Randomized, multicenter study: on-demand versus continuous maintenance treatment with esomeprazole in patients with non-erosive gastroesophageal reflux disease.

BACKGROUND: Most patients with gastroesophageal reflux disease experience symptomatic relapse after stopping acid-suppressive medication. The aim of this study was to compare willingness to continue treatment with esomeprazole on-demand versus continuous maintenance therapy for symptom control in patients with non-erosive reflux disease (NERD) after 6 months. METHODS: This multicenter, open-label, randomized, parallel-group study enrolled adults with NERD who were heartburn-free after 4 weeks' treatment with esomeprazole 20 mg daily. Patients received esomeprazole 20 mg daily continuously or on-demand for 6 months. The primary variable was discontinuation due to unsatisfactory treatment. On-demand treatment was considered non-inferior if the upper limit of the one-sided 95 % confidence interval (CI) for the difference between treatments was <10 %. RESULTS: Of 877 patients enrolled, 598 were randomized to maintenance treatment (continuous: n = 297; on-demand: n = 301). Discontinuation due to unsatisfactory treatment was 6.3 % for on-demand and 9.8 % for continuous treatment (difference -3.5 % [90 % CI: -7.1 %, 0.2 %]). In total, 82.1 and 86.2 % of patients taking on-demand and continuous therapy, respectively, were satisfied with the treatment of heartburn and regurgitation symptoms, a secondary variable (P = NS). Mean study drug consumption was 0.41 and 0.91 tablets/day, respectively. Overall, 5 % of the on-demand group developed reflux esophagitis versus none in the continuous group (P < 0.0001). The Gastrointestinal Symptom Rating Scale Reflux dimension was also improved for continuous versus on-demand treatment. Esomeprazole was well tolerated. CONCLUSIONS: In terms of willingness to continue treatment, on-demand treatment with esomeprazole 20 mg was non-inferior to continuous maintenance treatment and reduced medication usage in patients with NERD who had achieved symptom control with initial esomeprazole treatment. TRIAL REGISTRATION: ClinicalTrials.gov identifier (NCT number): NCT02670642 ; Date of registration: December 2015.

Cumulative incidence of, risk factors for, and outcome of dermatological complications of anti-TNF therapy in inflammatory bowel disease: a 14-year experience.

OBJECTIVES: The broader and prolonged use of anti-tumor necrosis factor (TNF) agents in inflammatory bowel disease (IBD) could expose patients to an increased risk of adverse reactions, including dermatological complications. We assessed the cumulative incidence of anti-TNF-induced cutaneous adverse reactions in IBD patients, their risk factors, their dermatological management, and their outcome in a large cohort of IBD patients. METHODS: In a single-center observational retrospective study, including all consecutive adult IBD patients treated with an anti-TNF agent between 2001 and 2014, all patients with dermatological complications under anti-TNF therapy were identified in a well-defined cohort of IBD patients. We conducted a survival analysis to determine the cumulative incidence of dermatological complications and risk factors for developing any dermatological complications, cutaneous infections, and psoriasiform lesions. Survival curves were estimated by the Kaplan-Meier method, and we used a Cox proportional hazards model to test the association between parameters and time to each event: any dermatological complication, cutaneous infections, and psoriasis lesions. RESULTS: Among 583 IBD patients, 176 dermatological complications occurred, involving 20.5% of patients. Median duration of follow-up was 38.2 months (range: 1-179). Psoriasiform lesions (10.1%; 59/583) and cutaneous infections (11.6%, 68/583) were the most frequently observed, with a cumulative incidence of, respectively, 28.9% and 17.6% at 10 years. They led to anti-TNF discontinuation, respectively, in 18.6% and 2.9% of patients. In case of switching to another anti-TNF agent for psoriasiform lesions, recurrence occurred in 57% of patients. Ulcerative colitis was associated with a lower risk of developing cutaneous infections than Crohn's disease (hazard ratio (HR)=0.25; 95% confidence interval (CI)=0.09-0.68; P=0.007). Higher dosing of anti-TNF agent was associated with a higher risk of developing cutaneous infections (HR=1.99; 95% CI=1.09-3.64; P=0.025). A younger age at time of anti-TNF initiation was associated with a higher risk of dermatological complications (HR=2.25; 95% CI=1.39-3.62; P<0.001). CONCLUSIONS: Dermatological complications involve one of five patients treated with anti-TNF therapy after a 14-year follow-up. Association of cutaneous infections with higher anti-TNF dosing suggests a dose-dependent effect. Discontinuation of anti-TNF therapy due to dermatological complications is required in one out of five patients with psoriasiform lesions, but specific dermatological treatment allows to continue anti-TNF therapy in half of them.

Long-term outcome of perianal fistulizing Crohn's disease treated with infliximab.

BACKGROUND & AIMS: Little is known about the long-term efficacy of infliximab for patients with fistulizing perianal Crohn's disease. We evaluated outcomes and predictors of outcomes in these patients. METHODS: The medical records of 156 patients treated with infliximab for fistulizing perianal Crohn's disease at 2 referral centers from 1999 through 2010 were reviewed through September 2011. Cumulative probabilities of fistula closure and recurrence were estimated by using the Kaplan-Meier method. Predictors of outcomes were identified by using a Cox proportional hazards model. RESULTS: When infliximab treatment began, only 17.9% of patients had a simple fistula; seton drainage was performed for 97 patients (62%). Concomitant immunosuppressants were given to 90 patients (56%). After a median follow-up period of 250 weeks, 108 patients (69%) had at least 1 fistula closure. Cumulative probabilities of first fistula closure were 40% and 65% at 1 and 5 years, respectively. Factors that predicted fistula closure were ileocolonic disease (hazard ratio [HR] = 1.88), concomitant immunosuppressants (HR = 2.58), duration of seton drainage <34 weeks (HR = 2.31), and long duration of infliximab treatment (HR = 1.76). Of the 108 patients with fistula closure, cumulative probabilities of first fistula recurrence were 16.6% and 40.1% at 1 and 5 years, respectively. Forty-four patients (28.9%) developed an abscess during follow-up. A number of infliximab infusions greater than 19 was associated with less abscess recurrence (HR = 0.33). At the maximal follow-up time, 55% of patients had fistula closure. CONCLUSIONS: About two-thirds of patients with fistulizing perianal Crohn's disease had fistula closure, and one-third had fistula recurrence after infliximab initiation. Combination therapy, duration of seton drainage less than 34 weeks, and long-term treatment with infliximab were associated with better outcomes.

Gaviscon® vs. omeprazole in symptomatic treatment of moderate gastroesophageal reflux. a direct comparative randomised trial.

BACKGROUND: Medical management of GERD mainly uses proton pump inhibitors. Alginates also have proven efficacy. The aim of this trial was to compare short-term efficacy of an alginate (Gaviscon®, 4 × 10 mL/day) and omeprazole (20 mg/day) on GERD symptoms in general practice. METHODS: A 14-day multicentre randomised double-blind double-dummy non-inferiority trial compared Gaviscon® (4 × 10 mL/day) and omeprazole (20 mg/day) in patients with 2-6 day heartburn episodes weekly without alarm signals. The primary outcome was the mean time to onset of the first 24-h heartburn-free period after initial dosing. Secondary outcomes were the proportion of patients without heartburn by D7, pain relief by D7, and reduction in pain intensity by D7 and D14. RESULTS: 278 patients were recruited; 120 were included in the Gaviscon® group and 121 in the omeprazole group for the per protocol non-inferiority analysis. The mean time to onset of the first 24-h heartburn-free period after initial dosing was 2.0 (± 2.2) days for Gaviscon® and 2.0 (± 2.3) days for omeprazole (p = 0.93); mean intergroup difference was 0.01 ± 1.55 days (95% CI = -0.41 to 0.43): i.e., less than the lower limit of the 95% CI of -0.5 days predetermined to demonstrate non-inferiority. The mean number of heartburn-free days by D7 was significantly greater in the omeprazole group: 3.7 ± 2.3 days vs. 3.1 ± 2.1 (p = 0.02). On D7, overall quality of pain relief was slightly in favour of omeprazole (p = 0.049). There was no significant difference in the reduction in pain intensity between groups by D7 (p = 0.11) or D14 (p = 0.08). Tolerance and safety were good and comparable in both groups. CONCLUSION: Gaviscon® was non-inferior to omeprazole in achieving a 24-h heartburn-free period in moderate episodic heartburn, and is a relevant effective alternative treatment in moderate GERD in primary care. TRIAL REGISTRATION: ISRCTN62203233.

Impact of azathioprine and tumour necrosis factor antagonists on the need for surgery in newly diagnosed Crohn's disease.

OBJECTIVE: The aim of the study was to assess whether azathioprine and antitumour necrosis factor (TNF) treatment decrease the long-term need for surgery in patients with Crohn's disease. METHODS: This was an observational study of a referral centre cohort. The cumulative incidence of the first Crohn's disease-related major abdominal surgery was estimated using the Kaplan-Meier method, and independent predictors of surgery were identified using Cox proportional hazards regression with propensity scores adjustment. Receiver operating characteristic (ROC) analysis was used to identify optimal cut-offs for duration of maintenance treatments. The electronic charts of 296 incident cases of Crohn's disease from Nancy University Hospital, France, diagnosed between 2000 and 2008, were reviewed through January 2010. RESULTS: The median follow-up time per patient was 57 months. Seventy-six patients (26%) underwent at least one major abdominal surgical procedure. The cumulative probabilities of the first Crohn's disease-related major abdominal surgery were 6.5, 25.9 and 44.3 at 1, 5 and 9 years, respectively. In the ROC analysis, the duration of anti-TNF and azathioprine treatment had significant cut-off values (≤ 475 days ~16 months and ≤ 45 days ~1.5 months, respectively) with positive likelihood ratios (PLRs) of 1.52 (p < 0.0001) and 1.51 (p = 0.003) for the first Crohn's disease-related major abdominal surgery. Using multivariate Cox proportional hazards regression analysis (after propensity score adjustment), independent positive predictors of major abdominal surgery were stricturing (HR = 12.01; 95% CI 5.97 to 24.17) or penetrating (HR = 10.77; 95% CI 4.87 to 23.80) disease behaviour at diagnosis, duration of anti-TNF treatment of < 16 months (HR = 3.86; 95% CI 1.77 to 8.45) and duration of azathioprine treatment of < 1.5 months (HR = 2.00; 95% CI 1.20 to 3.34). CONCLUSIONS: Non-complicated inflammatory disease behaviour and long-term anti-TNF treatment are associated with a lower risk for surgery whereas azathioprine only modestly lowers this risk.

Diffusion-weighted magnetic resonance without bowel preparation for detecting colonic inflammation in inflammatory bowel disease.

OBJECTIVE: Magnetic resonance imaging (MRI) enables accurate assessment of inflammatory bowel diseases (IBD), but its main limitation is the need for bowel preparation. Diffusion-weighted imaging is feasible in Crohn's disease. We evaluated the accuracy of MRI in combination with diffusion-weighted imaging (DWI-MRI) without oral or rectal preparation in assessing colonic inflammation in both ulcerative colitis and Crohn's disease. DESIGN: This was an observational study of a single-centre cohort. PATIENTS: All patients who underwent DWI-MRI-colonography without bowel preparation between January 2008 and February 2010 in our centre were analysed. RESULTS: Among the 96 patients (ulcerative colitis=35; Crohn's disease=61) who had DWI-MRI-colonography, 68 had concomitant endoscopy. In ulcerative colitis a segmental magnetic resonance score (MR-score-S) >1 detected endoscopic inflammation with a sensitivity and specificity of 89.47% and 86.67%, respectively (AUROC=0.920, p=0.0001). In the Crohn's disease group, a MR-score-S >2 detected endoscopic inflammation in the colon with a sensitivity and specificity of 58.33% and 84.48%, respectively (AUROC=0.779, p=0.0001). The MR-score-S demonstrated better accuracy for the detection of endoscopic inflammation in the ulcerative colitis group than in the Crohn's disease group (p=0.003). In ulcerative colitis, the proposed total magnetic resonance score (MR-score-T) correlated with the total modified Baron score (r=0.813, p=0.0001) and the Walmsley index (r=0.678, p<0.0001). In Crohn's disease, the MR-score-T correlated with the simplified endoscopic activity score for Crohn's disease (r=0.539, p=0.001) and the Crohn's disease activity index (r=0.367, p=0.004). The DWI hyperintensity was a predictor of colonic endoscopic inflammation in ulcerative colitis (OR=13.26, 95% CI 3.6 to 48.93; AUROC=0.854, p=0.0001) and Crohn's disease (OR=2.67, 95% CI 1.25 to 5.72; AUROC=0.702, p=0.0001). The accuracy of the DWI hyperintensity for detecting colonic inflammation was greater in ulcerative colitis than in Crohn's disease (p=0.004). CONCLUSIONS: DWI-MRI-colonography without bowel preparation is a reliable tool for detecting colonic inflammation in ulcerative colitis.

Predictors of infliximab failure after azathioprine withdrawal in Crohn's disease treated with combination therapy.

OBJECTIVES: Whether all Crohn's disease (CD) patients should maintain long-term azathioprine treatment in combination with infliximab remains controversial. We analyzed the predictive factors of infliximab failure after azathioprine withdrawal. METHODS: This was an observational study from a single referral center. All patients with luminal CD in remission who stopped azathioprine after receiving infliximab in combination with azathioprine for at least 6 months were studied. Cumulative probabilities of infliximab failure-free survival were estimated by the Kaplan-Meier method from the date of azathioprine withdrawal to the date of infliximab failure or last known follow-up. Infliximab failure was defined by: (i) disease flare requiring shortening of the dosing interval or increasing the infliximab dose to 10 mg/kg, or switching to adalimumab; (ii) acute or delayed hypersensitivity reactions leading to infliximab discontinuation; or (iii) CD-related surgery. RESULTS: At last known follow-up, 35 out of 48 (73%) patients were infliximab failure free. The survival probabilities were 85% (+/-5%) at 12 months and 41% (+/-18%) at both 24 and 32 months. Cox proportional-hazards regression identified three predictors of infliximab failure: infliximab-azathioprine exposure duration of < or = 811 days (hazard ratio (HR)=7.46, P=0.01), C-reactive protein > 5 mg/l (HR=4.79, P=0.008), and platelet count > 298 10(9)/l (HR=4.75, P=0.02). CONCLUSIONS: In CD in clinical remission under azathioprine-infliximab combination therapy, azathioprine withdrawal is associated with a high risk of relapse in patients with a duration of combination therapy of < 27 months and/or the presence of biological inflammation.

A multicenter experience with infliximab for ulcerative colitis: outcomes and predictors of response, optimization, colectomy, and hospitalization.

OBJECTIVES: The objective of this study was to evaluate short- and long-term outcomes of infliximab in ulcerative colitis (UC), including infliximab optimization, colectomy, and hospitalization. METHODS: This was a retrospective multicenter study. All adult patients who received at least one infliximab infusion for UC were included. Cumulative probabilities of event-free survival were estimated by the Kaplan-Meier method. Independent predictors were identified using binary logistic regression or Cox proportional-hazards regression, and results were expressed as odds ratios or hazard ratios (HRs), respectively. RESULTS: Between January 2000 and August 2009, 191 UC patients received infliximab therapy. Median follow-up per patient was 18 months (interquartile range=25-75th, 8-32 months). Primary non-response was noted in 42 patients (22.0%). "Hemoglobin at infliximab initiation ≤ 9.4 g/dl" (odds ratio=4.35; 95% confidence interval (CI)=1.81-10.42) was a positive predictor of non-response to infliximab. Infliximab optimization was required in 36 (45.0%) of 80 patients on scheduled infliximab therapy. The only predictor of infliximab optimization was "infliximab indication for acute severe colitis" (HR=2.75; 95% CI=1.23-6.12). Thirty-six patients (18.8%) underwent colectomy. Predictors of colectomy were: "no clinical response after infliximab induction" (HR=7.06; 95% CI=3.36-14.83), "C-reactive protein at infliximab initiation > 10 mg/l" (HR=5.11; 95% CI=1.77-14.76), "infliximab indication for acute severe colitis" (HR=3.40; 95% CI=1.48-7.81), and "previous treatment with cyclosporine" (HR=2.53; 95% CI=1.22-5.28). Sixty-nine patients (36.1%) were hospitalized at least one time and UC-related hospitalizations rate was 29 per 100 patient-years (95% CI=24-35 per 100 patient-years). Predictors of first hospitalization were: "no clinical response after infliximab induction" (HR=3.87; 95% CI=2.29-6.53), "infliximab indication for acute severe colitis" (HR=3.13, 95% CI=1.65-5.94), "disease duration at infliximab initiation ≤50 months" (HR=2.14, 95% CI=1.25-3.66), "hemoglobin at infliximab initiation ≤11.8 g/dl" (HR=1.77; 95% CI=1.03-3.04), and "previous treatment with methotrexate" (HR=0.30; 95% CI=0.09-0.97). CONCLUSIONS: Primary non-response to infliximab was noted in one fifth of patients and increased by seven and four the risks of colectomy and hospitalization, respectively. Infliximab optimization, colectomy, and hospitalization were required in half, one fifth, and one third of patients, respectively. Infliximab indication for acute severe colitis increased by three the risks of infliximab optimization, colectomy, and UC-related hospitalization.

Methionine synthase A2756G polymorphism may predict ulcerative colitis and methylenetetrahydrofolate reductase C677T pancolitis, in Central China.

BACKGROUND: The association of genetic polymorphisms related to metabolism of homocysteine with inflammatory bowel disease has been evidenced in Crohn disease and remains an open question in ulcerative colitis. We evaluated the association of the polymorphisms of MTHFR, MTR, MTRR and TCN2 genes with ulcerative colitis in Central China. METHODS: 168 patients were genotyped for these polymorphisms and compared to 219 matched controls. RESULTS: Methionine synthase 2756G allele frequency was higher in ulcerative colitis than in controls 0.15 (95% C.I. 0.11-0.19) vs 0.09 (95% C.I. 0.07 - 0.12), (P = 0.0137) and predicted ulcerative colitis risk in logistic regression, with an Odds ratio at 1.8 (95% C.I. 1.15-2.84). Methylenetetrahydrofolate reductase 677TT genotype was 2.7-fold more prevalent in individuals with pancolitis than in those with left colitis or proctitis, with respective percentages of 27.3 (95% C.I.16.4-42.0) and 10.5 (95% C.I. 6.3-17.1) (P = 0.0123). The carriage of 677TT or 677CT/1298AC genotypes of methylenetetrahydrofolate reductase was more frequent in cases with pancolitis than in subjects with left colitis or proctitis (P = 0.0048), with an Odds ratio adjusted by age and sex at 3.3 (95% C.I. 1.4-7.9), P = 0.0084) in logistic regression. CONCLUSION: Methionine synthase and methylenetetrahydrofolate reductase are genes of vitamin B12 and folate cellular metabolism associated respectively with risk and extent of ulcerative colitis, at least in Central China. This finding may open new insights, particularly for the potential interest in treating patients carrying the 677TT MTHFR genetic trait and a deficit in folate.

Adalimumab induction therapy for ulcerative colitis with intolerance or lost response to infliximab: an open-label study.

AIM: To evaluate the efficacy of adalimumab induction therapy in patients with ulcerative colitis who previously responded to infliximab and then lost response or became intolerant. METHODS: Ten patients with ulcerative colitis were enrolled in a 4-wk open-label trial. The patients received a loading dose of 160 mg adalimumab at wk 0 followed by 80 mg at wk 2. The primary efficacy measure was clinical improvement at wk 4, as defined by a decrease in clinical activity index (CAI) of more than 4. RESULTS: Four of 10 patients (40%) benefited from subsequent adalimumab therapy; one patient achieved remission (CAI<4) and 3 had clinical improvement at wk 4. 6 patients had no response (60%); 2 of 6 (33.3%) subsequently underwent colectomy. This was accompanied by a decrease in median CRP concentration from 16.8 mg/mL at baseline to 3.85 mg/mL at wk 4, excluding two patients who underwent colectomy after two infusions of adalimumab. Among the 6 patients with severe colitis (CAI>12) at baseline, none achieved remission and only one patient had clinical improvement at wk 4. CONCLUSION: The small advantage of adalimumab in patients with mild to moderate ulcerative colitis and lost response or intolerance to infliximab needs to be confirmed in randomised, double-blind, placebo-controlled trials.

[Therapeutic innovations in gastroesophageal reflux]. / Nouveautés thérapeutiques dans le reflux gastro-oesophagien.

Proton-pump inhibitors remain the most effective treatment for relieving symptoms, healing lesions and preventing recurrences of gastroesophageal reflux (GER). Drugs inhibiting transient relaxation of the lower esophageal sphincter have an unfavorable benefit/risk ratio. Endoscopic methods developed in recent years have not been shown effective in trials versus sham procedures. Surgical treatment is effective in GER but causes frequent uncomfortable side effects that are difficult to treat.

Contribution of computed tomography with oral media contrast to the diagnosis of esophago-pericardial fistula.

The esophago-pericardial fistula is a very rare and usually fatal complication of esophageal cancers. We report a case of a 56-year-old man who presented with chest pain 1 month after concurrent radiochemotherapy for squamous cell esophageal carcinoma. Thoracic computed tomography (CT) with oral iodinated media contrast revealed esophago-pericardial fistula visualizing the fistulous tract. We conclude that CT with oral contrast media may be the first imaging technique of choice to confirm the diagnosis of esophago-pleural fistula.

Ano-rectal complaints in general practitioner visits: consumer point of view.

AIMS: The perception patients consulting for primary care have of anorectal disorders has never been evaluated. Our aim was to analyze proctological complaints among outpatients consulting general practitioners. PATIENTS AND METHODS: Among 1484 physicians who responded to a nationwide mailing in France, 161 enrolled 437 females and 358 males consulting between October 2004 and December 2005. RESULTS: Females were younger than males (46 +/- 15 vs 51 +/- 13 years) (p<0.0001). Intermediate and upper social-occupational categories were overrepresented as compared with the general population. Symptoms were pain (48%), bleeding (37%), swelling (26%) and pruritus (24%). For 76%, these symptoms persisted for less than one month and 58% mentioned earlier visits or prior treatment. The first manifestation was correlated with a pregnancy in 31% of women. Present symptoms were secondary to acute constipation (52%), stress (33%), ingestion of spices (29%) or alcohol (20%), and diarrhea (8%). Symptoms were considered important in 61% or a cause of anxiety in 33% of patients. Treatment was prescribed for all patients: ointments (90%), phlebotonics (66%) or suppositories (51%), in combination for 75% of prescriptions. Patients preferred oral medicines (41%), ointments (30%) and suppositories (7%). CONCLUSION: Proctological complaints are a reason for repeated visits to the general practitioner and lead to repeated prescriptions. Patients appreciate anti-hemorrhoidal treatments variably.

[Epigenetic changes and liver carcinogenesis]. / Anomalies épigénétiques et carcinogenèse hépatique.

The molecular mechanisms involved in liver carcinogenesis are poorly understood. Over the past decade, epigenetic changes (DNA methylation) have received increasing attention for their potential involvement in the development of hepatocarcinoma. The DNA methylation level is influenced by environmental factors (folate and methionine diet), as well as by genetic factors (methylenetetrahydrofolate reductase/MTHFR polymorphisms). These findings provide new insight into the understanding of liver carcinogenesis. Interventional studies are now required to determine the role of folate supplementation in the development of liver tumors in targeted patients.

[Hepatitis A acquired from an asymptomatic adopted child]. / Hépatite A transmise par un enfant adopté asymptomatique.

We report the case of acute hepatitis in a 36-year-old woman that was acquired from an adopted African child with asymptomatic active infection. At present, most experts do not screen for hepatitis A. However, adoptive parents should be vaccinated against hepatitis A because of the risk of unrecognized active infection in adopted children from countries in which infection is endemic.

Negative Screening Does Not Rule Out the Risk of Tuberculosis in Patients with Inflammatory Bowel Disease Undergoing Anti-TNF Treatment: A Descriptive Study on the GETAID Cohort.

AIM: to describe the characteristics of incident cases of tuberculosis [TB] despite negative TB screening tests, in patients with inflammatory bowel disease [IBD] undergoing anti-TNF treatment, and to identify the risk factors involved. METHODS: A retrospective descriptive study was conducted at GETAID centers on all IBD patients undergoing anti-TNF treatment who developed TB even though their initial screening test results were negative. The following data were collected using a standardized anonymous questionnaire: IBD, and TB characteristics and evolution, initial screening methods and results, and time before anti-TNF treatment was restarted. RESULTS: A total of 44 IBD patients [including 23 men; median age 37 years] were identified at 20 French and Swiss centers at which TB screening was performed [before starting anti-TNF treatment] based on Tuberculin Skin Tests [n = 25], Interferon Gamma Release Assays [n = 12], or both [n = 7]. The median interval from the start of anti-TNF treatment to TB diagnosis was 14.5 months (interquartile range [IQR] 25-75: 4.9-43.3). Pulmonary TB involvement was observed in 25 [57%] patients, and 40 [91%] had at least one extrapulmonary location. One TB patient died as the result of cardiac tamponade. Mycobacterium tuberculosis exposure was thought to be a possible cause of TB in 14 cases [32%]: 7 patients [including 6 health care workers] were exposed to occupational risks, and 7 had travelled to endemic countries. Biotherapy was restarted on 27 patients after a median period of 11.2 months [IQR 25-75: 4.4-15.2] after TB diagnosis without any recurrence of the infection. CONCLUSION: Tuberculosis can occur in IBD patients undergoing anti-TNF treatment, even if their initial screening results were negative. In the present population, TB was mostly extrapulmonary and disseminated. TB screening tests should be repeated on people exposed to occupational risks and/or travelers to endemic countries. Restarting anti-TNF treatment seems to be safe.

[Pancreatic pseudocysts of the right hepatic lobe during acute biliary pancreatitis]. / Pseudokystes hépatiques du foie droit au décours d'une pancréatite aiguë biliaire.

The occurrence of pancreatic pseudocysts of the right hepatic lobe during acute biliary pancreatitis is a rare event. We report the unusual case of a 69-year-old woman who was hospitalised for biliary pancreatitis. The patient suffered from right hypochondrial pain. A CT-scan performed at day 12 showed pancreatic pseudocysts in the right hepatic lobe. A favorable outcome was obtained after percutaneous drainage. Most hepatic pseudocysts are described in the left hepatic lobe after alcoholic pancreatitis. Different hypotheses have been suggested to explain the extension of pancreatic pseudocysts in the liver, due to proteolytic effect of pancreatic enzymes that reach the lesser sac and then the liver either directly through the liver capsule, or indirectly through the hepatic hilum vessels, or the hepatic ligament. We suggest another reason for hepatic invasion: pancreatic enzymes could also cause liver damage, through the para - renal anterior space, often infiltrated during acute pancreatitis, reaching right hepatic lobe through area nuda.

[Circumstances of the diagnosis and clinical course of inflammatory bowel disease]. / Circonstances diagnostiques et évolution des maladies inflammatoires chroniques de i'intestin.

The diagnosis of inflammatory bowel disease is sometimes difficult. The cardinal symptom of ulcerative colitis is bloody diarrhoea. The clinical characteristics of Crohn's disease are more heterogeneous, but typically include abdominal pain in the right lower quadrant, diarrhoea, weight loss and/or perianal disease. Extra intestinal (joint, cutaneaous and eye) manifestations can precede digestive symptoms and lead to the diagnosis of inflammatory bowel disease. The clinical course of these two diseases is unpredictable. The risk of colorectal cancer is significantly increased 8 years after diagnosis of pancolitis. Thus, regular surveillance by colonoscopy with random biopsies is recommended.

Impact of immunosuppressive therapy on hepatitis B vaccination in inflammatory bowel diseases.

BACKGROUND AND AIMS: The vaccination rate against hepatitis B virus (HBV) is low in inflammatory bowel disease (IBD) patients. The Consensus from the European Crohn's and Colitis Organisation on opportunistic infections recommends testing all IBD patients for HBV at diagnosis and vaccinating all HBV-negative patients. We compared the efficacy of HBV vaccine between IBD patients and healthy controls and investigated the impact of immunosuppressive therapy on vaccine response in IBD patients. MATERIALS AND METHODS: IBD patients and healthy adult workers were vaccinated against HBV following a standard protocol (at 0, 1, and 6 months; Engerix B). The efficacy of vaccination was evaluated at 8 months by a titer of antibodies against hepatitis B surface antigen (anti-HBs). RESULTS: Among 164 participants (96 with IBD and 68 healthy workers), the level of anti-HBs was greater than 10 IU/l in 80.2 and 94.1% (P=0.0115) of IBD patients and healthy controls, respectively, and anti-HBs levels greater than 100 IU/l were seen in 45.8 versus 77.9% (P<0.0001) of IBD patients and healthy controls, respectively. The median level of anti-HBs was significantly higher in healthy controls (497.0±386.2) than in IBD patients (253.9±34.5) (P<0.0001). None of the baseline characteristics of IBD patients, including immunomodulators and antitumor necrosis factor therapy, influenced the vaccine response. In the multivariate analysis, ileal disease was the only factor associated with a lower response to the vaccine (odds ratio=3.2; 95% confidence interval=1.0-9.7; P=0.049). CONCLUSION: The response rate to HBV vaccination is significantly lower in IBD patients than in the general population. Immunosuppressive therapy for IBD did not influence the vaccine response.