Cerebrovascular accidents in Ethiopia

The causes, risk factors and outcome of cerebrovascular accidents (CVA) in 150 patients admitted to Tikur Anbessa Hospital, Addis Ababa, Ethiopia, between 1983 and 1985 were studied. Cerebral thrombosis was the commonest cause of CVA (50.6%), followed by cerebral haemorrhage (24%) and cerebral embolism (15%). The single most important risk factor for CVA was hypertension. Mortality was highest with cerebral haemorrhage (89.4%) and lowest with cerebral embolism (13%). An important measure which could reduce the incidence of CVA is the vigorous and sustained control of hypertension.     

Complicated peptic ulcer disease in Tikur Anbessa Hospital, Addis Ababa

There are few published surgical reports on peptic ulcer disease (PUD) in Ethiopia. Of 405 complicated peptic ulcer patients operated on in Tikur Anbessa Hospital, Addis Ababa, from 1997 to 2001, the records of 351 patients were retrieved and retrospectively analyzed to assess the pattern of PUD complication and the outcome of surgical treatment. During the study period, complicated PUD patients comprised 3.8% of the total major surgical procedures. The male to female ratio was 5.6: 1.0. The mean age was 36.5 +/- 12.7 years. Of 351 patients, 337 (96%) had abdominal pain, in most epigastric, and 330 (94%) had vomiting as presenting complaints. Dehydration was observed in 44 (12.5%). Gastric outlet obstruction (GOO) was the commonest complication followed by perforation that necessitated surgical intervention. The commonest operative procedure was truncal vagotomy and drainage. Nearly 5.0% died in hospital, most from complicated perforated peptic ulcer. Follow-up was possible in 262 patients for a mean of 16.2 +/- 15.0 months. Dumping and diarrhea were observed in 2.7% and 0.4% of the patients, respectively. Bile reflux gastritis was encountered in 1.5%. Truncal vagotomy and drainage remained to be easily learnable procedures with acceptable morbidity and mortality rates.     

Surgical treatment of achalasia cardia in Tikur Anbessa Hospital, Ethiopia

OBJECTIVE: This review aims to evaluate 61 patients with achalasia cardia treated with Heller's cardiomyotomy in Tikur Anbessa Hospital (TAH). METHODS: A hospital based cross sectional analysis was conducted in TAH, Department of Surgery, Addis Ababa, Ethiopia between January 1996 and December 2005. Medical records and operation theater registers of 61 patients operated upon for achalasia cardia were analyzed retrospectively. RESULTS: Thirty-four were male and twenty-seven female with mean age of 25 years (range 9-58). All had dysphagia to solid foods. Thirty-one (50.8%) patients had weight loss. The diagnosis of achalasia cardia was confirmed in 60 (98.4%) patients by barium swallow; in 23/25 (92.0%) by esophagoscopy. Cardiomyotomy was performed through transabdominal (83.6%) and transthoracic (16.4%) approaches. Immediate postoperative course was uneventful in 52 (85.2%) patients, while 9 (14.8%) patients developed immediate postoperative complication. There was no in-hospital mortality. Median operation time and hospital stay were 60 minutes and 7 days respectively. Late complications occurred in 7/52 (13.5%) patients, Gastroesophageal Reflux Disease (GERD) (9.6%) being the most common. A very good palliation of dysphagia was achieved in 88.5% of cases (p < 0.0001). CONCLUSION: Significant improvement in dysphagia of patients with achalasia cardia following modified Heller's myotomy alone is possible in majority of the patients.     

Diabetic infections: clinical and bacteriological study at Tikur Anbessa Specialized University Hospital, Addis Ababa, Ethiopia

INTRODUCTION: Infection is the most serious complication of diabetes and recognized as causing significant morbidity and mortality. OBJECTIVES: To assess the prevalence and pattern of infection, determine the causative organisms. METHODS: A cross sectional study involved 179 diabetic patients admitted to the Department of Internal Medicine of Tikur Anbessa Specialized University Hospital performed between Nov. 2000 - Nov 2002, clinical data were documented, a total of 114 clinical specimens (40 pus, 23 blood and 51 urine) were submitted to bacteriology laboratory for bacterial isolation and identification. RESULTS: The mean +/- SD fasting blood sugar was 246.0 +/- 153.3 mg/dl. Fifty eight (32.4%) of patients were admitted in state of diabetic ketoacidosis. The prevalence of infection in diabetic patients was 44%. Diabetic foot infection (35%) was the commonest, followed by pulmonary tuberculosis 22%, urinary tract infection (14%), pneumonia (12.8%), skin and subcutaneous infection (12.8%). About 30% of bacterial isolates were Staphylococcus aureus followed by Klebsiella pnumeniae (23.4%), Escherichia coli (19%) and Pseduomonas spp (15%). The rest of the isolates were less frequent and ranged between 2 to 6.4%. More than one bacterial species were also isolated from 10% of the positive cultures. Main causes of deaths in hospitalized diabetic patients were cardiovascular diseases (6/15), end stage renal disease (3/15) and sepsis (2/15). CONCLUSION: Infections were the leading cause of morbidity while cardiovascular diseases were the leading cause of mortality. Diabetic foot ulcers were the major cause of infection followed by tuberculosis, skin and subcutaneous infections and pneumonia. The prevalence of tuberculosis in diabetic patient is increasing; S. aureus from wound infection and E. colifrom urinary tract infection were the common pathogens.     

Experience of surgical therapy in 72 patients with thoracic hydatidosis over a 10-year period

OBJECTIVE: This review aims to evaluate retrospectively 72 patients diagnosed to have thoracic hydatid disease and treated surgically in Tikur Anbessa Hospital between December 1993 and November 2003. DESIGN: Retrospective Analysis hospital records. SETTINGS: Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa, Ethiopia. PATIENTS AND METHODS: Medical records and Operation theater registers of seventy-two Patients operated on for Thoracic hydatidosis were evaluated retrospectively. Chest Roentgenogram was the main diagnostic tool used Main surgical techniques employed were evacuation in 44 (52.4%) cysts, cystotomy in 30 (35.7%) cysts, and enucleation in 10 (12%) cysts. Additional palliative procedures (such as pericystectomy and Capitonnage) and radical procedures (such as resection of the lung) were also employed. RESULTS: forty of the patients were male and thirty-two female with a mean age of 31.4 years. The most Common presenting symptoms were cough in 60 (83.3%) patients, expectoration in 47 (65.3%) patients and chest pain in 38 (52.8%) patients. Chest radiography revealed a round opacity or shadow in 58 (80.6%) patients. All patients were treated surgically. The mean hospital stay was 38.3 days. Major postoperative Complications occurred in 12 (16.9%) patients; pneumonia, pleural effusion and prolonged air leak were the complications in order of their frequency. There was one postoperative death and one recurrence at 6-months follow-up period. CONCLUSION: Surgical excision of pulmonary hydatidosis with maximum preservation of lung parenchyma is possible in the majority of patients and should remain the mainstay of surgical treatment.     

Preliminary experience with endoscopic retrograde cholangiopancreatography in Ethiopia

This study was undertaken to evaluate the outcome of diagnostic endoscopic retrograde cholangiopancreatography and to increase the awareness of physicians practicing in Ethiopia about the procedure. Between April 1993 and October 1997, 47 patients underwent endoscopic retrograde cholangiopancreatography at Tikur Anbessa Hospital, Addis Ababa. Cholestasis, postcholecystectomy syndrome and abdominal pain with intermittent jaundice accounted for 91% of the indications. The success rate of endoscopic retrograde cholangiopancreatography was 81%. Cholestasis provided the highest diagnostic yield followed by postcholecystectomy syndrome and abdominal pain with intermittent jaundice. The endoscopic retrograde cholangiopancreatography finding was normal in 18% of cases. The commonest abnormal findings were gall stones (45%), biliary strictures (16%) and pancreatic carcinomas (11%). Using ultrasonography and endoscopic retrograde cholangiopancreatography, choledocholithiasis was diagnosed in three (21%) and 13 (93%) cases, respectively. The endoscopic retrograde cholangiopancreatography diagnosis of choledocholithiasis was confirmed at surgery in all but one patient. Acute cholangitis and asymptomatic elevation of serum amylase and/or lipase were noted in three (6%) and four (9%) cases, respectively. Endoscopic retrograde cholangiopancreatography is generally a safe diagnostic modality and should be used more frequently for the diagnosis of biliary and pancreatic diseases.     

Management of cervical ribs causing neurogenic thoracic outlet syndrome: a ten year experience in the neurosurgery unit, Tikur Anbessa Hospital

Eighteen cases of cervical Ribs causing numbness, paraesthesia and wasting of hand muscles were seen during the years 1990 to 1999 in neurosurgery unit of Tikur Anbessa, a central, referral teaching hospital. There were thirteen cases of unilateral, and 5 bilateral brachialgic pains M:F = 1:2 with ages range from 15-50 yrs (mean age 32 +/- 4.8 yrs); though it is 3 times common in women specially those with neurologic symptoms. 5 cases didn't have any cervical ribs. All had respective cervical rib resections and scalenotomy done. Paraesthesia and pain were relieved in about 90% of the cases. Cervical rib causing Thoracic Outlet Syndrome (TOS) is a rare condition commonly seen in less than 1% of the population as seen here in 18 cases in 10 years period. The absence of cervical rib doesn't rule out thoracic outlet syndrome as it can be from anomalous first ribs, scalenus anticus syndrome or congenital fibromuscular bands. Surgical excision has a good neurological outcome. No subclavian vessel especially arterial compression cases were seen in this study as cervical ribs can cause neurovascular compression. The diagnostic and therapeutic measures are clearly stated as this syndrome is a diagnostic and treatment challenge to the practicing general surgeons. Accurate diagnosis and proper surgical intervention are very crucial for the good outcome.     

Magnitude of episiotomy in a teaching hospital in Addis Ababa, Ethiopia

OBJECTIVE: To assess the rate of Episiotomy in vaginal birth in Tikur Anbessa teaching Hospital and the associated factors that influences the use of episiotomy in the unit. METHODS: A cross-sectional study was conducted in the delivery unit of the Tikur Anbessa Hospital from May to September 2000. Data on mothers who delivered in the study period was collected using structured questionnaire. Variables on use of episiotomy, parity, fetal presentation, duration of labor, mode of delivery, Apgar scores at first and fifth minutes, indications for episiotomy and the practice of analgesia & anesthesia in the management of Episiotomy were collected Medical charts and the labor ward logbook were reviewed for collecting the data. RESULTS: A total of 917 deliveries were attended during the study period among which 672 mothers (83.1%) delivered vaginally. Among the vaginal deliveries, 270 (40.2%) mothers had episiotomy. Of these 203 (75.2%) mothers were primigravidae. Nulliparity (77.7% vs 21.3%), the duration of the second stage of labor more 90 minutes (76% vs. 13.8%) and instrumental delivery (86.2% vs. 13.8%) has been shown to be significantly associated to having episiotomy, while the birth weight and Apgar scores didn't show significant differences. Local anesthesia was used only in 71 (28.1%) cases among the 253 on whom information regarding the use of local anesthesia was retrieved. CONCLUSION: The rate of episiotomy is significantly higher than the recommended practice for many centers. Measures should be taken to lower the rate of episiotomy rate that include preparation of guidelines and protocols according to the standard and training and nurses, midwives and doctors on the selective use of episiotomy. The current practice of perineal repair without analgesia/anesthesia should be revised and making labor and delivery less painful needs to be advocated.     

A six-year review of maternal mortality in a teaching hospital in Addis Ababa

The case notes of all patients who died over the January 1980 to December 1985 period in Tikur Anbessa Teaching Hospital, Addis Ababa, Ethiopia, as a result of conditions associated with pregnancy, labor, and puerperium were reviewed in an effort to identify the most common causes of maternal death. Postpartum autopsy seldom was possible; consequently, the cause of death was based on clinical findings only. 216 deaths occurred over the 6-year period; there were 22,404 live births in the same period, giving a maternal mortality rate (MMR) of 9.6/1000. This rate included deaths from complications following abortions. 197 of the deaths occurred in women who were not booked into Tikur Anbessa Hospital. In terms of direct causes of death, abortion, puerperal sepsis, and ruptured uterus together accounted for 75.9% of deaths. Of indirect causes, infectious hepatitis, relapsing fever, and malaria accounted for 56.8% of deaths. Of deaths due to abortion, 21/48 occurred in nulliparas, and 25 were below age 19. Of the deaths caused by ruptured uterus, 20/29 occurred in multipara, and all of those women were from rural areas. The majority of deaths from hepatitis occurred in the 30-34 years age group. In Ethiopia, the maternal mortality rate is high because of both poor or inadequate antenatal and postnatal care as well as because of poor transportation and communication systems.     

Cryptococcosis in patients from Tikur Anbessa Hospital, Addis Ababa, Ethiopia

A study was done to investigate the occurrence of Cryptococcus neoformans infection in patients admitted to Tikur Anbessa Hospital. Cryptococcus neoformans is an important opportunistic fungal pathogen in immunocompromised patients. The study was done over a period of 18 months, from October 1998 to April 2000. During this period, a total of 1088 cerebrospinal fluid (CSF) specimens were sent to the bacteriology laboratory in Tikur Anbessa Hospital, out of which 275 were subjected for India ink examination. Out of these 19 (7%) were India ink positive. Additionally one lymph node aspirate was also India ink positive. All these specimens were culture positive for Cryptococcus neoformans. The medical records of these patients were retrospectively reviewed and all presenting clinical symptoms were recorded. In this group of patients with meningitis the most common presenting were fever and headache. In addition, at the time of admission, 75% of the patients had other opportunistic infections, such as oral candidiasis, herpes zoster and Pneumocystis carini pneumonia. The mortality rate was high even in patients with appropriate therapy. All the isolates were identified as C. neoformans var. neoformans. The variety gatti was not isolated in this study.     

The surgical management and outcome of oesophageal cancer in Addis Ababa

One hundred and forty two patients with oesophageal cancer seen from 1992-1996 at a surgical unit of Tikur Anbessa Hospital (TAH), Department of Surgery, Faculty of Medicine were studied retrospectively. It represented 13.8% of all malignant tumours that were seen in the department during the study period. Seventy four patients (52%) were explored and thirty four (46%) of them had resection, 27 (80%) had locally invasive tumours). Of the thirty four patients that were explored, thirty had an Ivor-Lewis type of resection, using stomach tube through the right side of the chest, and four had partial gastero-oesophagectomy with gastero-oesophagostomy in the left side of the chest. The post operative mortality was 21 (28%). The commonest causes of death were sepsis secondary to anastomotic leak and pneumonia. Follow up was possible for eighteen patients, eleven of them for seven months and the rest for seventeen months, all were doing well. Sixteen patients could not be traced.     

Chronic idiopathic thrombocytopenic purpura (ITP) in adult Ethiopians: clinical findings and response to therapy

Between January 1982 and December 1989, thirty four cases of chronic idiopathic thrombocytopenic purpura (ITP) were seen in adult Ethiopians in the Department of Internal Medicine in-patient and haematology referral clinic, of Tikur Anbessa teaching hospital. Twenty three were females and eleven males; female to male ratio of 2.1:1. The age range was 13-57 years, with a mean of 24.9 years. The commonest manifestations were: purpura, epistaxis, gum-bleeding and menorrhagia. The duration of symptoms ranged from one month to over ten years (median 4.5 months). The platelet counts ranged from 4000/mm3 to 77,000/mm3 (mean - 19,200/mm3), haemoglobin 3.01 to 15.4 gm/dl (mean - 8.2 gm/dl). Four (11.8%) patients were not treated; of these, one went into spontaneous remission. Thirty patients (88.2%) were treated with prednisolone 1.0 to 1.5 mg/kg/day orally. Of these, 7 (23.3%) had excellent, 2 (6.7%) good, 6 (20%) fair, and 15 (50%) had poor responses. Ten patients had splenectomy with 5 (50%) excellent 2 (20%) good, 2 (20%) fair and 1 (10%) poor response. One patient with refractory ITP was treated with immunosuppressive drugs and had an excellent response. Fifteen patients are alive and on followup 3-122 months (median 33 months) after diagnosis, fifteen are lost after followup of 1-66 months (median 9 months) and four have died 1-18 months (median 2 months) after diagnosis. Chronic ITP is frequently seen in adult Ethiopians, its clinical features and response to therapy are similar to those reported in the literature.     

Clinical profile of acute renal failure in children admitted to the department of pediatrics, Tikur Anbessa Hospital

Case records of 30 pediatric patients with the diagnosis of acute renal failure (ARF) admitted to Tikur Anbessa Hospital in Addis Ababa between October 1997 and October 2001 were analyzed There were 15 females and 15 males. Three patients had glomerulonephritis, in two patients the cause of acute renal failure was not known, one child had obstructive uropathy. Twenty-three patients had post-diarrheal hemolytic uremic syndrome. The age ranges of post-diarrheal hemolytic uremic syndrome cases were between 0.6 years and 7 years with a median age of 2.2 years. Fourteen patients died of acute renal failure among this hemolytic urmic syndrome contributed to the death of 9 patients. The commonest clinical presentation was severe oligo-anuria in (25 patients), edema in (22 patients), and bloody diarrhea in (21 patients). From stool cultures of 16 patients with hemolytic uremic syndrome, there were five isolates of Shigella species, two isolates of E. coli, and two isolates of Salmonella species. Five patients had non-oliguric acute renal failure. Hemolytic uremic syndrome is the leading cause of acute renal failure in infants and young children in our series. Vigorous resuscitation and early dialysis will reduce mortality rate.     

Clinical value of uroflowmentry in selected cases of bladder outlet obstruction

Fifteen patients with Benign Prostatic Hyperplasia (BPH), 42 urethral stricture patients, and 34 controls were included in this study to describe outflowmetry findings at Tikur Anbessa Hospital in Addis Abeba from April to August 2000. Normal values for maximum and average urine flow rates were determined Uroflowmetry findings in BPH and urethral stricture were compared with normal subjects. The average age for BPH, urethral stricture, and controls were 63.3 (SD +/- 10.3), 38.4 (SD +/- 12.4), and 28.5 (SD +/- 7.9) respectively. The mean maximum flow rates for normal subjects was 22.7 ml/sec (range 15 to 42 ml/sec) and mean average flow rates 14.7 ml/sec (range 9 to 25 ml/sec). Mean maximum flow rate for BPH and Urethral Stricture were 11.5 (SD +/- 8.2) and 8.7 (SD +/- 6.5) ml/sec respectively. For urethral stricture maximum flow rate had sensitivity and specificity of 91% and 85% respectively. For BPH sensitivity was 100% and specificity 80%. Normal values are set for the study population. Uroflowmetry has high sensitivity and specificity. It can widely be used in routine-evaluation of BPH and urethral stricture patients.     

Elective hysterectomy at Tikur Anbessa Teaching Hospital,Addis Ababa

A retrospective analysis of 969 elective hysterectomies performed at Tikur Anbessa teaching hospital from February 1992-October 2000 is presented. The objectives of the study were to outline the major indications, the frequencies of intraoperative and postoperative complications and the variations of these frequencies in the various types of hysterectomy, thereby providing data on this important gynaecologic operation in an Ethiopian hospital set-up. Elective hysterectomies accounted for 79.3% of all hysterectomies performed at the unit. There was a preference for the abdominal approach to hysterectomy (77.3%) with vaginal hysterectomy being done in only 22.7%. The three major indications for hysterectomy were leiomyoma 396/969 (41.1%), uterovaginal prolapse 221/969 (23%) and ovarian tumours 188/969 (19.5%). 567/969 (58.5%) of the patients had an underlying medical condition; anaemia being the commonest, accounting for 325/969 (33.5%). In 294/969 (30.2%) of the operations, intraoperative adhesions requiring adhesiolysis were encountered. A high proportion of intraoperative complications 167/969 (17.2%), and postoperative complications, 316/969 (32.6%), were found. Intraoperative haemorrhage rate 135/969 (14%) is significantly higher than reports from other series of hysterectomy. Postoperative febrile morbidity, 260/969 (27%), is also significantly higher than rates reported from other series. Unexplained fever was however lower, being responsible for only 20% of the febrile morbidity. There was a significantly increased risk of urinary tract infection in vaginal hysterectomies and unexplained fever in abdominal hysterectomy (P < 0.05). There is a need to use the vaginal approach to hysterectomy whenever feasible and introduce infection prevention protocols to reduce the high incidence of infection at the unit. Analytic studies to assess risk factors for haemorrhage and infection are required in order to devise preventive strategies.     

Upper gastrointestinal endoscopy: a review of 10,000 cases

A total of 10,000 patients underwent upper gastrointestinal endosopy examination between August 1979 and October 1994 at Tikur Anbessa Hospital, Addis Ababa. The major indications were dyspepsia (59.4%), upper gastrointestinal bleeding (18%) and liver disease (10.8%). The other indications include dysphagia (2.2%), gastric outlet obstruction (2.1%), postoperative dyspeptic symptoms (1.9%), weight loss and/or anemia (1.4%), epigastric mass (0.6%) and odynophagia 0.2%. The mean age of the patients and their sex ratio was 36 years and 2:1, respectively. Twenty eight percent of the patients had normal findings. The commonest abnormal findings include duodenal ulcer (41%), esophageal varices (9%), acute gastritis (6%), duodenitis (3.4%), and reflux esophagitis (2.3%). Benign gastric ulcer was rare. The ratio of duodenal ulcer to gastric ulcer was 19.1%. Duodenal ulcer (45.6%), esophageal varices (15.6) and acute gastritis (5.7%) were found to be the commonest causes of upper gastrointestinal bleeding. The endoscopy or histology diagnosis of cancer in both the esophagus and stomach was 2.8% and 1.3%, respectively. The agreement between endoscopy and histology in the diagnosis of esophageal and gastric cancer was 80%. There was no major complication related to endoscopy or premeditation. Endoscopy is a fairly accurate and safe procedure and therefore should be available and applied widely for the diagnosis of upper gastrointestinal diseases in Ethiopia.     

Prospective study of patients with hand injury: Tikur Anbessa University Teaching Hospital, Addis Ababa

OBJECTIVES: To describe the nature of hand injuries among patients seen in a referral teaching hospital in Addis Ababa. PATIENTS AND METHODS: All six hundred and two patients with a total of 621 injured hands seen at the emergency out patient department of Tikur Anbessa University Hospital over a one- year period, May 1, 2003 - April 30, 2004 were evaluated and findings documented and analyzed. RESULTS: of the 602 patients, 511 (84.9%) were males and 91 (15.1%) females. The mean age was 28.3 years (males 28.8 years and females 25.4 years). The majority of the injuries 488 (81.1%) occurred either in a factory, on a street, at home or at a construction site. The commonest causes included machine accidents 195 (32.4%), followed by crushing 95 (15.8%), road traffic accidents 83 (13.8%) and injury from a sharp object 80 (13.4%). Fifty six percent of all the patients (336/602) had been injured at work, of whom 156 of 195 (80.0%) had been working with an unguarded machine. Fifteen of those injured 195 (7.7%) had suffered a previous machine injury. Work related hand injuries occurred more often among manual workers 77.7% (261/336). Three hundred and seven of the 621 injured hands had one or more fractures (49.4%), 233 a severe soft tissue injury (37.5%), 126 an amputation (20.3%), 40 a dislocation (6.4%), and 34 (5.5%) foreign bodies in the hands. Four hundred and sixty five (77.2%) arrived within eight hours of the injury, and this included the majority of those most severely injured. CONCLUSION: It is suggested that the provision of adequate safety guards on industrial machines, and their use, would significantly reduce the number of severe hand injuries occurring in Addis Ababa.