. ...Item Surgery in developing nations(British Journal of Surgery, 2006-05) Archampong, E.Q.