Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

With the increasing use of antiplatelet agents (APA), their management during the periendoscopic period has become a more common and more difficult problem. The increase in use is due to the availability of new drugs and the widespread use of drug-eluting coronary stents. Acute coronary syndromes can occur when APA therapy is withheld for noncardiovascular interventions. Guidelines about APA management during the periendoscopic period are traditionally based on assessments of the procedure-related risk of bleeding and the risk of thrombosis if APA are stopped. New data allow better assessment of these risks, of the necessary duration of APA discontinuation before endoscopy, of the use of alternative procedures (mostly for endoscopic retrograde cholangiopancreatography [ERCP]), and of endoscopic methods that can be used to prevent bleeding (following colonic polypectomy). This guideline makes graded, evidence-based, recommendations for the management of APA for all currently performed endoscopic procedures. A short summary and two tables are included for quick reference.

[Place of laparoscopic radical cystectomy in the treatment of invasive bladder urothelial carcinoma]. / Place de la cystectomie radicale par voie laparoscopique dans le traitement des carcinomes urothéliaux infiltrants de vessie.

Radical cystectomy is the reference treatment for recurrent superficial or invasive bladder tumours. The most standardized incision is midline infra-umbilical laparotomy. The first laparoscopic cystectomy was performed in 1992 in a patient with neurogenic bladder and several teams have subsequently described this incision for the treatment of bladder tumours. The advantages of laparoscopy have been reported in terms of morbidity and earlier return to daily activities. The current oncological results of this incision are difficult to compare with those of conventional open surgery due to the insufficient follow-up. However, published series have not reported any significant difference in the intermediate term. Until convincing results become available, it therefore appears legitimate to allow teams skilled in laparoscopy to demonstrate the oncological efficacy of this approach. At the present time, the reference treatment for invasive bladder cancer remains open cystectomy.

Symptomatic duodenal stenosis in chronic pancreatitis: a study of 17 cases in a medical-surgical series of 306 patients.

The aim of this study was to assess the prevalence, presentation, cause, and location of symptomatic duodenal stenosis, and its relation to the natural course of chronic pancreatitis in a medical-surgical series of 306 patients (86% alcoholics). Mean follow-up of the series was 7.9 years. Symptomatic duodenal stenosis occurred in 17 patients (5.6%). Diagnosis was confirmed by a barium series. The cause of stenosis was compression by the pancreatic head in all patients, associated with a pancreatic abscess in two. No pseudocysts were found at the time of diagnosis. The location was the 1st and 2nd part of the duodenum or the entire duodenal loop in 4, 6, and 7 patients, respectively. Cholestasis due to common bile duct stenosis occurred in association with duodenal stenosis in 9 patients. Fifteen patients were treated surgically; 11 for gastroenterostomy, and 4 for duodenopancreatectomy. Two patients were not treated surgically. We conclude that during the course of chronic pancreatitis, symptomatic duodenal stenosis occurred in 5.6% of patients, mainly during the first years of the clinical course of chronic pancreatitis, was due to pancreatic head compression and not pseudocysts, usually involved the 2nd part of the duodenum and, was associated with biliary stenosis in half of the cases. Since these two complications require surgery, common bile duct stenosis should be investigated when symptomatic duodenal stenosis is diagnosed.

Unusual presentation of a tuberculous peritonitis in a patient with concomitant AIDS and liver cirrhosis.

We report a case of tuberculous peritonitis in a patient with concomitant HIV infection and liver cirrhosis. A 50-year-old man with viral B and delta liver cirrhosis and AIDS was diagnosed with spontaneous Escherichia coli peritonitis and successfully treated with beta-lactamins. Three months later, ascites reappeared and Mycobacterium tuberculosis was identified in peritoneal fluid cultures. The triple antituberculosis regimen was adjusted to his level of liver failure but the patient died of hepatic encephalopathy. Concomitant HIV infection and liver cirrhosis favour tuberculous peritonitis but they also make its diagnosis extremely difficult. Considering the poor prognosis of this infection when untreated, tuberculous peritonitis should be systematically suspected in such patients.

[Simultaneous study of duodenal and biliopancreatic bicarbonates in rats]. / Etude simultanée des bicarbonates duodénaux et bilio-pancréatiques chez le rat.

OBJECTIVES: The aim of the present study was to assess the relative contribution of duodenal and biliopancreatic bicarbonate secretion to acid neutralization in the duodenum, in basal conditions, during stimulation by PGE2 and during acid infusion in the duodenum. METHODS: Forty rats were anaesthetized and the duodenum was infused with 0.9% saline. Bicarbonate originating from duodenal mucosa and from biliopancreatic secretion was independently collected and measured. In neutralization studies, HCl was infused in the duodenum, and the amount of residual acid escaping from the duodenum was determined with and without bile and/or pancreatic juice diversion. RESULTS: Basal duodenal and biliopancreatic bicarbonate outputs were respectively 10.0 +/- 0.66 and 2.4 +/- 0.31 mumol/10 min. PGE2 increased duodenal mucosal bicarbonate by about 100%. Eighty-five percent of infused HCl was neutralized by duodenal mucosal bicarbonate. In neutralizing the remaining 15%, pancreatic secretion was slightly predominant, 46% for a HCl concentration of 5 mM and 71% for a HCl concentration of 40 mM. CONCLUSIONS: These results shows that in the anaesthetized rat, available bicarbonate in the duodenal lumen and HCl neutralization ability are mainly dependent upon bicarbonate secreted by the duodenal mucosa.

[Does chronic pancreatitis promote duodenal ulcer in men?]. / La pancréatite chronique de l'homme favorise-t-elle la survenue d'un ulcère duodénal?

The aims of this study were to assess the prevalence of duodenal ulcer during chronic pancreatitis and the relationship between the occurrence of duodenal ulcer and the course of chronic pancreatitis. The population consisted of 264 men with chronic pancreatitis, 94 percent of which were of alcoholic origin. Duodenal ulcer occurred in 37 patients (14 percent). Fifteen patients with gastric or anastomotic ulcer were excluded. The 37 patients with duodenal ulcer were compared with 212 patients without ulcer. There was no significant difference between the two groups as regards the course of chronic pancreatitis except for insulin-dependent diabetes mellitus which was significantly more frequent in patients without duodenal ulcer (P less than 0.05). Eight patients with duodenal ulcer died but the cause of death was not related to their ulcer. All patients with duodenal ulcer and 92 percent of those without were smokers (not significant). Duodenal ulcer occurred in 25/37 patients (68 percent) before the clinical onset of chronic pancreatitis. The risk of duodenal ulcer occurrence was constant in 17-65 year old patients and independent of the time of chronic pancreatitis onset. We concluded that in men with chronic pancreatitis: a) prevalence of duodenal ulcer is 14 percent; b) duodenal ulcer occurred most often before clinical onset of chronic pancreatitis; c) duodenal ulcer occurs independently of the course of pancreatitis which cannot account for its high prevalence. Smoking may be a promoting factor.

[Dysphagia with fever revealing mediastinal lymph node tuberculosis. Apropos of 2 cases]. / Dysphagie avec fièvre révélant une tuberculose ganglionnaire médiastinale. A propos de 2 cas.

The oesophagus is a rare localization of extrapulmonary tuberculosis. We report 2 cases of tuberculous mediastinal lymph nodes revealed by dysphagia and fever in immunocompetent subjects. With the actual outbreak of tuberculosis, this localization is worth mentioning, as the precocity of the diagnosis and the therapeutic handling is an important prognostic factor.

[Increase of alpha-fetoprotein in pancreatic endocrine tumors with hepatic metastases. Apropos of 2 cases]. / Elévation de l'alpha-foetoprotéine au cours des tumeurs endocrines pancréatiques avec métastases hépatiques. Présentation de deux cas.

We report two cases of metastatic non-functioning pancreatic endocrine tumour with very elevated plasma levels of alpha-fetoprotein. In these two cases, serial plasma levels of alpha-fetoprotein, initially normal, correlated well with hepatic tumour progression and were associated with fatal outcome. These results suggest that elevated plasma concentration of alpha-fetoprotein may be caused by metastatic pancreatic endocrine tumour and than alpha-fetoprotein serial measurement may be useful in prognostic evaluation.

[Non-gastroduodenal digestive toxicity of non-steroidal anti-inflammatory agents]. / Toxicité digestive non gastro-duodénale des anti-inflammatoires non stéroïdiens.

Recent data have confirmed that non-steroidal anti-inflammatory drugs can cause serious damage to the gastrointestinal tract involving localizations other than the well-known gastroduodenal complications. Perforation and hemorrhage of the small bowel have been reported as well as ulcerations, stenoses and diaphragm disease. The same type of lesions can occur in the large bowel in addition to ischemia and collagen colitis. Diverticular diseases of the colon can be complicated by use of non-steroidal anti-inflammatory drugs which may also trigger flare-ups of inflammatory diseases. Use in suppository form can complicate rectitis and rectal stenosis. Non-steroidal anti-inflammatory drugs apparently increase intestinal permeability by inhibiting the cyto-protective effect of prostaglandins. The exact frequency of such complications remains to be determined, but prolonged treatment in elderly subjects appears to increase risk. Current data have not shown greater or lesser toxicity for any specific drug. Non-steroidal anti-inflammatory drugs should be entertained as the cause of intestinal disorders in patients under long-term treatment.

[Natural history of duodenal ulcer]. / Histoire naturelle de l'ulcère duodénal.

The authors have studied the natural history of duodenal ulcer from published data, in an attempt to determine precisely the evolutive potential of this disease both spontaneously and during its treatment. They deal successively with the risk of complication and the short- or long-term influence of medical and surgical treatment on the occurrence of exacerbations and complications. The role played by Helicobacter pylori in healing of the ulcer and in the long-term course of the ulcerous disease, as well as the problems concerning its duration and mortality, are discussed. The data clearly show that the medical and surgical treatment of duodenal ulcer can slow down, at least temporarily, the course of the disease. Other studies are needed before drawing firm conclusions concerning the relationship between H. pylori and duodenal ulcer, even though numerous studies seem to have demonstrated that eradication of this micro-organism is associated with a substantial decrease in the risk of recurrent ulcer.

[Pseudocysts of the pancreas. Diagnosis, course and principles of treatment]. / Pseudo-kystes du pancréas. Diagnostic, évolution et principes de traitement.

Pseudocysts of the pancreas are collections of liquid more or less completely composed of pancreatic secretions. Patients with acute pancreatitis without underlying chronic pancreatitis may develop necrotic pseudocysts while those with chronic pancreatitis may develop either necrotic or retention pseudocysts. The prevalence and localization are largely dictated by the cause of the pancreatitis. Ultrasonography and computed tomography give the diagnosis and reveal the size, localization and relations of the pseudocyst. Some pseudocysts may regress spontaneously, usually within a few weeks, especially necrotic pseudocysts measuring less than 6 cm. In others, complications include acute infection, intracystic bleeding, rupture, fistulization and compression of neighboring organs. Surgery was classically proposed for all pseudocysts, but puncture-evacuation and percutaneous or endoscopic drainage have also been successful. The risk of recurrence is higher with puncture-evacuation. Today, complicated forms and unsuccessful medical treatment are good indications for surgery. Cystodigestive drainage is preferred although exeresis may be required in specific cases.

[Electrolyte abnormalities in elderly people. Prevalence and relation to drug treatment. Multicenter study of 631 subjects aged 70 years and over]. / Anomalies électrolytiques chez les personnes âgées. Prévalence et relation avec le traitement médicamenteux. Etude multicentrique chez 631 sujets de 70 ans et plus.

In order to assess the responsibility of medicinal drugs for the disorders in electrolytes observed in elderly people, the prevalence of abnormal natraemia and kalaemia was prospectively established in 631 subjects aged 70 or more on the first day of hospitalization. Among 337 subjects not taking drugs likely to create problems (diuretics, angiotensin-converting enzyme inhibitors, anti-inflammatory agents) 3.6 percent had hyponatraemia (below 130 mmol/l) and 12.2 percent had hypokalaemia (below 3.5 mmol/l). Subjects with normal renal function who were taking angiotensin-converting enzyme inhibitors or non-steroidal anti-inflammatory agents showed no more electrolytic abnormalities than those who did not take them. Conversely, subjects on thiazides were more frequently hyponatraemic (11.8 percent) or hypokalaemic (16.2 percent; 20 percent in the absence of associated distal diuretics). These abnormalities were more frequent in women than in men (21.7 and 13 percent). This, together with the fact that 68 percent of subjects taking thiazides were women accounts for the marked female predominance of electrolytic abnormalities reported in the literature.