Subjective parameters markedly limit the referral of transplantation candidates to liver transplant centres.

BACKGROUND & AIMS: Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End-stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step. METHODS: This observational study included consecutive inpatients with cirrhosis of whatever origin in a cohort constituted between 2003 and 2008, using medical records and structured questionnaires concerning patient characteristics and the opinions of hospital clinicians. Candidates for LT were defined in line with these opinions. RESULTS: Four hundred and thirty-three patients, mostly affected by alcoholic cirrhosis, were included, 21.0% of whom were considered to be candidates for LT. Factors independently associated with their candidature were: physician empathy [odds ratio (OR) = 10.8; 95% CI: 4.0-29.5], adherence to treatment (OR = 16.6; 95% CI: 3.7-75.2), geographical area (OR = 6.8; 95% CI: 2.2-21.3) and the patient's physiological age (OR = 2.3; 95% CI: 1.1-4.7). CONCLUSIONS: Several subjective markers restrict the referral of patients from local hospitals to liver transplant centres. Their advancement to this second step is thus markedly weakened by initial subjectivity. The development of objective guidelines for local hospital physicians to assist them with their initial decision-making on LT is now necessary.

Prevalence of hepatitis C infection and risk factors in hospitalized diabetic patients: results of a cross-sectional study.

OBJECTIVES: Although there may exist a nosocomial risk of hepatitis C virus (HCV) infection in patients with type 1 or type 2 diabetes, this risk has not been fully investigated thus far and its magnitude is unknown. The aim of this multicenter cross-sectional study was to evaluate the prevalence of, and risk factors for, hepatitis C infection in consecutive hospitalized patients with diabetes and to assess the nosocomial risk and magnitude of HCV infection in these patients. PATIENTS AND METHODS: Consecutive hospitalized patients with diabetes seen in 11 French hepatogastroenterology and diabetology departments were studied. The prevalence of anti-HCV antibodies was compared with that observed in healthy blood donors and individuals seen during routine medical checkup. Diabetic patients with anti-HCV antibodies were compared with patients without anti-HCV antibodies for assessment of risk factors. RESULTS: In total 1561 patients were studied. Independent risk factors for HCV infection were assessed through multivariate analysis. Thirty-three patients (2.11%) had anti-HCV antibodies and 21 (63.70%) had HCV identified risk factors. The prevalence of HCV infection was higher in patients with diabetes than in blood donors (0.08%) or healthy controls (0.20%) (P<0.001). Multivariate analysis identified four independent risk factors for HCV infection: blood transfusion before 1991 [odds ratio (OR)=2.88, P=0.033], intravenous drug use (OR=21.37, P=0.012), treatment in a hepatogastroenterology center (OR=4.17, P=0.002) and a high number (>2) of previous admissions since the onset of diabetes (OR=2.52, P=0.039). CONCLUSION: A nosocomial source of HCV infection in hospitalized diabetic patients is suggested by the increased risk of HCV infection associated with the number of hospitalizations. This may account for at least 36% of cases of HCV infection.

[Cardiovascular complications of alpha interferon]. / Complications cardiovasculaires de l'interféron-alpha.

Interferon-alpha is a biological response modifier with antiviral and tumoral effect that is used in the treatment of chronic viral hepatitis. Cardiovascular complications occurred in clinical trials of interferon. The most common presentations of cardio toxicity were cardiac arrhythmia, dilated cardiomyopathy, atrial extrasystole and symptoms of ischemic heart disease, including myocardial infarction and other effects less common and dangerous: low-level conduction impairment or reversible hypertension. The physiopathology of this cardiotoxicity remains unknown, but rigorous cardiological monitoring of all patients receiving this treatment seems necessary.

Cystic dystrophy of the duodenal wall associated with chronic alcoholic pancreatitis. Clinical features, diagnostic procedures and therapeutic management in a retrospective multicenter series of 23 patients.

AIM OF THE STUDY: The aim of this retrospective multicenter study was to collect data from patients with chronic alcoholic pancreatitis and cystic dystrophy of the duodenal wall in order to better understand the outcome after medical, endoscopic and/or surgical treatment. PATIENTS AND METHODS: The data from medical records of 23 patients consecutively seen in ten primary referral centers from January 1990 to July 2004 were studied. Clinical, biological, and endoscopic features as well as imaging findings were recorded. Response to treatment was noted. RESULTS: Twenty-three patients (20 men), aged 45 years (range: 30-66), with chronic alcohol intake, cystic dystrophy of the duodenal wall, and previously known (N=14) or simultaneously diagnosed (N=9) chronic pancreatitis were included. Symptoms most frequently encountered were abdominal pain (N=22) and weight loss (N=16). An abdominal ultrasound was available for 10 patients, abdominal computed tomography for 22, upper endoscopy for 18, and endoscopic ultrasonography for 22. Endoscopic ultrasonography enabled diagnosis of cystic dystrophy of the duodenal wall in 19/22 patients. Six patients were symptom-free after alcohol withdrawal. Seven patients received octreotide 200 to 400 microg per day, 5 of whom subsequently underwent surgery (71%). Fourteen patients out of 23 were operated on (61%), 11 of whom underwent pancreaticoduodenectomy and remained symptom-free for 47 months follow-up. Mean follow-up was 56 months (range: 2-78) for non surgical patients (39%) and 47 months (range: 12-108) for surgical patients (61%). CONCLUSION: Cystic dystrophy of the duodenal wall complicating chronic alcoholic pancreatitis may be the revealing sign of pancreatitis. Endoscopic ultrasongraphy is the most reliable imaging method for diagnosis. Pancreaticoduodenectomy is the most frequently employed definitive treatment.

[Endoscopic drainage of cystic dystrophy of the duodenal wall: report of three cases]. / Traitement endoscopique de la dystrophie kystique de la paroi duodénale. A propos de trois cas.

Optimal management of cystic dystrophy of a heterotopic duodenal pancreas or cystic dystrophy of the duodenal wall has not yet been established. Surgical treatment by pancreaticoduodenectomy or by-pass procedure is indicated in patients with the most serious symptoms. Endoscopic cystic drainage is an alternative to surgery. We report three cases of cystic dystrophy of the duodenal wall successfully treated by endoscopic drainage. Symptoms disappeared immediately in all cases. No complications were observed. In one case, a second drainage was necessary 15 months after the first one. The 3 patients were free of symptoms after 6, 36, and 44 months of follow-up, respectively. No recurrence was found with CT-scan. The long-term efficiency of the endoscopic procedure must to be evaluated.

[Acute tubular necrosis with acute renal failure during the first month of treatment with 5-amino-salicylate (Pentasa(R))]. / Insuffisance rénale aiguë par nécrose tubulaire aiguë au cours du premier mois de traitement par l'acide 5-amino-salicylique (Pentasa(R)).

We report a case of acute tubular necrosis in a patient with Crohn's disease treated by 5-amino-salicylate (Pentasa(R)) since one month. Normalization of renal biological parameters occurred rapidly after treatment withdrawal. This case raises the question of the optimal modalities of monitoring of renal function during treatment with 5-amino-salicylate.

[Pancreatic tuberculosis: a rare cause of pseudoneoplastic obstructive jaundice]. / Tuberculose pancréatique: une cause rare d'ictère pseudo-néoplasique par compression de la voie biliaire principale.

Isolated pancreatic tuberculosis is rare, and can mimic pancreatic carcinoma. We report a case of pseudoneoplastic pancreatic tuberculosis revealed by an obstructive jaundice in a 35-Year-old man. Surgical pancreatic histopathology showed a caseating granulomatous inflammation and diagnosis was confirmed by detection of Mycobacterium tuberculosis DNA using specific polymerase chain reaction-based assay (PCR). The patient was successfully treated with quadruple antituberculous therapy. In the context of the diagnostic work-up of a hypodense pancreatic mass, the diagnosis of tuberculosis relies on the presence of pancreatic caseating granulomas, that can be obtained by endosonography-guided biopsy, thus avoiding laparotomy.

[Alpha-fetoprotein-producing poorly differentiated gastric adenocarcinoma: hepatoid carcinoma?]. / Adénocarcinome gastrique peu différencié produisant de l'alfafoetoprotéine: tumeur hépatoïde?

We report the case of a 42-Year-old man with a poorly differentiated gastric cancer revealed by a very high level of serum alpha-fetoprotein-protein, associated with liver metastasis, and treated by chemotherapy. We discuss the possible diagnosis of hepatoid carcinoma.

Comment on the British Society of Gastroenterology guidelines for management of autoimmune hepatitis (part 1).

The British Society of Gastroenterology guidelines for management of autoimmune hepatitis were recently published in Gut. The chapters concerning epidemiology, presentation and diagnosis are addressed here.

Comment on ESGE clinical guideline for biliary stenting.

The European Society of Gastrointestinal Endoscopy (ESGE) guidelines for biliary stenting published in 2012 are summarised and discussed.

Comment on the British Society of Gastroenterology guidelines for management of autoimmune hepatitis (part 2).

The British Society of Gastroenterology guidelines for management of autoimmune hepatitis (AIH) were recently published in Gut. The chapters concerning the treatment of AIH are addressed here.