Impact of direct-acting antiviral on subclinical atherosclerosis in chronic hepatitis C infected patients.

INTRODUCTION: The impact of direct antiviral drugs (DAAs) on extrahepatic manifestations in chronic hepatitis C (CHC) has been poorly studied. AIM: To assess the prevalence of subclinical atherosclerosis in patients with CHC and the impact of DAAs on atherosclerotic lesions. Methods A 5-year prospective evaluative study, including patients followed for CHC at hepato-gastroenterology department. The subclinical atherosclerosis was assessed by ultrasound measurement of carotid intima-media thickness (IMTc) and the highest IMTc measurements from the left and right side defined the IMTc maximum (IMTc max). IMTc>75th percentile (IMTc75) define subclinical atherosclerosis with high cardiovascular risk. Patients were evaluated before (T0) and one year after DAAs therapy achievement (T1). RESULTS: At time T0, forty patients (median age: 55 y.; sex ratio M / F = 0.48), were included. Average value of IMTc max was 0.68 ± 0.16 mm. Subclinical atherosclerosis was noted in 82.5 %. At time T1, 28 patients were evaluated, all of whom completed sustained virological response (SVR). Compared to time T0, there was a significant increase in cholesterol (p = 0.001) and triglyceride (p = 0.009) levels. IMTc max was significantly higher at time T1 compared to T0 (0.75 Vs 0.67 mm, p = 0.04). Prevalence of IMTc75 was 82.1% at time T0 and 75% at time T1 (p=0.5). CONCLUSIONS: SVR, in CHC patients treated with DAA, was associated with worsening of carotid atherosclerotic lesions.

Performance of GPR score for non-invasive assessment of liver fibrosis in chronic hepatitis B Tunisian patients.

INTRODUCTION: Several non-invasive tests (NIT) have been reported for predicting liver fibrosis to avoid percutaneous liver biopsy (PLB). AIM: To evaluate the performance of NIT in Tunisian patients with chronic hepatitis B (CHB). METHODS: We calculated the ASAT/platelet ratio index (APRI), GGT-to-platelet ratio (GPR), Fibrosis-4 score (FIB-4), and RDW/platelet ratio (RPR). The accuracy of NIT was compared with the Metavir score for the detection of liver fibrosis stage using the area under the ROC curves (AUROC). RESULTS: Seventy-seven CHB patients were included. For predicting significant fibrosis, the AUROC of GPR (0.81; CI95% [0.68-0.93]; P < 0.001) was significantly higher than that of RPR (0.67; CI95% [0.52-0.82]; P = 0.03) and FIB-4 (0.746; CI95% [0.61-0.88]; P = 0.002), but was similar to APRI (0.88; CI95% [0.79-0.97]; P < 0.001). For advanced fibrosis, the AUROC of GPR (0.93; CI95% [0.84-1]; P < 0.001) was higher than that of RPR (0.83; CI95% [0.69-0.97]; P < 0.001) and FIB-4 (0.88; CI95% [0.76-0.99]; P < 0.001), but similar to APRI (0.93; CI95% [0.87-0.99]; P < 0.001). For predicting cirrhosis, the AUROC of GPR (0.98; CI95% [0.95-1]; P < 0.001) was higher than that of APRI (0.95; CI95% [0.90-1]; P = 0.02), similar to RPR (0.99; CI95% [0.98-1]; P < 0.001) but lower than that of FIB-4 (1; CI95% [1-1]; P < 0.001). In multivariate analysis, APRI (OR = 3.78; P = 0.002) and FIB-4 (OR = 2.65; P = 0.01) were independent predictors of significant fibrosis. GPR was the only independent predictor of advanced fibrosis (OR = 4.64; P = 0.001) and FIB-4 was the independent predictor of cirrhosis (OR = 2.85; P < 0.001). CONCLUSION: GPR does not demonstrate significant advantages over APRI, FIB-4, and RPR in identifying liver fibrosis in patients with chronic hepatitis B (CHB).

Thyroid storm-induced acute liver dysfunction and portal hypertension in a patient with Graves' disease: a case report.

Thyroid storm is a life-threatening condition associated with multiorgan dysfunction and decompensation. We report the case of a 41-year-old woman having Graves' disease presented with thyroid storm complicated with liver dysfunction and portal hypertension in the absence of congestive heart failure or known liver disease. After successful therapeutic management, all biological, clinical and morphological abnormalities regressed.

Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones. We report the case of a 41-year-old woman with Graves' disease who presented with reversible liver dysfunction and high blood pressure in the portal vein (located in the abdomen) following the withdrawal of her treatment.

Air embolism complicating endoscopic retrograde cholangiopancreatography.

Aim: Venous air embolism is a rare but potentially life threatening complication of endoscopic retrograde cholangiopancreatography. Diagnosis is difficult because of the lack of specific signs or symptoms. Case: A 62-year-old man underwent endoscopic retrograde cholangiopancreatography for choledocholithiasis. A cardiovascular collapse occurred during the procedure. The echocardiography showed air within the right ventricle. Aspiration of air from the right ventricle was done and saved the patient's life. Conclusion: We highlight through this case that increased awareness is essential for prompt recognition of the air embolism to allow life-saving therapy.

Endoscopic treatment is the first-line treatment for biliary stones. It may be associated with various complications. We report the case of a 62-year-old patient who underwent endoscopic treatment for biliary stone. During the procedure, he experienced disturbed cardiac function due to the passage of air bubbles into the cardiac cavities. The bubbles were aspirated with a good outcome.

Liver biopsy revealing anti-neutrophil cytoplasmic antibody-associated vasculitis: a tale for a challenging diagnosis.

A 62-year-old woman presented with a chronic fever and fatigue. Biological investigations showed leukocytosis and elevation of acute phase markers. Liver blood tests showed deterioration with both cholestatic and hepatocellular patterns (there were, respectively, elevations in serum alkaline phosphatase levels as well as in serum alanine and aspartate aminotransferases). Viral serologies were negative. Mycobacterial infection and endocarditis were excluded. Results from blood cultures were negative. Autoantibody tests including ANCA (anti-neutrophil cytoplasmic antibody), anti-nuclear, anti-smooth muscle and anti-mitochondria were all negative. A liver biopsy revealed epithelioid granulomatous necrotizing vasculitis. Subsequently, immunological testing was repeated revealing MPO-ANCA (myeloperoxidase-ANCA). A diagnosis of ANCA-associated vasculitis with liver involvement was then made. The patient was started on steroids and her clinical state gradually improved.

A 62-year-old woman presented to the internal medicine department of our university hospital with chronic unresolved fever and an increase in liver function tests. Liver biopsy was performed. Microscopic examination revealed epithelioid granulomatous necrotizing vasculitis. Immunological testing revealed a perinuclear anti-neutrophil cytoplasmic antibody (ANCA) staining pattern with the presence of MPO-ANCA (Myeloperoxidase-ANCA). A diagnosis of ANCA-associated vasculitis with liver involvement was then made. The patient was started on steroids and her clinical state gradually improved.

Risk of metabolic syndrome in patients with chronic hepatitis C.

INTRODUCTION: Chronic hepatitis C is associated with several metabolic abnormalities including diabetes and insulin resistance. Metabolic syndrome, a major cardiovascular risk factor, may represent an additional risk of morbidity and mortality in patients with viral hepatitis C. AIM: To assess the risk of metabolic syndrome in patients with chronic hepatitis C and its impact on liver fibrosis. METHODS: Retrospective cohort study, including a group of exposed patients with untreated chronic hepatitis C and a group of unexposed patients with negative hepatitis C serology. We compared the prevalence of metabolic syndrome between the two groups and evaluated the association between metabolic syndrome and advanced fibrosis in the exposed patients. RESULTS: Forty exposed and 40 unexposed were included. The two groups were matched for age, sex and anthropometric data. Fibrosis was significant in 67.5% of the exposed group. The exposed group had a significantly higher prevalence of metabolic syndrome and insulin resistance compared to the unexposed group (37.5% VS 15%; p=0.02 VS 67.5% , 37.5%; p=0.02 VS 67.5%, 37.5%; p=0.007, respectively). The relative risk of metabolic syndrome in the exposed group was 2.5. Metabolic syndrome was not associated with significant fibrosis (p=0.7).

Performance of the ADRESS-HCC score in the assessment of the risk of hepatocellular carcinoma in viral cirrhosis in Tunisia.

INTRODUCTION: The ADRESS-HCC score allows predicting the risk of occurrence of Hepatocellular carcinoma in cirrhosis at one year of follow-up. AIM: Measuring the performance of ADRESS-HCC in predicting the risk of degeneration on post-viral cirrhosis, in a gastroenterology department in Tunisia. METHODS: Retrospective study, including patients followed for compensated viral cirrhosis in the gastroenterology department of the Mohamed Taher Maamouri hospital. The ADRESS-HCC score was calculated at diagnosis of cirrhosis. We divided patients into two groups depending on whether they developed Hepatocellular carcinoma or not. We evaluated the performance of the ADRESS-HCC score in predicting the risk of Hepatocellular carcinoma according to a threshold value. RESULTS: We enrolled 60 patients; the mean age was 62 years. Twenty-five patients developed hepatocellular carcinoma during follow-up. The mean value of ADRESS-HCC score was 5.08. To predict the occurrence of hepatocellular carcinoma at 1 year of follow-up, the area under the curve of the ADRESS-HCC score was 0.74 (p=0.01). For a threshold value of 5.63 its sensitivity was 91 % with a negative predictive value of 95.83%. CONCLUSION: The ADRESS-HCC score had an average performance in predicting degeneration in post-viral cirrhosis.

A rare case of gastric metastasis originating from primary lung adenocarcinoma: a case report.

Unlike liver and lung, the stomach is rarely a metastatic location for cancers. We report a case of a 62-year-old man known to have lung adenocarcinoma poorly differentiated presented with melena 1 month after diagnosis. Upper endoscopy revealed an ulcerated tumor in the prepyloric antrum. The diagnosis of gastric metastasis from pulmonary cancer was confirmed by the immunohistochemical staining for the thyroid transcriptional factor-1 and the pattern cytokeratine CK7+/CK20-. In conclusion, gastric metastasis from primary lung cancer is a rare phenomenon that every clinician must keep in mind.

A 62-year-old man known to have lung adenocarcinoma poorly differentiated presented with melena 1 month after diagnosis. Upper endoscopy revealed an ulcerated tumor in the prepyloric antrum. The diagnosis of gastric metastasis from pulmonary cancer was confirmed by histology.

A rare cause of spontaneous hemoperitoneum: intra-abdominal vein rupture.

Aim: Ruptures of the intra-abdominal vein causing a spontaneous hemoperitoneum in cirrhotic patients is a rare condition. However, diagnosis must be considered early in cirrhotic patients with hematic ascites as a delayed diagnosis with hemodynamic instability is associated with a poor prognosis. Case report: We present the case of a 54-year-old cirrhotic patient who presented a spontaneous hemoperitoneum due to the rupture of the intra-abdominal vein that was diagnosed during exploratory laparoscopy. Conclusion: Early diagnosis and management of spontaneous hemoperitoneum due to the rupture of intra-abdominal vein helps improve its prognosis.

Spontaneous hemoperitoneum is a rare but catastrophic condition caused by the rupture of the liver, spleen or abdominal vessels. In patients with cirrhosis, diagnosis of spotaneous hemoperitoneum is difficult. This is a case report of a 54-year-old cirrhotic man with a spontaneous hemoperitoneum due to the rupture of a vein within the abdomen. The diagnosis was suspected as the patient had signs of blood in the abdomen. To confirm spontaneous hemoperitoneum, the doctors performed a procedure called exploratory laparoscopy, which involves inserting a small camera into the abdomen. The laparoscopy confirmed the presence of blood and thus the diagnosis of spontaneous hemoperitoneum.

Multifocal nodular lesions in fatty liver mimicking neoplastic disease: a case report.

Usually, fatty hepatic infiltration is diffuse and homogeneous. However, in some cases, it can be localized simulating benign or malignant tumors. We present a case of a 61-year-old female patient with family history of malignancy: sister with lung cancer, an other sister with colon cancer and a mother with breast cancer; who presented with multiple hepatic nodules at the ultrasonography images. CT scan and MRI were not sufficient to pose a certain diagnosis which was later confirmed by liver biopsy.

In some cases, fatty hepatic infiltration may simulate benign or malignant tumors. We present a case of a 61-year-old female patient with family history of malignancy who presented with multiple hepatic nodules at the ultrasonography images. CT scan and MRI were not sufficient to pose a certain diagnosis which was later confirmed by liver biopsy.

Synchronous primary gastric and renal tumors: a case report.

Synchronous multiple primary cancers of the stomach and kidney are very rare, only 45 cases of synchronous multiple primary cancers of the stomach and kidney had been reported in the literature up until 2020. Thus far, no particular risk factors have been identified. We present a case of synchronous multiple primary cancers of the stomach and kidney in a 67-year-old female presenting with a 3-month history of vomiting and abdominal pain. The diagnosis of gastric adenocarcinoma with signet ring cells was confirmed through upper endoscopy with biopsies, while CT-guided biopsies of the renal tumor confirmed the diagnosis of primary kidney neoplasm.

Having more than one cancer at the same time is known as multiple primary malignancies. Having cancers in both the stomach and kidney at the same time is even rarer, with only 45 cases reported in literature. The exact causes of such cancers occurring together are not yet known. We present a 67-year-old woman who was diagnosed with synchronous multiple primary cancers of the stomach and kidney. She presented with vomiting and abdominal pain. The diagnosis of gastric cancer was confirmed through upper endoscopy with biopsies, while biopsies of the renal tumor confirmed the diagnosis of primary kidney cancer.

Tunisian consensus on the management of Helicobacter Pylori infection.

Helicobacter pylori infection is the most common infectious disease worldwide. It is associated with duodenal and gastric ulcer disease and the risk of gastric neoplasia. The management of helicobacter pylori infection currently represents a real challenge for clinicians, given the ever-increasing rate of resistance of Helicobacter pyolori to various antibiotics. In this consensus document, we present recommendations adapted to the Tunisian context, including indications for the detection of helicobacter pylori infection, indications for the use of different diagnostic methods, and a therapeutic strategy for the management of Helicobacter pylori infection.

Esophageal hirudiniasis: an unusual cause of upper gastrointestinal bleeding.

Leeches are carnivorous, hermaphroditic, segmented worms mainly found in fresh water. The majority of leech attachments are external and short-lasting. Internal surfaces can be involved. Yet, esophageal attachment is very rare. We report a case of a 59-year-old female who presented with hematemesis, melena and chest pain. Upper gastrointestinal endoscopy revealed a round black foreign body in the mid-third of the esophagus identified as a leech. We carefully extracted the worm with a forceps applied to the middle of its body. The diagnosis of leech infestation should be kept in mind when exploring gastrointestinal bleeding in patients living in rural areas and those with poor living conditions.

[Predictors of hepatic encephalopathy in patients with severe acute liver injury]. / Facteurs prédictifs de l'encéphalopathie hépatique au cours de l'atteinte hépatique aiguë sévère.

Introduction: severe acute liver injury (SALI) formerly known as severe acute hepatitis is an acute inflammation of the liver with markers of liver injury (elevated transaminases) and signs of hepatocellular failure (jaundice and INR greater than 1.5) according to the latest definition of the European Association for the Study of the Liver (EASL). An important prognostic factor in SALI is the development of hepatic encephalopathy (HE) and thus its progression to acute liver failure (ALF), formerly known as acute severe hepatitis. The purpose of this study is to investigate factors predicting the development of hepatic encephalopathy during SALI. Methods: we conducted a retrospective study of patients treated for SALI between January 2000 and December 2019. We divided patients into two groups depending on whether hepatic encephalopathy occurred. We performed an analytical study comparing the two groups according to their epidemiological, biological and evolutionary data. Results: data from the medical records of fifty-nine patients were collected. A virus was the most frequent cause (63%). Hepatic encephalopathy occurred in 15 patients (25.4%). Factors predicting the development of HE in univariate analysis were a delay in consultation of more than 9 days, an INR level of more than 2.45, a bilirubin level of more than 230 µmol/l, creatinine greater than 60.5 µmol/l, urea greater than 5.5 mmol/l and MELD score greater than 26.5 (p=0.023, p=0.017, p=0.0001, p=0.049, p=0.0001, p=0.0001 respectively). Autoimmune hepatitis and an undetermined cause were associated with the development of HE (p=0,003 and p=0,044, respectively). In multivariate analysis, autoimmune aetiology and a urea level above 5.5 mmol/l were significantly associated with the occurrence of HE. No statistically significant differences were found between the two groups with regard to age, sex and diabetes. Conclusion: SALI is a rare disease, mainly due to a virus in our country. Predictive factors of HE are important for early identification of patients at risk of adverse outcomes.

Post-chemotherapy Gastric Obstruction in Diffuse Large B-Cell Lymphoma: Endoscopic Dilation Can Fix It!

Treatment of diffuse large B-cell lymphoma (DLBCL) is based on immunochemotherapy with overall good outcomes. Complications related to the treatment or the disease itself can occur during follow-up. We herein report a case of a 37-year-old male who was diagnosed with stage IV gastric DLBCL. Subsequently, he underwent R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone) chemotherapy. After six cycles of treatment, complete remission has been achieved. But afterwards, the patient presented with a symptomatic gastric obstruction related to a tight stenosis in the antro-fundic junction. Endoscopic dilation was performed and multiple macrobiopsies within the stenosis were taken. Pathological examination concluded to the fibrous character of the stricture. In cases of post-chemotherapy obstruction in gastric DLBCL, endoscopic treatment should be attempted carefully in patients with no evidence of active lymphoma. Diagnosis of fibrosis can avoid surgery and its morbidity.

Spleen metastases secondary to gastric neuroendocrine carcinoma: case report.

Neuroendocrine carcinoma (NEC) in the stomach represents a rare and rapidly growing type of gastric tumors. They are considered a distinct entity of neuroendocrine tumors characterized by an aggressive behavior and high metastases rate. On the other hand, spleen metastases of neuroendocrine tumors are extremely rare. We report the first case of spleen metastases of gastric neuroendocrine carcinoma. The patient was a 54-year-old male who presented with a 10-month history of epigastralgia. Upper gastro-intestinal endoscopy revealed a 5 cm ulcerative lesion located in the greater gastric curvature. Biopsies with immunohistochemical staining revealed gastric neuroendocrine carcinoma. Abdominal computed tomography showed thickening of the stomach with two large solid spleen lesions. Abdominal Magnetic Resonance Imaging and 18-fluorodexyglucose positron-emission tomography revealed peritoneal carcinosis and splenic metastases with splenic vein invasion. Clinicians should keep in mind that splenic metastases can arise from gastric neuroendocrine tumors (NETs).

Fatal invasive gastric mucormycosis: Two case reports.

Mucormycosis is a fungal infection affecting most commonly immunocompromised patients. Hereby, we report two cases: the first one is about a 61-year-old female with diabetes who presented with vomiting. The upper gastrointestinal endoscopy showed a budding grayish process which corresponded to an invasive mucormycosis in histology. As laboratory tests showed renal dysfunction, conventional amphotericin B was started at low doses since liposomal form was unavailable in Tunisia. Evolution was marked by a worsening of renal function leading to drug therapy withdrawal. Total gastrectomy was delayed because of a pulmonary embolism and was practiced 2 months later. The patient passed away 10 days after surgery. The second patient was a 59-year-old man who presented with vomiting and fast worsening of general state. At admission, he had a septic shock. Explorations revealed an invasive gastric mucormycosis. He died few days after admission. Thus, prompt diagnosis of mucormycosis and rapid initiation of treatment based on amphotericin B and surgical debridement is necessary to improve prognosis.

Osteopetrosis: a rare case of portal hypertension.

Osteopetrosis is a rare genetic bone disorder characterized by a defect in osteoclasts recruitment and function. Its manifestations are numerous and they mainly include skeletal and dental deformities, cranial nerve entrapment and infections. Over time, osteoclastic expansion invades bone marrow leaving little space for hematopoietic cells. As a result, extramedullary hematopoiesis takes place in the reticular system mainly in the spleen and liver. In these patients, portal hypertension can occur as a result of extramedullary hematopoiesis associated splenomegaly. We are reporting in this article a rare case of spontaneous bacterial peritonitis associated with portal hypertension in a patient with osteopetrosis.

Colonic tuberculosis: a case report.

Aim: Colonic tuberculosis is rare. It accounts for 2-3% of abdominal tuberculosis. Clinical, radiological and endoscopic features are nonspecific. The diagnosis must be considered in front of chronic abdominal pain, vesperal fever and weight loss with on colonoscopy the presence of nodules or ulcers. The diagnosis is made on pathological findings. Case report: We report a case of an 82-year-old female patient with the diagnosis of colonic tuberculosis. The diagnosis were suspected on clinical presentation: chronic abdominal pain, fever and weight loss. The colonoscopy showed a nodular aspect of the left and sigmoid colonic mucosa and the pathology examination of the multiple biopsy specimens showed an epithelioid and gigantocellular granulomas with caseous necrosis. Conclusion: In front of a nonspecific clinical and endoscopic aspects, multiples colonic biopsies are mandatory to rule out differential diagnosis and confirm colonic tuberculosis.

Clinical and radiological features of colonic tuberculosis are nonspecific. The diagnosis must be considered in case of abdominal chronic pain and general symptoms. The mainly differential diagnosis are colorectal cancer or Crohn's disease. We report a case of an 82-year-old female patient with the diagnosis of colonic tuberculosis.

Solitary gastric Peutz-Jeghers polyp: a case report.

Peutz-Jeghers syndrome is an inherited condition that is characterized by mucocutaneous pigmentation and hamartomatous polyposis in the gastrointestinal tract. It increases significantly the risk for developing of several cancers such as breast, colon, rectum, pancreas and stomach. Solitary Peutz-Jeghers polyp is defined as a unique hamartomatous polyp having the same histological features as Peutz-Jeghers syndrome polyps without associated intestinal polyposis, mucocutaneous pigmentation and family history of Peutz-Jeghers syndrome. Gastric solitary Peutz-Jeghers polyp is extremely rare. We found only 13 cases in the literature. We report a new case of solitary gastric Peutz-Jeghers polyp associated with a branch duct intraductal papillary mucinous neoplasm revealed by an acute pancreatitis. Computed tomography of the abdomen found a branch duct intraductal papillary mucinous neoplasm with a pedicled polypoid formation in the greater gastric curvature. Endoscopic resection was performed without complications. Histologic examination showed Peutz-Jeghers hamartomatous polyp. The risk of cancer remains unclear in this entity. Therefore, the follow-up of these patients is necessary because of the possible risk of malignancy.