[Management of intestinal complications in inflammatory bowel diseases]. / Traitement des complications digestives des maladies inflammatoires chroniques de l'intestin.

The evolution of inflammatory bowel disease (IBD) is characterized by the occurrence of gastrointestinal complications. For Crohn's disease (CD), it is mainly strictures, fistulas and abdominal or pelvic abscess in luminal forms and perianal lesions (ulcers, fissures, fistula/abscess) in the perineal forms. For ulcerative colitis (UC), main complications are severe flare up and dysplasia/cancer. In Crohn's disease, stenosis can be treated medically in first line (steroid-immunosupppresseurs or antiTNF) especially when the inflammatory component is predominant or in extensive lesions. In case of limited lesions (< 4 cm) and low inflammatory component, endoscopic dilatation can be propose before surgery, especially in patients previously operated on. Abdomino-pelvic abscess should be drained if the size is greater than 4-5 cm and treated with antibiotics. If obstructive signs are present after the resolution of the abscess, surgery is usually required. In some cases, an antiTNF therapy can be discussed (ongoing trial with the GETAID). Surgery during the MC should be performed laparoscopically, particularly in uncomplicated forms (first ileocecal resection) but also whenever possible for complicated diseases. Anoperineal abscess must be drained by non-tight setons. Medical treatment also involves antibiotics and antiTNF, usually in combotherapy. Biological glue is especially interesting in simple fistulas. Collagen plugs have not demonstrated efficacy in simple or complex perianal Crohn's disease fistulas and may have a deleterious effect. They are therefore not recommended. Severe UC flare up are still conventionally treated with corticosteroids IV for 3-5 days, followed in case of failure of a 2nd line treatment with infliximab or ciclosporin. The place of emergency colectomy had regressed due to the effectiveness of medical treatments.

[What is the REAL long-term risk of proton pump inhibitors?] / Quel est le VRAI risque au long cours des inhibiteurs de la pompe à protons ?

Proton pump inhibitors (PPIs) are among the most prescribed drugs in the world. While their efficacy in acute management is indisputable, it has long been suggested that PPI therapy is safe in the long term. In recent years, there has been growing and justified concern about the long-term risks of PPIs. The majority of reported side effects are based on observational studies with a low level of evidence. Concerning digestive risks, PPIs seem to increase the risk of Salmonella and Campylobacter infections. However, the link between PPIs and Clostridium difficile infection is not established. Long-term PPIs may be responsible for an increased risk of gastric cancer according to several recent studies. With regard to extra-digestive risks, PPIs are associated with a moderate increase in the risk of chronic renal failure via an interstitial nephritis mechanism. PPIs also provide martial deficiency and may be associated with vitamin B12 and magnesium deficiency in some patients. Other adverse reactions have been suggested without any causal relationship being established (i.e., dementia or bone fractures, cardiovascular risk). In this review we will discuss the different long-term adverse effects of PPIs and their level of evidence.

[Acute severe colitis]. / La colite aiguë grave.

Acute severe colitis is a potentially life-threatening medical and surgical emergency requiring hospitalization and intensive monitoring. The diagnosis of severe acute colitis is based on clinical and biological criteria. Colectomy should be discussed at each stage of management and is indicated immediately in case of complications. Thromboembolic prevention with low molecular weight heparin is essential in any patient with severe acute colitis. The first-line medical treatment is intravenous corticosteroid at a dose of 0.8mg/kg/day of prednisone equivalent. In case of failure, a second line of medical treatment can be attempted in the absence of complications. The two possible treatments are infliximab and ciclosporin.

[Therapeutic advances in the management of biliary tract carcinoma]. / Les progrès dans la prise en charge des cholangiocarcinomes.

Cancers of the bile ducts or cholangiocarcinomas are a rare entity whose incidence is increasing in France. Surgical resection of cholangiocarcinoma remains the only curative therapy. Adjuvant therapy with capecitabine at a fixed dose of 1250mg/m2 twice daily from day 1 to day 14 (21-day cycle) for a 6 months period is now the standard of care after curative surgery. At a metastatic stage, the reference treatment consists of the combination of a platinum salt in addition to gemcitabine. No biomarker has been identified to predict the response to chemotherapy. DNA sequencing of the tumor can identify specific tumor mutations in bile duct cancers that are the focus of targeted studies.

Impact of a dedicated multidisciplinary meeting on the management of superficial cancers of the digestive tract.

Background The recent development of endoscopic resection for superficial gastrointestinal cancers could justify the need for a dedicated oncological multidisciplinary meeting (MDM). The aim of our study was to evaluate the impact of the dedicated MDM on the management of superficial cancers of the digestive tract. Methods A dedicated MDM was developed at our tertiary referral center. A retrospective review of the MDM conclusions for all patients referred from March 2015 to March 2017 was performed. Outcomes measurements were the outcomes of endoscopic resection, and the concordance rate between the MDM recommendations, European Society of Gastrointestinal Endoscopy (ESGE) guidelines, and final patient management. Results In total, 153 patients with a median age of 69 years were included. Half of the patients had major comorbidities. The mean lesion size was 25 mm, and R0 and curative resection rate were 73.9 % and 56.9 %, respectively. Forty-three patients had an indication for surgery after endoscopic resection. The concordance rate between ESGE guidelines and MDM recommendation was 92.2 %, and 12 patients did not receive the treatment recommended due to comorbidities. Conclusion A MDM dedicated to superficial tumors helped tailor the ESGE guidelines to each patient in order to avoid unnecessary surgery.

[Usefulness of small-bowel capsule endoscopy in gastrointestinal bleeding]. / Intérêt de l'exploration de l'intestin grêle dans les hémorragies digestives.

In France, upper gastrointestinal haemorrhages have an estimated annual incidence of 143 cases per 100,000 inhabitants. Classically, two types of digestive hemorrhage are described: acute and chronic digestive hemorrhages. Upper endoscopy is carried out in case of hematemesis or melena. It requires that the patient has been fasting for at least 6hours for solids and 3hours for liquids. The main etiologies of hemorrhagic hemorrhage of the origin are the vascular abnormalities, inflammatory or drug-induced ulcerations, intestinal tumors, Meckel's diverticulum, and Dieulafoy ulcer. The modalities of exploration of the small intestine before digestive hemorrhage are the wireless capsule, a reference examination for the exploration of the small intestine, enteroscopy, therapeutic examination, entero-CT or MRI, and 99mTc-labeled red blood cell scintigraphy. In this review, we will discuss the different etiologies of the digestive haemorrhage of intestinal origin and propose a management algorithm.