[Nocturnal gastroesophageal reflux. About a pH metric series]. / Le reflux gastro-oesophagien acide nocturne pathologique. A propos d'une série pHmétrique.

BACKGROUND: Nocturnal gastroesophageal reflux has been shown to be associated with the more severe forms of gastroesophageal reflux disease (GERD), particularly with extraesophageal manifestations as well as complications of mucosal damage. AIM: To determine the frequency of nocturnal gastro esophageal reflux disease on 24-hour esophageal pH monitoring in patients with digestives or extra-digestives symptoms and to evaluate the clinical and pHmetric characteristics of nocturnal reflux in these patients. METHODS: We conducted a retrospective study based on results of 24- hour esophageal pH monitoring during a 11-year period in patients with or without digestive symptoms of gastroesophageal reflux disease. The nocturnal gastroesophgeal reflux was defined. RESULTS: We studied 696 patients (299 men, 397 women; mean age: 34.05 years). Gastroesophageal reflux was found in 350 patients (50%). Nocturnal reflux was observed in 240 patients (34.3%), mostly in association with pathological reflux in the total period (223 cases). Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes (21.9±27.4 vs 67.4±5.,1 ; p<0.0001), more longer duration of reflux episodes (24.4±37.9 minutes vs 13.9± 17.5 minutes ; p<0.001), and a lower symptomatic correlation (26% vs 45% ; p=0.0005). CONCLUSION: Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by longer reflux episodes, less number of reflux episodes and less symptomatic correlation.

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Diagnosis and management of refractory celiac disease: a systematic review.

BACKGROUND: Refractory celiac disease is defined by persisting malabsorptive symptoms in spite of a strict gluten free diet for at least 6 to 12 months. Alternatives to gluten free diet seem to be still controversial. AIM: To describe the clinical and epidemiologic aspects of refractory celiac disease, and to identify therapeutic options in this condition. METHODS: Systematic review and critical analysis of observational studies, clinical trials and case reports that focused on diagnosis and management of refractory celiac disease. RESULTS: Refractory celiac disease can be classified as type 1 or type 2 according to the phenotype of intraepithelial lymphocytes. Great complications such as enteropathy-associated T-cell lymphoma may occur in a subgroup of these patients mainly in refractory celiac disease type 2. Curative therapies are still lacking. CONCLUSION: Refractory celiac disease remains a diagnosis of exclusion. Its prognosis remains still dismal by the absence yet of curative therapies. However, some new treatments seem to hold promise during few cohort-studies.

[Post-infectious irritable bowel syndrome]. / Une nouvelle entité clinique: le syndrome de l'intestin irritable postinfectieux.

BACKGROUND: Post-infectious irritable bowel syndrome (PI-IBS) is a disorder wherein symptoms of IBS begin after an episode of acute gastroenteritis. AIMS: To determine epidemiology, clinical features and prognosis of PI-IBS and to precise its physiopathology and treatment. METHODS: Literature review. RESULTS: Published studies have reported an incidence of PI-IBS ranging from 4 to 32 % with a mean of 10 %. Bacterial infections are the most responsible agents. Risk factors for PI-IBS include patient's demographics, psychological disorders and the severity of enteric illness. The most common symptoms are those of diarrheapredominant IBS. The mechanisms underlying PI-IBS include especially changes in intestinal permeability and persistent mucosal inflammatory process. In fact, there is increase in lymphocytic, mast and enterochromaffin cells in the gut mucosa. Furthermore, increased inflammatory cytokines have been demonstrated. Treatment of PIIBS is similar to that idiopathic IBS. CONCLUSION: PI-IBS is a novel clinic entity that suggests a novel approaches to IBS.

[Is APRI score a suitable tool for prediction of fibrosis in Tunisian patients with genotype 1 chronic viral hepatitis C?]. / Le score April est il fiable pour la prediction de la fibrose chez les patients Tunisiens atteints d'hepatite chronique virale C de genotype 1?

BACKGROUND: Therapeutic indications in chronic genotype 1 hepatitis C are based on severity of fibrosis. APRI score is a simple, cheap and reproducible biochemical test. Performances of APRI score in Tunisian population with chronic hepatitis C were not previously prospectively studied. AIM: To evaluate the performances of APRI score in prediction of severity of fibrosis in chronic genotype 1 hepatitis C based on a prospective study. METHODS: We prospectively include patients with chronic genotype 1 hepatitis C and positive viral load. Hepatic biopsy was performed in all included patients and abnormalities were classified according to METAVIR classification. In all patients, APRI score was calculated based on biochemical data collected within the 15 days before hepatic biopsy. RESULTS: We studied 140 patients (46 men, mean age 48.4 years (20 - 65 years)). Mean APRI score was 0.89 (0.18 - 3.72). Statistically significant correlation was observed between APRI score and fibrosis severity (r = 0.31 p < 0.0001). APRI score was higher in patients with severe fibrosis (F2, F3 or F4) compared to patients with moderate fibrosis (F0 or F1) (0.97 + 0.68 vs 0.62 + 0.44; p 0.009). Threshold value of APRI score of 0.72 was associated with area under the curve of 0.65 + 0.05 (0.57 - 0.73), sensitivity of 56.3% and specificity of 75.8% in prediction of severe fibrosis. APRI score was also higher in patients with cirrhosis (1.24 + 0.79 vs 0.85 + 0.61; p = 0.01). Threshold value of 0.86 was associated with area under the curve of 0.69 + 0.07 (0.61 - 0.77), sensitivity of 76.4% and specificity of 65.8% in prediction of cirrhosis. CONCLUSION: APRI score is not a good alternative to hepatic biopsy although a strong correlation with fibrosis severity, because of relatively low area under the curve, sensitivity and specificity in prediction of severe fibrosis and cirrhosis.

[24-hour esophageal impedance-ph monitoring: technical aspects, indications and results]. / L'impédancemétrie couplée à la ph-mètrie oesophagienne des 24 heures: technique, indications et résultats.

BACKGROUND: Classical techniques like endoscopy and esophageal pH-metry are the gold standard to study patients with symptoms related to gastroesophageal reflux disease. Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical gastroesophageal reflux disease symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. AIM: To precise the technical aspects of the esophageal impedancepH monitoring, indications and results of this technique in clinical practice. METHODS: Literature revue of the esophageal impedance - pH monitoring Results: Combined multichannel intraluminal impedance and pH monitoring is a new technique that can be used to evaluate both bolus transport and all types of reflux (acid, weakly acidic and weakly alkaline), without radiation hazards. With this technique, higher rates of sensitivity and specificity than standard techniques are obtained in the diagnosis of pathological gastroesophageal reflux. The technique has also been used in the evaluation of atypical gastroesophageal reflux symptoms, in the assessment of the association of different patterns of reflux with symptoms, and in the evaluation of therapeutic outcome mainly in patients with refractory gastroesophageal reflux disease. CONCLUSION: The esophageal impedance represents real progress in understanding the different mechanisms involved in the pathophysiology of gastroesophageal reflux. This technique should also allow a better understanding of the responsibility of non-acid reflux in special clinical situations, such as patients resistant to antisecretory or extra-intestinal manifestations of gastroesophageal reflux.

Correlation of C-reactive protein with clinical and endoscopic activity in patients with ulcerative colitis.

BACKGROUND AND AIMS: Evaluating disease activity is important in ulcerative colitis. Laboratory markers should be a non-invasive alternative to endoscopy for patients. The objective of our study was to scrutinize the correlation between C-reactive protein (CRP) levels and clinical and endoscopic activity in ulcerative colitis patients. MATERIALS AND METHODS: We conducted a prospective study between January 2007 and December 2009. In the study we chose consecutive patients of our department with ulcerative colitis. All patients received a standardized questionnaire, clinical examination, and colonoscopy. Based on clinical and endoscopic data, we calculated the disease activity index (DAI) and the Rachmilewitz score. RESULTS: One-hundred and one patients were included. At the time of inclusion, 67 patients had an active disease and 34 patients were in remission. The mean DAI was 6.9 (1-12). The mean Rachmilewitz score was 4.7 (0-12). The median CRP rate was 20.2 ± 24.5 mg/l (1-107 mg/l). An increased CRP was found in 46 patients (46%). An increased CRP level was observed in patients with active disease (P < 0.0001). The DAI was higher in patients with increased CRP (9.5 ± 1.6 vs. 4.7 ± 3.6; P < 0.0001). The Rachmilewitz score was also higher in patients with increased CRP (7.2 ± 2.3 vs. 2.7 ± 3.2; P < 0.0001). A statistically significant association was found between the CRP and the DAI (r = 0.51, P < 0.0001) and between the CRP and the Rachmilewitz score (r = 0.46, P < 0.0001). The optimum cut-off of CRP level that separates active or inactive disease was calculated to be 10 ml/l, with AUC estimated at 0.81 ± 0.04 (95%CI: 0.72-0.88), a sensitivity of 67.1 (95%CI: 54.6-78.1) and a specificity of 97% (95%CI: 84.6-99.5). CONCLUSION: Levels of CRP are correlated to clinical and endoscopic activity in ulcerative colitis patients.

[Management of failure of infliximab in inflammatory bowel disease]. / Que faire devant un échec de l'Infliximab au cours des maladies inflammatoires chroniques de l'intestin ?

BACKGROUND: Infliximab is a chimeric monoclonal anti TNFa whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options. METHODS: Literature review RESULTS: The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNFa, a relay by adalinumab or certolizumab may be proposed. CONCLUSION: The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed.

[Long term evolution of corticodependant and corticoresistant Crohn's disease patients treated by azzathioprine]. / Évolution a long terme des patients atteints de maladie de Crohn corticodépendante et corticorésistante traites par azathioprine.

BACKGROUND: Immunosupressors, particularly azathioprine, represents the therapeutic alternative in patients with corticodependant or corticoresistant Crohn's disease. The prescription of azathioprine in Tunisia is common, but there is not Tunisian studies evaluating the long term results of this drug in Crohn's disease patients. AIMS: To evaluate the long term results of azathioprine treatment with determination of rates of relapses, surgery and need to corticosteroids in patients with corticodependant or corticoresistant Crohn's disease, and to look for predictive factors to theses events. METHODS: A retrospective study on 12 years including all patients treated by azathioprine for corticodependant or corticoresistant Crohn's disease. We excluded the cases of follow up less than 6 months. RESULTS: We studied 56 patients (46 corticodependant and 10 corticoresistant). Induction of remission was obtained in 89% of the cases. Concerning the long term results, the relapse rate was 60% of patients treated with azathioprine, with actuarial rates of 38% at one year, 65% at 5 years and 75% at 10 years. Need for corticosteroid treatment was estimated at 42% and need for surgical treatment was estimated at 24%. The only predictive factor for relapse was duration of treatment by azathioprine more than 36 months, with sensitivity of 93% and specificity of 50%. CONCLUSION: Although an excellent result of azathioprine in induction remission, long term results showed deterioration of results of treatment. Physicians must be followed up Crohn's disease patients in order to rapidly detect and treat the clinical relapses of the disease.

[Long-term functional outcome of laparoscopic anti-reflux surgery]. / Résultats fonctionnels à long terme de la chirurgie anti-reflux sous coelioscopie.

BACKGROUND: Medical treatment of gastro esophageal reflux is associated with relapse in 30% of cases. In these patients, the best therapeutic option is surgical treatment, performed laparoscopically.However, there are few data on long-term functional outcome. AIM: To determine long-term results of laparoscopic antireflux surgery the mechanisms involved in patients with worse results. METHODS: We studied patients operated for reflux disease. They had either total or partial laparoscopic fundoplication. These patients were contacted to assess postoperative improvement, satisfaction and asked about the occurrence or not of a persistent postoperative dysphagia. RESULTS: Seventy one patients were included (Nissen in 61% of the cases and Toupet in 39%). After an average period of 52.4 months,80 % of patients were satisfied. 58% were completely improved,while 31% were partially improved after surgery. Persistent reflux symptoms reflux were observed in 8 patients and postoperative dysphagia was reported by 11 patients. Gastroesophageal reflux revealed by chronic cough was the only independent parameter associated with bad functional results in our patients. CONCLUSION: Laparoscopic anti reflux surgery is associated with a high frequency of satisfaction. However, patients with chronic cough respond less better to surgery. Strict selection of the patients before surgery must be done, to improve the functional results after anti reflux surgery.

[Evaluation of small bowel involvement in Crohn's disease by small- bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowel radiography]. / Évaluation de l'atteinte du grêle de la maladie de Crohn par vidéocapsule endoscopique : étude prospective et comparative avec le transit du grêle et l'entéroscanner.

BACKGROUND: Small-bowel videocapsule endoscopy (VCE) is a new technique in evaluation of intestinal involvement in several pathologies. Crohn's disease affects principally terminal ileum. Small bowel involvement in Crohn's disease is not well estimated by endoscopic and radiologic conventional techniques. AIMS: To evaluate the performances of VCE in detection of asymptomatic proximal small bowel lesions in consecutive patients with Crohn's disease with terminal ileal involvement, to compare the results of VCE to small bowel radiography and CT-enteroclysis and to determine the therapeutic impact of VCE in these patients. METHODS: A prospective study which included Crohn's disease patients with distal ileal involvement, based on radiological or endoscopic findings. We performed in all patients small bowel radiography, CT enteroclysis and VCE. Proximal involvement was characterized by presence of aphtoid, superficial or deep ulcerations in the jejunum or the proximal ileum. RESULTS: We studied 20 patients (12 men, mean age 31.6 years). VCE confirmed the distal ileal involvement in all patients. Significative proximal lesions was observed in nine patients (jejunum only: one case, jejunum and ileum: six cases and proximal ileum: two cases), in most cases aphtoid or superficial lesions. Deep ulcerations were observed in two patients. Small bowel radiography showed proximal ileal lesions in only two patients, and CT-enteroclysis in only one patient. Treatment by azathioprine was prescribed in two patients with severe and extended small bowel lesions in VCE examination. CONCLUSION: VCE is more accurate than radiologic techniques in detection of small bowel lesions in Crohn's disease. In cases of severe and extended small bowel involvement, VCE can conduct to changes of therapeutic approach.

Primary resistance to clarithromycin, metronidazole and amoxicillin of Helicobacter pylori isolated from Tunisian patients with peptic ulcers and gastritis: a prospective multicentre study.

BACKGROUND: The frequency of primary resistance to antibiotics in H. pylori isolates is increasing worldwide. In Tunisia, there are limited data regarding the pattern of H. pylori antibiotic primary resistance. AIM: To evaluate the primary resistance of H. pylori to clarithromycin, metronidazole and amoxicillin and to detect the mutations involved in clarithromycin resistance. MATERIALS AND METHODS: 273 strains isolated from adults and children were enrolled. The primary resistance to clarithromycin, metronidazole and amoxicillin was evaluated by means of E-test minimal inhibitory concentration (MIC). The real-time PCR using Scorpion primers was performed in all cases to assess clarithromycin primary resistance and point mutations involved. RESULTS: No resistance to amoxicillin was detected. For adults, resistance to clarithromycin and metronidazole was found respectively in 14.6% and 56.8%, and respectively in 18.8% and 25% in children. Overall, the rates of global primary resistance to clarithromycin and metronidazole in Tunisia were respectively determined in 15.4% and 51.3%.By the use of Scorpion PCR, the A2143G was the most frequent point mutation observed (88.1%), followed by the A2142G (11.9%); the A2142C was not found and 18 of 42 patients (42.8%) were infected by both the resistant and the susceptible genotype.The association of clarithromycin resistance with gender was not statistically significant, but metronidazole resistant strains were isolated more frequently in females (67.8%) than in males (32.2%) and the difference was significant. As for gastroduodenal diseases, the difference between strains isolated from patients with peptic ulceration and those with non peptic ulceration was not statistically significant. When about the distribution of resistant strains to clarithromycin and metronidazole between the three Tunisian cities (Tunis, Menzel Bourguiba and Mahdia), the difference was not statistically significant. CONCLUSION: Local data regarding the primary resistance of H. pylori to clarithromycin, metronidazole and amoxicillin and the main genetic mutation involved in clarithromycin resistance in vivo (A2143G) are necessary to prove a clear need for a periodic evaluation of antibiotic consumption and new therapeutic strategies in Tunisia in order to avoid the emergence of resistant strains.

Predictive factors of azathioprine prescription in adult patients with Crohn's disease.

BACKGROUND/AIMS: Azathioprine is the most commonly used immunomodulator in Crohn's disease. The aims of the study are to determine the cumulative frequency of azathioprine prescription in non selected consecutive inpatients with Crohn's disease and to identify a subgroup of patients with high risk of azathioprine prescription during the follow-up. METHODOLOGY: We studied consecutive in patients with established diagnosis of Crohn's disease admitted in our department in years 2002 and 2003. Cumulative frequency of azathioprine use during the follow-up was calculated. Predictive factors of azathioprine use were studies based on clinical, biological and endoscopic charts at the first hospitalization in our department. RESULTS: We include 88 patients (52 males, mean age 31.3 years (18 - 68)). Azathioprine was prescribed in 38 patients (43.2%) with a mean period of 12.9 months (1 - 90) after the first hospitalization. The cumulative frequency of azathioprine prescription was 11% the first month, 31% at 6 months, 35% at one year and 49% at 6 years. In univariate analysis, azathioprine use was more frequent in previously treated patients in an other department (p = 0.05), in case of ileal involvement > 40 cm (p = 0.02), previously treated patients with corticosteroids (p = 0.001), first treatment in our unit by corticosteroids (p < 0.0001), duration of the flare more than 6 months (p = 0.01), CDAI > 204 points (p < 0.0001), Hemoglobin level < 9.7 g/ dl (p < 0.0001) and cholesterolemia level < 1.32 g/l (p < 0.0001). Independent factors associated with azathioprine use in our population were diffuse involvement of the ileum at initial hospitalization (p = 0.0001; OR [95%CI]: 17.9 [4.1-77.9]), and previous prescription of corticosteroid therapy (p = 0.04; OR [95% CI]: 5 [1.1-25]). CONCLUSION: Azathioprine is frequently used in adult Crohn's disease patients, maximally within the first year after the first hospitalization. Patients with diffuse ileal involvement and previously treated patients with corticosteroids are at higher risk to azathioprine use and should have systematically the preventive strategies to ovoid opportunistic infections since their first visit.

[Technical aspects, indications and results of small bowel videocapsule endoscopy]. / Technique, indications et resultats de la videocapsule endoscopique du grêle.

BACKGROUND: Videocapsule endoscopy is a new non-invasive endoscopic tool useful for small bowel examination. AIM: The aims of this review are to precise the technical aspects of videocapsule endoscopy, indications and results of this technique in clinical practice. METHODS: Literature review. RESULTS: The main indication of vidéocapsule endoscopy is obscure gastrointestinal bleeding. Videocapsule endoscopy can precise the aetiology of the bleeding and guide the therapeutic approach. The second indication is Crohn's disease, in establishment of the diagnosis, evaluation of small bowel extension or in differential diagnosis of indeterminate colitis. Videocapsule endoscopy is also useful in patients with small bowel neoplasia, polyposis and some patients with celiac sprue. CONCLUSION: Videocapsule endoscopy is an important endoscopic technique which is must be quickly part of endoscopic diagnosis tools.

[Difficulty in diagnosing pseudotumoral autoimmune pancreatitis: two cases]. / Difficultés diagnostiques de la pancréatite auto-immune pseudotumorale: à propos de deux cas.

BACKGROUND: In recent years, autoimmune pancreatitis (AIP) has been increasingly recognized. The diagnosis of AIP is based on a series of clinical, biological and radiological criteria. In imaging, it may appear as two different forms: a diffuse form by destroying channels and pseudotumoral lesions that can cause inadequate resections. AIM: To report two new cases of pseudotumoral autoimmune pancreatitis CASES REPORT: We report two cases of pseudotumoral autoimmune pancreatitis, with different clinical, biological and radiologic features. The diagnosis was established easily in one case and after surgery in a 2nd case. CONCLUSION: Our two cases underline the difficulties still encountered in the diagnosis of AIP.

[Fertility and inflammatory bowel diseases]. / Fertilité et maladies inflammatoires chroniques de l'intestin.

BACKGROUND: Data concerning fertility during inflammatory bowel disease are insufficient and sometimes contradictory. The aims of this review are to precise the impact of inflammatory bowel disease on fertility. METHODS: Literature review. RESULTS: The risk of infertility seems to be raised at one under group of patients and made to intervene several factors of which, in particular for the Crohn's disease, the activity of the disease and the psychological impact leads by this chronic disorder. The decrease of the fertility, as very feminine as male, during the ulcerative colitis is essentially bound to the surgery. Data concerning the impact of various therapeutic used during inflammatory bowel disease on the fertility are very insufficient and interest especially male fertility.

[Sleep disorders in patients with gastroesophageal reflux disease: an open clinical and pH metric prospective study]. / Perturbations du sommeil au cours du reflux gastro-oesophagien: Résultats d'une etude prospective ouverte clinique et Ph-métrique.

BACKGROUND: Sleep disorders are frequent in patients with GERD. Severity of sleep disorders could be related to occurrence of nighttime symptoms, but the relationship between severity of GERD and the severity of sleep disorders is not well established. AIM: To identify the frequency of sleep disorders in patients with suspected GERD and the correlation between the severity of sleep disorders and pHmetric parameters in these patients. METHODS: We studied prospectively 50 patients with esophageal and supra-esophageal symptoms of GERD. 24-hour esophageal pH monitoring examination was performed in all patients. Standard survey was applied to determine the frequency and the severity of sleep disorders in these patients. RESULTS: We included 50 patients (10 men, 40 women), mean age 43.7 years (18-70). Nighttime symptoms were present in 26 patients (52%). Pathological acid gastro-esophageal reflux was diagnosed by 24-hour esophageal pH recording in 18 patients (36%), with nocturnal acid reflux in 19 patients (38%). Sleep disorders were reported by 29 patients (58%). Mean number of hours of sleep was 6.8 hours by night (4-9 hours). Clinical factors associated with higher frequency of sleep disorders were occurrence of nighttime symptoms (p < 0.0001) and duration of symptoms of GERD (53.2 +/- 41.4 months vs 26.0 +/- 18.1 months ; p = 0.007), with no association with BMI, age and sex. pHmetric parameters associated with sleep disorders were pathological acid reflux (p < 0.0001; OR [CI 95%]: 28.3 [3.3-240.8]) and nocturnal acid reflux (p < 0.0001; OR[CI95%] :32.7 [3.8 - 279.2]). Patients with sleep disorders had significant changes of pHmetric parameters compared to those without sleep disorders: Acid exposition time, numbers of reflux episodes, number of episodes longest than five minutes, duration of longest reflux episode and DeMeester score (respectively 6.1 +/- 8.8 vs 1.3 +/- 1.5 p = 0.01; 59.2 +/- 52.0 vs 20.7 +/- 21.6 p = 0.001; 3.1 +/- 6.1 vs 0.1 +/- 0.3 p = 0.03; 8.9 +/- 9.3 minutes vs 3.4 +/- 4.0 minutes p = 0.01; 24.0 +/- 33.2 vs 4.8 +/- 4.9 p = 0.01). Number of hours of sleep was significantly lower in patients with pathological acid reflux (5.3 +/- 1.2 hours vs 7.6 +/- 1.7 hours, p < 0.0001) and in patients with nocturnal acid reflux (5.2 +/- 1.1 hours vs 7.8 +/- 1.5 hours, p < 0.0001). Number of hours of sleep was strongly correlated with esophageal pH parameters CONCLUSION: Sleep disorders are frequent in patients with GERD symptoms. Severity of sleep disorders are strongly correlated with severity of global and nocturnal acid reflux as attested by 24-hour esophageal pH monitoring.

Tolllike receptor 4 (TLR4) polymorphisms in Tunisian patients with Crohn's disease: genotype-phenotype correlation.

BACKGROUND: The immune responses to bacterial products through the pattern recognition receptor (PRR) play a pivotal role in pathogenesis of Crohn's disease. A recent study described an association between CD and some gene coding for bacterial receptor like NOD2/CARD15 gene and TLR4. In this study, we sought to determine whether TLR4 gene was associated with Crohn's disease (CD) among the Tunisian population and its correlation with clinical manifestation of the disease. METHODS: 90 patients with CD and 80 healthy individuals are genotyped for the Asp299Gly and Thr399Ile polymorphisms by restriction fragment length polymorphism analysis. RESULTS: The allele and genotype frequency of the TLR4 polymorphisms did not differ between patients and controls. The genotype-phenotype correlation permitted to show that the Thr399Ile polymorphism was associated with early onset disease. CONCLUSION: this study reported the absence of association between CD and TLR4 gene in the Tunisian population, but this gene could play a role in clinical expression of the disease.

[Crohn's disease, primary sclerosing cholangitis and antiphospholipid syndrome: an uncommon association]. / Maladie de crohn, cholangite sclerosante primitive et syndrome des anti-phospholipides: une triple association exceptionnelle.

BACKGROUND: Inflammatory bowel diseases are frequently associated with extra-intestinal manifestations and other autoimmune disorders. Association between primary sclerosing cholangitis and Crohn's disease is established. However, the association of antiphospholipid syndrome with Crohn's disease was reported in the literature only in the form of isolated case reports. AIMS: To report a Tunisian case of association of Crohn's disease, primary sclerosing cholangitis and antiphospholipid syndrome. CASE REPORT: We report the case of a patient presenting a colonic Crohn's disease associated with primary sclerosing cholangitis and antiphospholipid syndrome. Sclerosing cholangitis was diagnosed basing on disturbances of the hepatic biochemical tests. Antiphospholipid syndrome was revealed by a venous thrombosis of the lower limbs. CONCLUSION: Although the anticardiolipin antibodies were frequently found during the course of primary sclerosing cholangitis, the association with antiphospholipid syndrome is exceptionally described. In the same way, triple association of primary sclerosing cholangitis, Crohn's disease and antiphospholipid syndrome was not brought back in the literature.