Diagnosis of liver fibrosis by transient elastography (FibroScan) and non-invasive methods in Crohn's disease patients treated with methotrexate.

BACKGROUND: Methotrexate is an effective treatment in Crohn's disease, which may induce liver fibrosis with high cumulative doses. Transient elastography (FibroScan, Echosens, Paris, France) is a new non-invasive rapid, allowing assessment of liver fibrosis by measurement of liver stiffness. AIM: A prospective study to evaluate liver fibrosis with FibroScan and non-invasive biochemical methods in Crohn's disease patients treated with methotrexate. METHODS: Consecutive Crohn's disease patients had evaluation of liver fibrosis with non-invasive methods. Two subgroups of patients were compared: cumulative dose of methotrexate of more than 1500 mg (group 1) and naive for methotrexate (group 2). Liver biopsy was performed in patients with persistent liver enzyme abnormalities or FibroScan value >8.7 kPa. RESULTS: Fifty-four consecutive Crohn's disease patients were fully investigated (45 females, mean age 41 +/- 14 years). Median FibroScan values were similar in group 1 (n = 21) and in group 2 (n = 33), 5.5 and 4.5 kPa, respectively. FibroScan values were not correlated with the cumulative dose of methotrexate. CONCLUSION: In Crohn's disease patients treated with a high dose of methotrexate, significant liver fibrosis is rare and not accurately detected with liver enzymes abnormalities. FibroScan could be recommended and liver biopsy could be performed only with patients with high values and/or with chronic liver enzymes abnormalities.

Successful treatment with infliximab and methotrexate of pyostomatitis vegetans associated with Crohn's disease.

A 35-year-old woman with severe fistulizing Crohn's disease presented with pyostomatitis vegetans affecting both the mouth and the vulva. The coalescing pustules transformed within several days into vegetating lesions on areas of inflammation. Microbial assessments revealed no pathogenic agent. Histology showed neutrophilic microabscesses, but no granulomas. Three injections of infliximab and maintenance therapy with methotrexate resulted in rapid and complete regression of both the pyostomatitis vegetans and the Crohn's disease. Infliximab and methotrexate may be a promising treatment for the rare cases of pyostomatitis vegetans associated with Crohn's disease.

Hepatic porphyrin concentration and uroporphyrinogen decarboxylase activity in hepatitis C virus infection.

Previous studies have shown a high prevalence of hepatitis C virus (HCV) infection in patients with porphyria cutanea tarda (PCT). The aim of this study was to assess hepatic porphyrin concentrations (HPC) and hepatic uroporphyrinogen decarboxylase (UROD) activity in HCV-infected patients free of PCT. Thirty-two HCV-infected patients (20 M, 12 F, mean age 51 years) and seven control patients (4 M, 3 F, mean age 59 years) free of liver disease, were studied. Knodell's score was determined on liver biopsy by two independent anatomopathologists. Measurement of HPC and hepatic UROD activity levels were carried out on liver biopsy. Relative to controls, HCV-infected patients had high HPC levels (mean +/- SD: 47 +/- 20 vs. 17 +/- 6 pmol/mg protein, P < 0.001) and low hepatic UROD activity levels (514 +/- 95 vs. 619 +/- 125 pmol Copro/h/mg protein, P < 0.05). HPC was not correlated with hepatic UROD activity and the increase was due to coproporphyrin accumulation. No correlation was observed between HPC or hepatic UROD activity values and HCV-RNA concentrations, Knodell's score, hepatic fibrosis, periportal necrosis, periportal inflammation or hepatic iron content in HCV-infected patients. Hepatocellular necrosis was significantly correlated with HPC value (P < 0.005). Hence, in HCV-infected patients, HPC is significantly increased and hepatic UROD activity is very slightly decreased as compared to controls. HPC values and UROD activity are not correlated with HCV-RNA concentrations, hepatic iron content and hepatic fibrosis. The small increase in HPC values in hepatitis C infection is linked with hepatic injury and not with a direct effect on hepatic UROD enzyme.

Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas.

OBJECTIVE: To compare incidence rates and epidemiological characteristics of acute upper gastrointestinal haemorrhage (AUGIH) in France with those of other European studies. DESIGN: Population-based multi-centre prospective survey. SETTING: 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. SUBJECTS: A total of 2133 AUGIH patients 18 years and over were included in the six-month study. OUTCOME MEASURES: Incidence and mortality. RESULTS: The overall incidence in France was 143 cases per 100000 persons per year, classified as out-patients (16%), emergency admissions (59%) and in-patients (25%). The incidence rates increased with age except for in-patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, antiinflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out-patients excluded) was 14.3% (10.7% for emergency patients and 23% for in-patients). Mortality was associated with comorbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non-steroid anti-inflammatory drugs, and higher in in-patients using corticosteroids. CONCLUSIONS: In France, patients with AUGIH are frequently managed as out-patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in-patients.

[Management of upper digestive hemorrhage occurring in the community: patterns of patient care in 4 French administrative areas]. / Prise en charge des hémorragies digestives hautes communautaires. Trajectoires des malades dans 4 départements français.

AIMS: To describe patterns of health care management in patients with upper gastrointestinal hemorrhage and to identify factors linked to the different patterns. PATIENTS AND METHODS: We conducted a prospective study of patients over 18 with upper gastrointestinal hemorrhage (inpatients excluded) among all public hospitals and private practice gastroenterologists in 4 French administrative areas (3 in Northern France and one in the South West). RESULTS: One thousand six hundred and two patients were included over a six-month period (1996). An endoscopic procedure was performed in 1532 patients in public (70%) or private (20.5%) hospitals, or at private office (9.5%). Hospitalization was necessary in 78.8% of the patients in university, non university public or private hospitals (38.9, 45.5 and 15.6%, respectively) with a median duration of 6.5 days. Admission was associated to old age, short delay between hemorrhage and endoscopic procedure, previous gastrointestinal bleeding, cirrhosis or cancer, bleeding from peptic ulcer or esogastric varices. Endoscopic hemostasis was performed in 21.4% of the patients, more often in university and no university public hospitals. Surgery was necessary in 4% of the patients. Death rate was 10.7%. Important geographical variations were observed concerning referral patterns. Patients' characteristics did not differ between the 4 areas. On the other hand, health care supply provided in the management of upper gastrointestinal hemorrhage was different in the four French geographical areas. CONCLUSION: a) An initial endoscopic procedure is nearly always performed in patients with an upper gastrointestinal hemorrhage in France; in 1 patient out of 10, endoscopy was performed in a private gastroenterologist office; b) hospital admission was strongly related to epidemiological and clinical criteria of severity; c) the geographical variations observed in referral patterns depend in part on health care supply; d) upper gastrointestinal haemorrhage status could be used as an indicator of the quality of health care organizations.

[Hemorrhaging eso-gastro-duodenal ulcers: epidemiology and management. A multicenter prospective study]. / Les ulcères oeso-gastro-duodénaux hémorragiques: épidémiologie et prise en charge. Etude prospective multicentrique.

UNLABELLED: The aim of this study was to estimate the incidence, and to describe the characteristics and medical care in patients with bleeding upper gastrointestinal ulcers in the general population. PATIENTS AND METHODS: A study was performed over six months in 1996 in 4 French geographical areas: Finistère, Gironde, Seine-Maritime, and the Somme (3 million people minimum 18 years). All public or private hospitals, and specialist gastroenterologists in private practice participated in the study, based on a standardized questionnaire. RESULTS: Over 6 months 793 patients with bleeding ulcers were identified, corresponding to 27 per 100,000 inh./year or 24,000 cases in France. Most patients were men (60%) and 40.1% were 75 years and older. The ulcer was oesophageal (6%), gastric (47%), or duodenal (69%). In 406 patients (51.2%) a chronic disease was present (cancer, cirrhosis, circulatory, respiratory or cardiac disease). In 237 cases (29.9%) the ulcer occurred in patients, 453 patients (57.1%) were admitted and 103 patients (13%) were managed as outpatients. Gastrotoxic drugs were taken by 349 patients (44%): non steroidal anti-inflammatory drugs (18.7%), aspirin (21.2%, including 2/3 with doses under 330 mg/day), corticosteroids (7.8%) and 24.3% had anticoagulant therapy. Patients were managed in university hospitals (39.3%), other public or non profit hospitals (44.2%) or private hospital (16.5%) with geographical differences between the 4 areas. Therapeutic endoscopy was performed in 16.9% and a surgical procedure was performed in 5.9%. The mortality rate (outpatients excluded) was 13.5% (n = 93), but only 2% (n = 16) of death were associated with a bleeding ulcer: mortality was higher in inpatients (24.1%) than in out patients (8.1%). A chronic disease was also associated with higher mortality (17.9% versus 8.1%). CONCLUSION: Bleeding ulcers are frequent and severe, especially in inpatients or associated with chronic conditions. A gastrotoxic drug used is found in about fifty percent of the cases.

Tolerance, effectiveness, and acceptability of sulfate-free electrolyte lavage solution for colon cleaning before colonoscopy.

BACKGROUND AND STUDY AIMS: The unpleasant taste of the solution used for preparation before colonoscopy may limit patients' compliance with the procedure. However, the published results concerning the acceptability of sulfate-free electrolyte lavage solution (SF-ELS) for colon cleansing before colonoscopy are conflicting. The aim of this study was to compare SF-ELS with the standard polyethylene glycol (PEG) solution with regard to tolerance, effectiveness, and acceptability. PATIENTS AND METHODS: In the first part of the study, 24 patients were assigned to receive either one liter of SF-ELS or one liter of the standard PEG solution. After two hours, the patients had to choose two further liters (of either the first or second solution), and preparation for colonoscopy was completed. In the second part, fifty further patients were randomized into two groups: 25 patients received four liters of standard solution, and 25 patients received four liters of SF-ELS. The patients' opinions regarding the preparation and their willingness to repeat the use of the same preparation were recorded by questionnaire. The quality of the colon preparation was assessed by the endoscopists. RESULTS: Seventeen patients (71%; P < 0.05) preferred SF-ELS. The compliance rate in the two groups was 96%, and the frequency of occurrence of adverse effects was also similar. Colonoscopy was completed in 24 of the 25 patients in the SF-ELS group and 22 of the 25 patients in the standard PEG group (the difference was not significant). Visualization of the mucosa in the areas explored was perfect in 20 of the 25 patients in the SF-ELS group and in 17 of the 25 patients in the PEG group (not significant). Patients had a significant preference for SF-ELS. Eighteen of the 25 patients in the SF-ELS group were willing to accept the same preparation for a further colonoscopy, compared with 11 of the 25 in the other group (P < 0.05). CONCLUSIONS: Improving the acceptability of colonic preparation before colonoscopy could improve patients' compliance and the quality of the follow-up. The results of this study justify further investigation of SF-ELS.

[Conditions of practice of upper digestive endoscopy in ambulatory care. Results of a national survey (I)]. / Conditions de réalisation de l'endoscopie digestive haute en ambulatoire. Résultats d'une enquête nationale (I).

OBJECTIVES: The aim of the study was to describe the usual conditions of practice of esophagogastroscopy in ambulatory care by French gastroenterologists. METHODS: During a week, a questionnaire was filled out for each esophagogastroscopy performed in ambulatory or day care. RESULTS: Seven hundred and thirty nine gastroenterologists participated in the study (25.9% of French gastroenterologists) and enrolled 4585 patients. Intra-venous sedation was performed in 36.6% of endoscopic examinations, with diazepam (17.8%), midazolam (41.7%), propofol (14.9%), diazepam and propofol (2.1%) or midazolam and propofol (23.5%). A morphinomimetic was associated in 58.6% of cases. Monitoring equipment of endoscopy units was: aspiration (58.6%), pulse oxymeter (41.6%), electrocardiographic monitoring (37.7%). Recommendations about follow-up after ambulatory anaesthesia were not implemented in 7.3% of examinations with anaesthesia (patient discharged alone). Seventeen minor adverse events were recorded. CONCLUSION: The study underlines variability of practice, mainly about use of sedation, monitoring and follow-up of patients during esophagogastroscopy performed in ambulatory care in France. An improvement in quality of endoscopy practice is likely.

[Patient's opinion following an upper digestive endoscopy in ambulatory care. Results of a national survey (II)]. / Opinion des patients après la réalisation d'une endoscopie digestive haute en ambulatoire. Résultats d'une enquête nationale (II).

OBJECTIVES: The aim of the study was to evaluate patient satisfaction after esophagogastroscopy performed in ambulatory care and to correlate it with conditions of usual practice. METHODS: Study was proposed to the French gastroenterologists. During a week, 2 questionnaires were filled out for each esophagogastroscopy performed in ambulatory care: one recorded conditions of examination and one was independently filled out by the patient one day after endoscopy. RESULTS: Seven hundred and thirty nine gastroenterologists and 4,585 patients participated in the study. Among the patients, 3,758 (82%) filled out the questionnaire. Sedation was performed in 36.6% of cases. Subsequent endoscopy would be accepted by 79.3% of patients in the same conditions. Acceptance was significantly better with use of sedation and use of propofol. Without sedation, independent factors associated with a better acceptance were: male gender, absence of habitual benzodiazepine medication, endoscopy performed in private practice or private hospitals, smaller size of endoscope. CONCLUSION: This study underlines factors associated with a good acceptance of esophagogastroscopy without sedation and could help to improve decision-making regarding use of sedation.

[Quality of psychomotor recovery after colonoscopy under general anesthesia using propofol. Value of tests of awakening]. / Qualité de la récupération psychomotrice après une coloscopie sous anesthésie générale par propofol. Intérêt des tests de réveil.

Achieving colonoscopy under general anaesthesia entails the problem of ambulatory-care anaesthesia, in particular because perception of patient's recovery determines to some extent the length of monitoring following colonoscopy. The aims of the study was to assess the quality of patient's recovery after a colonoscopy under general anaesthesia while using propofol, by means of psychomotor-tests. METHODS--Colonoscopy was performed in 40 patients according to the following anaesthetic protocol: induction: propofol 2 mg/kg, continuous support: propofol 10 mg/kg/h i.v. with a 50 mg bolus in case of insufficient sedation; series of 3 psychomotor-tests were performed the day before and 1 hour, 3 hours and 6 hours after colonoscopy. The 3 psychomotor-tests studied: coordination (Newman test), time-space orientation and short-term memory. RESULTS--Forty patients, 25 females and 15 males, underwent colonoscopy with general anaesthesia for an average time-period of 22 +/- 11 min. The mean dose of propofol used was 286 +/- 102 mg. Awakening was complete in all patients, according to physical criteria such as consciousness and cardiovascular status, 20 min after receiving colonoscopy. The average psychomotor-tests results over time were (as percentages of original values) (*P < 10(-3); **P < 0.05): [table: see text] At 6 hours, 35 patients (87.5%) had recovered to their original performance and at 3 hours, 30 patients (75%) retained 90% their former state as measured with 3 psychomotor-tests. Neither by age or sex nor by propofol doses used or length or anaesthesia, the study population differed significantly. CONCLUSION--Three hours after colonoscopy under general anaesthesia using propofol, 30 patients (75%) had recovered at least 90% to their initial performances. Newman test was the most disturbed but there was no predictive factor for the quality of recovery. Psychomotor-tests may be useful before authorizing early discharge after colonoscopy under general anaesthesia but other recommendations about conditions of discharge after sedation must be also implemented.

[Quality assessment of colonscopies in current practice in the Aquitaine area]. / Qualité des coloscopies réalisées en pratique courante dans la région Aquitaine.

UNLABELLED: Sensitivity of colonoscopy depends on the technical quality of the procedure. The aims of this study were to evaluate the usual of colonoscopy in the French area of Aquitaine and to determinate the factors associated with a procedure of good quality. Thirty four gastroenterologists prospectively recorded indications, conditions of practice and results of the colonoscopies that were performed during 4 consecutive weeks. Six hundred and eighty six colonoscopies were analysed, performed in 387 women and 299 men, mean age: 59.9 years. INDICATIONS: irritable bowel syndrome: 34%, patients belonging to high risk groups: 30%, recent transit disturbance: 27%, rectal bleeding: 23%, positive fecal occult blood test: 4.3%. Preparations: polyethylene glycol (PEG) 78%, in 2 doses: 20%; PEG alone: 43%, associated with enemas and laxatives: 19%, with enemas: 14%, with laxatives: 2%; minimum-residue diet before colonoscopy: 58%. The caecum was reached in 86% of colonoscopies. Ninety-nine colonoscopies were incomplete. Fifty one per cent of colonoscopies reached the caecum with visualization of total colic mucosa, 35% reached the caecum with one at least imperfectly seen colic area.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of decontamination procedures used at digestive endoscopy units in Gironde]. / Evaluation des procédures de décontamination utilisées dans les centres d'endoscopie digestive de Gironde.

Decontamination procedures used for endoscopes were noted in 23 digestive endoscopy units, public and private, in the department of Gironde and compared to recommended procedures. Serial, bacteriological samples were obtained from one esogastroscope and one colonoscope in each unit, after upper endoscopy and colonoscopy diagnostic procedures at the end of the endoscopy session. Six units of 23 used complete decontamination procedures. In the 17 other units, principal errors of decontamination procedures were: inadequate cleaning of internal channel of scopes (12 units) and lack of utilization of glutaraldehyde between each endoscopy (8 units). Bacteriological samples were negative in 11/12 endoscopes after a complete decontamination procedure and in 8/39 after an inadequate procedure (p less than 0.01). Complete procedures are efficacious but not used often enough. Information and changes in endoscopic practices are necessary in digestive endoscopy units.

[Changes in circulating lymphocyte subsets in alcoholic hepatopathies. Respective role of alcohol, hepatocellular insufficiency and malnutrition]. / Etude des modifications des sous-populations lymphocytaires circulantes au cours des hépatopathies alcooliques. Rôle respectif de l'alcool, de l'insuffisance hépato-cellulaire et de la dénutrition.

Peripheral lymphocyte subpopulations have been quantified by a direct and indirect, immunofluorescence technique, using monoclonal antibodies, in 22 patients with continued heavy drinking, hepatocellular dysfunction (spider angiomata, ascites, and factor V decrease) (group I), in 16 patients with a history of heavy drinking and abstinence maintained for at least 6 months and hepatocellular dysfunction (group II) and in 28 patients admitted for continued heavy drinking, without hepatocellular dysfunction (group III). Sixteen normal subjects were studied as controls. The total number of lymphocytes and T lymphocytes (OKT3+) were significantly reduced (p less than 0.001) in groups I and II. A significant decrease of B lymphocytes was observed in group II (p less than 0.02). The OKT8+ lymphocytes were significantly reduced in group I (p less than 0.01) and in group II (p less than 0.001); the decrease of the OKT4+ lymphocytes was significant in group II (p less than 0.01) only. The OKT4/OKT8 ratio was higher in group I (p less than 0.05) and group II (p less than 0.01) than in the control group. Normal values of total lymphocytes, B lymphocytes, T lymphocytes subsets and OKT4/OKT8 ratio were observed in group III. In group III, the lymphocyte subpopulations and OKT4/OKT8 ratio were similar in patients with or without abnormalities of liver function tests. In group I and II, no correlation was found between the lymphocyte subpopulations or the OKT4/OKT8 ratio and factor V or nutritional status assessed by anthropometrical and biological tests. T-cell imbalance in alcoholic liver disease does not seem to be related to alcohol consumption, factor V decrease or malnutrition.