Changes of Crohn's disease phenotype over time.

Background - Crohn's disease is a clinically heterogeneous condition. Our aim was to identify the phenotype evolution of Crohn's disease over time according to the Montreal Classification and to precise predictive factors of the need for immunosuppressant treatment or surgery. Methods - We included Crohn's disease patients who were followed up for at least 5 years. We excluded patients who were lost to follow up before five. Patients were classified according to the Montreal classification for phenotype at diagnosis and five years later. The evolution of phenotype over time and the need for surgery, immunosuppressive or immunomodulatory drugs were evaluated. Results - One hundred twenty consecutive patients were recruited: 70 males and 50 females. At diagnosis, 68% of patients belong to A2 as determined by the Montreal classification. Disease was most often localized in the colon. The disease location in Crohn's disease remains relatively stable over time, with 93.4% of patients showing no change in disease location. Crohn's disease phenotype changed during follow up, with an increase in stricturing and penetrating phenotypes from 6% to 11% after 5 years. The only predictive factor of phenotype change was the small bowel involvement (OR=3.7 [1.2-7.6]). During follow-up, 82% of patients have presented a severe disease as attested by the use of immunosuppressive drugs or surgery. The factors associated with the disease severity were: small bowel involvement (L1), the stricturing (B2) and penetrating (B3) phenotypes and perineal lesions (OR=17.3 [8.4-19.7]; 12 [7.6-17.2]; 3[1.7-8.3] and 2.8 [2.2-5.1] respectively), without association with age, sex or smoking habits. Conclusion - Crohn's disease evolves over time: inflammatory diseases progress to more aggressive stricturing and penetrating phenotypes. The ileal location, the stricturing and penetrating forms and perineal lesions were predictive of surgery and immunosuppressant or immunomodulatory treatment.

Colorectal neoplasia in elderly versus young patients in Tunisia: analysis of colonoscopic findings.

BACKGROUND: Colorectal cancer occurs more frequently in older patients. Since the older population is increasing, a better understanding of the characteristics of colorectal neoplasm according to the age would be useful. AIM: To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. METHODS: Colonoscopy database from 2004 to 2008 was retrospectively analyzed. There were 1510 eligible patients who underwent colonoscopy with a mean age of 54 years. Patients were classified into two groups: the older age group (Group 1, aged ³ 60 years, n = 626) and the younger age group (Group 2, aged < 60 years, n = 884). Data were recorded on age, gender, colonoscopic indications, colonoscopic findings, and their related histological findings and tumor location. RESULTS: The risk of finding polyps and cancer at colonoscopy increases with age (29.4% in the older age group and 11% in the younger age group (p < 0.05). Left-sided lesions were noted to be more frequent in both age groups (66% and 67% respectively). CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly. However, both groups had the lesions predominately located in the left side.

Successful treatment of massive ascites due to lupus peritonitis with hydroxychloroquine in old- onset lupus erythematosus.

Systemic lupus erythematous (SLE) is an auto-immune disease with multiple organ involvements that occurs mainly in young women. Literature data suggest that serositis is more frequent in late-onset SLE. However, peritoneal serositis with massive ascites is an extremely rare manifestation. We report a case of old-onset lupus peritonitis treated successfully by Hydroxychloroquine. A 77-year-old Tunisian woman was hospitalized because of massive painful ascites. Her family history did not include any autoimmune disease. She was explored 4 years prior to admission for exudative pleuritis of the right lung without any established diagnosis. Physical examination showed only massive ascites. Laboratory investigations showed leucopenia: 3100/mm3, lymphopenia: 840/mm3 and trace protein (0.03 g/24 h). Ascitic fluid contained 170 cells mm(3) (67% lymphocytes), 46 g/L protein, but no malignant cells. The main etiologies of exudative ascites were excluded. She had markedly elevated anti-nuclear antibody (ANA) titer of 1/1600 and a significantly elevated titer of antibody to double-stranded DNA (83 IU/mL) with hypo-complementemia (C3 levl was at 67 mg/dL). Antibody against the Smith antigen was also positive. Relying on these findings, the patient was diagnosed with SLE and treated with Hydroxychloroquine 200 mg daily in combination with diuretics. One month later, there was no detectable ascitic fluid and no pleural effusions. Five months later she remained free from symptoms while continuing to take chloroquine. This case was characterized by old age of onset of SLE, the extremely rare initial presentation with lupus peritonitis and massive painful ascites with dramatic response to only hydroxychloroquine treatment.

Retroperitoneal abscess: a rare localization of tubercular infection.

Incidence of tuberculosis infection has considerably increased during the past 20 years due to the HIV pandemic and continues to be one of the most prevalent and deadly infections worldwide. Extrapulmonary tuberculosis lacks specific clinical manifestation and can mimic many diseases. It can invade neighbouring tissue and form a big cyst with manifesting clinical symptoms. We describe a rare case of 31-year-old immunocompetent man affected by a retroperitoneal abscess secondary to tubercular infection. Exploratory laparotomy and histopathological examinations of tissue were required for achieving diagnosis of tuberculosis. No pulmonary or spinal involvement was identified. The patient was successfully treated with standard four-drug antitubercular therapy.