Firmin Ankouane

In low-income countries, the cost of digestive endoscopy procedures is often unknown, yet its understanding is crucial for including them in the universal health coverage benefit package. The management of digestive endoscopy requires substantial financial contribution from patients, especially in Cameroon where more than 70% of health expenditures are incurred by households. This study assessed the direct costs of diagnostic digestive endoscopy, based on indications and patient outcomes in Yaoundé, Cameroon. A retrospective cross-sectional study was conducted, over a period of twelve months in the digestive endoscopy units of two referral health facilities (one private and one public). The sampling exhaustively included the reports of gastroscopies and diagnostic colonoscopies. Direct costs were estimated from expenditures for examination, anaesthesia, biopsy, colonic preparation in the patient's perspective in relation to clinical indications, endoscopies (type of anaesthesia, type of endoscopy, biopsy, results) of gastroscopies and colonoscopies performed. The average total cost was estimated by dividing the overall total cost by the number of patients. The costs were expressed in Central Africa Francs XAF, and US Dollars (\$1= 554.24 XAF). Statistical analyses used the non-parametric Mann-Whitney test. Differences at the 5% threshold were considered significant. A total of 1,147 reports met our selection criteria: 754 gastroscopies and 393 diagnostic colonoscopies with an average patient age of 45 years. In gastroscopy, 46.8% were men and 53.2% were women, while in colonoscopy, there were 58.3% men and 41.7% women. The average direct cost of gastroscopy was estimated at 46,981 XAF (\$84.77) per patient; while the cost of colonoscopy was 117,692 XAF (\$212.35) per patient. The main indications that influenced the overall direct cost of gastroscopy were: pyrosis with 42,000 XAF (\$75.7) and melena with 45,000 XAF (\$81). The endoscopic findings responsible for a fluctuation in this cost were mainly: bulbar ulcer and absence of lesions, each with 60,000 XAF (\$108.11). The overall direct cost of colonoscopy was influenced by indications such as: rectorrragies with 109,000 XAF (\$196.4) and abdominal pain with 108,200 XAF (\$194.96); as well as by certain results such as: absence of lesions with 108,000 XAF (\$194.59) and colonic polyps with 142,000 XAF (\$255.86). The study concludes that digestive endoscopy was likely expensive in the study setting. Often some inappropriate indications were posed, such as pyrosis and abdominal pain, thereby contributing to increase the cost of digestive endoscopy. This makes digestive endoscopy financially inaccessible to less well-off patients. The policy implications lies in providing evidence for subsidising the costs of digestive endoscopy as part of universal health coverage benefit package in Cameroon.

Background: Minimal hepatic encephalopathy (MHE) is the presence of neuropsychological abnormalities detectable by psychometric tests. Psychometric Hepatic Encephalopathy Score (PHES) is a gold standard test for the early diagnosis of MHE in cirrhotic patients. The aim of this study was to standardize the PHES in a healthy Cameroonian population and to evaluate the prevalence of MHE among cirrhotic patients. Methods: This was a prospective, multicentric study from 1 December 2018 to 31 July 2019 in two groups: healthy volunteers and cirrhotic patients without clinical signs of hepatic encephalopathy. The results of the number connection test-A, number connection test-B, serial dotting test, line tracing test were expressed in seconds and those of the digit symbol test in points. Results: A total of 102 healthy volunteers (54 men, 48 women) and 50 cirrhotic patients (29 men, 31 women) were included. The mean age was 38.1 ± 12.55 years in healthy volunteers and 49.3 ± 15.6 years in cirrhotic patients. The mean years of education level was 11.63 ± 4.20 years in healthy volunteers and 9.62 ± 3.9 years in cirrhotic patients. The PHES of the healthy volunteer group was − 0.08 ± 1.28 and the cut-off between normal and pathological values was set at − 3 points. PHES of the cirrhotic patients was − 7.66 ± 5.62 points and significantly lower than that of volunteers (p < 0.001). Prevalence of MHE was 74% among cirrhotic patients. Age and education level were associated with MHE. Conclusion: PHES cut-off value in Cameroonians is − 3, with MHE prevalence of 74% among cirrhotic patients.

Rapporter l’expérience du traitement endoscopique des polypes coliques et rectaux au centre médical La Cathédrale à Yaoundé (Cameroun). Entre janvier 2010 et avril 2015, les données de 112 résections de polypes coliques ou rectaux consécutives, ont été colligées rétrospectivement chez 71 patients (âge médian de 49 ans- extrêmes : 3–75 ans). Ont été étudiés : a) l’âge et le sexe des patients ; b) la localisation, l’aspect et la taille des polypes ; c) la technique endoscopique ; et d) les complications. La résection a été effectuée avec des anses diathermiques tressées de 25 mm en endocoupe (ERBE-ICC 200) avec une puissance de coupe de 75–150 Wet une coagulation de 35–55 W, associée à l’injection de sérum physiologique à la base du polype dans deux cas. Le sex ratio H/F était de 1,96/1. Deux pics de fréquence de résection étaient retrouvés à 20 mm dans 11,6 %. Soixante-deux (55,4 %) polypes ont été réséqués à l’anse diathermique. Parmi les cinq mucosectomies, quatre polypes 20 mm par fragmentation. Tous les polypes de e jour et a été pris en charge chirurgicalement. La pièce opératoire a montré une perforation. Aucun décès n’a été enregistré. Cette expérience montre que la polypectomie est une méthode efficace et sûre. Nos limites sont dues à une expertise insuffisante et à un plateau technique inadéquat.

Introduction: The relationship between the Helicobacter pylori (H. pylori) infection and gastroesophageal reflux disease (GERD) is complex. Some epidemiological studies have suggested a protective role of the H. pylori infection in the development of GERD and its eradication would lead to the increase in GERD frequency. This article assesses the prevalence of the H. pylori infection among patients with GERD without injury, erosive esophagitis or Barrett’s esophagus. Materials and methods: Between January and May 2015, 103 consecutive patients with daily or weekly GERD symptoms for at least one year were assessed at the Medical Center “la Cathédrale” of Yaoundé, Cameroon. All patients underwent anamnesis, physical examination, upper GI endoscopy with antral biopsies and rapid urease test HelicotecUT^® plus commercial kit (Strong Biotech Corp., Taipei, Taiwan). All statistical analyzes have used the software Epi-Info 3.5.1 and the SPSS version 16.0 (IBM, Chicago, USA). Results: The study included 43 men and 60 women with an average age of 46.5 ± 15.3 years (range: 14-79 years). The prevalence of the H. pylori infection was 39.8% (95% CI: 30.4 to 49.3). H. pylori was positive in 34.6% of patients with erosive esophagitis against 41.6% in patients with endoscopy-negative GERD (p=0.533). Among the 41 H. pylori positive patients, only nine (22.0%) had erosive esophagitis, all of Savary-Miller grade 1. Conclusion: The prevalence of the H. pylori infection is low among the Cameroonian patients with GERD. Severe damage to the esophageal mucosa is rare among H. pylori positive patients compared to H. pylori negative ones. However, our data do not enable us have proof in defining the relationship between the H. pylori infection and GERD in our H Pylori endemic context. Further studies are awaited.

Cases of splanchnic venous thrombosis have not been described in Cameroon. Their prevalence in acute pancreatitis is variable. With the emergence of acute intra-abdominal infections including typhoid fever and peritoneal tuberculosis in situations of acquired immunodeficiency syndrome, these cases will become frequent. We report the case of a portosplenomesenteric venous thrombosis related to necrotizing acute pancreatitis associated with proteins C and S deficiency, in a 46-year-old Cameroonian man, without particular past medical history. He was admitted for abdominal pain which had been evolving for 3 weeks and accompanied by vomiting. In the absence of hemorrhagic risk factor, the patient received low molecular weight heparin followed by oral warfarin. The abdominal ultrasound check on the 12th day showed a partial recanalization of venous thrombosis. The abdominal contrast-enhanced CT scanner at day 30 on oral anticoagulation therapy showed collateral vessels and small bowel edema. At the same time the upper gastrointestinal endoscopy showed grade II esophageal varices. We have maintained oral anticoagulation therapy. This case highlights that an early effective anticoagulation heparin therapy is needed for a clear benefit in case of suspected PSMVT. It is certain that the sooner the treatment is given, the better outcome will be. Cases of splanchnic venous thrombosis have not been described in Cameroon. Their prevalence in acute pancreatitis is variable. With the emergence of acute intra-abdominal infections including typhoid fever and peritoneal tuberculosis in situations of acquired immunodeficiency syndrome, these cases will become frequent. We report the case of a portosplenomesenteric venous thrombosis related to necrotizing acute pancreatitis associated with proteins C and S deficiency, in a 46-year-old Cameroonian man, without particular past medical history. He was admitted for abdominal pain which had been evolving for 3 weeks and accompanied by vomiting. In the absence of hemorrhagic risk factor, the patient received low molecular weight heparin followed by oral warfarin. The abdominal ultrasound check on the 12th day showed a partial recanalization of venous thrombosis. The abdominal contrast-enhanced CT scanner at day 30 on oral anticoagulation therapy showed collateral vessels and small bowel edema. At the same time the upper gastrointestinal endoscopy showed grade II esophageal varices. We have maintained oral anticoagulation therapy. This case highlights that an early effective anticoagulation heparin therapy is needed for a clear benefit in case of suspected PSMVT. It is certain that the sooner the treatment is given, the better outcome will be.

Les lésions de Cameron sont une entité rare et mal connue. Il s’agit d’érosions et des ulcères linéaires des plis de la muqueuse gastrique au niveau du collet des volumineuses hernies hiatales diaphragmatiques. Elles sont responsable à la fois d’anémies aiguës et de carences martiales sur des pertes occultes. Très rarement, elles sont la cause d’hémorragie gastro-intestinale aiguë sévère. Nous rapportons le cas d’un homme camerounais de 56 ans, alcoolotabagique avec une histoire de douleur épigastrique d’allure ulcéreuse et de prise d’anti-inflammatoires non stéroïdiens depuis une dizaine d’années et une hypertension artérielle, admis au centre hospitalier et universitaire de Yaoundé pour hématémèse et méléna ayant entraîné un état de choc hypovolémique. L’endoscopie digestive haute a montré deux larges ulcérations linéaires oesogastriques au sein d’une volumineuse hernie hiatale, non connue préalablement, associées à un ulcère duodénal. Les lésions ont été assimilées aux ulcères de Cameron. Le patient a bénéficié de mesures de réanimation, de la transfusion de sept unités de concentrés globulaires et des inhibiteurs de la pompe à protons en double dose. Après une récidive hémorragique au 5^e jour, on n’a plus noté de complication et le patient a été autorisé à quitter l’hôpital au 15^e jour. Le suivi pendant un mois est sans particularité. Cameron lesions are uncommon. They can be found as an incidental finding during esogastroduodenoscopy. Cameron lesions are linear gastric ulcers or erosions on the mucosal folds at the diaphragmatic impression found in 5.2% of patients with large hiatal hernias. They are clinically presented with chronic gastrointestinal bleeding and associated iron deficiency anemia. The rate of acute gastrointestinal bleeding is found to be variable. We are reporting the case of a 56-year-old Cameroonian male, whose past-medical history is relevant for hypertension, alcohol and tobacco abuse, and a ten year use of nonsteroidal anti-inflammatory drugs. He was admitted to the Yaounde Teaching Hospital for hypovolemic shock in the setting of hematemesis and melena associated with epigastric pain. The patient underwent esogastroduodenoscopy, which showed two Cameron ulcers in the hiatal hernia at the level of the diaphragmatic junction, and a duodenal ulcer. No active bleeding was found. The patient had a drop in hemoglobin level, which required blood transfusion. He was discharged on proton pump inhibitors. After one episode of rebleeding on the 5^th day, we no longer noticed any complications and the patient was allowed to leave the hospital on the 15th day. The follow-up at one month was unremarkable.

Posttraumatic pseudoaneurysm associated with arteriovenous fistula of the upper or lower limb is exceptional. We are reporting herein the history of two cases in civil life that have been followed and repaired in our service. Both patients were shot more than a year before being referred to our tertiary hospital for an enlarging mass which was a pseudoaneurysm associated with an arteriovenous fistula. The aneurysm was repaired and the fistula closed. Due to the absence of well-trained professionals, vascular injuries and their complications are usually discovered late in Cameroon while these pseudoaneurysms can reach very dramatic sizes. This presentation intends to raise the attention on a careful clinical exam and search of vascular lesion in the case of penetrating wound of the limb associated with profuse bleeding.

INTRODUCTION: the study aimed at determining the different types of precancerous conditions of the stomach and searches the frequency of Helicobacter pylori in these lesions in patients with chronic antral gastritis in Yaounde, Cameroon. METHODS: five gastric biopsies were performed during upper gastrointestinal endoscopy for pathology and fixed in formol 10% before being coated in paraffin. Both the modified Giemsa and Periodic acid of Shift ? Alkaline blue stains were used for the histological diagnosis of Helicobacter pylori infection. Hematoxylyn and eosin stain was used to determine the activity of gastritis, atrophic gastritis and intestinal metaplasia in accordance to the Sydney?s classification of gastritis. Data were analysed using both the Epi info 6.04 and Excel 2007 softwares. Means and their standard deviations, medians and their interquartiles (IQR) were calculated. Proportions were established for qualitative variables and chi square analysis done in this study with a p value set at 0.05. RESULTS: seventy-nine patients with chronic antral gastritis were enrolled, of which 43 (54.4%) were male, median age: 43 years (range from 21 to 70 years). The rate of atrophic gastritis was 74.7% (59/79). The activity of atrophic gastritis was mild in 47.5% (28/59) of cases, moderate in 47.5% (28/59) and severe in 5% (5/59). Intestinal metaplasia and follicular gastritis were present in 6.3% (5/79), and 10.1% (8/79), respectively. Concerning Helicobacter pylori infection, 71.2% (42/59) of patients with atrophic gastritis tested positive against 28.8% (17/59) who tested negative (p = 0.00003). Helicobacter pylori infection was related to the severity of gastric atrophy (p = 0.0001). Among patients with intestinal metaplasia and follicular gastritis, the proportion of those who tested positive for Helicobacter pylori infection was 80% (4/5), and 75% (6/8), respectively. There were no significant differences in the occurrence of atrophic gastritis according to age groups (p = 0.908). CONCLUSION: this study concludes that atrophic gastritis, which is most often caused by Helicobacter pylori, is the most frequent precancerous condition of stomach in Cameroon. Routine gastric sampling for pathologic analysis is mandatory for effective diagnosis and surveillance of Helicobacter pylori infection and precancerous conditions of the stomach.