Screening for celiac disease, by endomysial antibodies, in patients with unexplained hypertransaminasaemia.

OBJECTIVE: To do a serological screening for celiac disease in patients with unexplained liver cytolysis. MATERIALS AND METHODS: Fifty-six patients with liver cytolysis without known aetiology were studied. Endomysial antibodies were determined by indirect immunofluorescence on human umbilical cord. Two thousand and five hundred blood donors served as control group. For statistical analysis, we used Chi-square or Fisher's exact test. RESULTS: The frequency of IgA endomysial antibodies in our patients was significantly higher than in the control group (8.92% vs. 0.28%, p < .001). In female, endomysial antibodies were significantly more frequent in patients than in healthy subjects (12.12% vs. 0.4%; p < .001). In male, endomysial antibodies were significantly more frequent in patients than in healthy subjects (4.34% vs. 0.22%; p = .006). The frequency of positive EMA in female patients was higher than in male, but the difference was not statistically significant (12.12% vs. 4.43%; p = .6). Two patients were non-compliant with the gluten-free diet. One patient was out of touch. For the two other patients, transaminase levels reverted to normal level within six months of strict gluten withdrawal. CONCLUSIONS: A screening for celiac disease should be included within the diagnosis protocol of liver cytolysis.

Quality of life in inflammatory bowel disease in Tunisian patients.

BACKGROUND: The management of the health-related quality of life (HRQL) is increasingly considered as an important treatment goal in chronic diseases including inflammatory bowel diseases (IBD). AIM: The aim of our study was to determine the impact of IBD on HRQLand identify the factors involved in the deterioration of HRQL in these patients. METHODS: We conducted a case-control study including 108 patients; 66 had Crohn's disease (CD) and 42 had ulcerative colitis (UC). In the measurement of HRQL, we used a general questionnaire "Short Form 36: SF36" and a specific questionnaire "Tunisian Inflammatory Bowel Disease Questionnaire: T-IBDQ". RESULTS: HRQL of patients was worse than controls with a statistically significant difference for six of the eight dimensions of the SF 36 "Physical Functionning PF", "Role Physical RP", "General health GH","SocialFunctionning SF "," Mental Health MH "and" Role Emotional RE "as well as the Mental summary score (MCS) and the Physical summary score (PCS ) (p <0.05). The factors involved in the alteration of HRQL were: age <30 years, poor socioeconomic conditions, disease activity, use of corticosteroids, a number of surgeries ≥2 and anterior hospitalization history. CONCLUSION: In this study, IBD cause impaired HRQL affecting almost all areas of the SF 36 questionnaire. Incriminated factors may be related to the patient, disease and even treatment.

[Prévalence de l'infection à Helicobacter pylori et des lésions endoscopiques hautes chez les diabétiques: Etude cas/témoins]. / Prevalence of helicobacter pylori infection and gastroscopic finding in diabetic patients: a case-control study.

BACKGROUND: Current data on the prevalence of Helicobacter pylori infection in dyspeptic diabetic patients are contradictory in the literature. AIM: the aim was to assess the prevalence of Helicobacter pylori infection, gastroscopic lesions, and gastric histopathological lesions, in dyspeptic diabetic patients. METHODS: It was a case-control study collecting 394 dyspeptic patients (194 diabetic and 200 nondiabetic patients). RESULTS: The average age of patients was 47 years. 144 patients (47%) were male and 150 patients (53%) were female. The two patient groups were matched for age and sex. The prevalence of Helicobacter pylori infection was comparable between the two groups of patients (85% in diabetics versus 90% in the controls). The frequency of gastroscopic lesions was 50% in diabetics and 55% in controls with no significant difference between the two groups. At histology, the prevalence of chronic gastritis, intestinal metaplasia, and gastric atrophy was 85%, 13% and 39% respectively in the group of diabetic patients. These results were comparable to those found in patients without diabetes. CONCLUSION: Our work shows no difference between diabetics and non-diabetics on the prevalence of Helicobacter pylori infection, gastroscopic, and gastric histopathological lesions.

[Primary biliary cirrhosis: a retrospective study of 36 cases]. / La cirrhose biliaire primitive: étude rétrospective d'une série de 36 cas au centre Tunisien.

BACKGROUND: Primary biliary cirrhosis is a rare cholestasis liver disease affecting the women of mature age,it association with Autoimmune hepatitis defined the overlap syndrome. AIM: It was to determine epidemiological, clinic-biological, immunological, histological, therapeutic and evolutive characteristics of PBC and to compare them to those in subjects having an overlap syndrome. METHODS: It is a retrospective study grouping all the cases of PBC hospitalized over a period of 15 years (1995-2009) in the hepatogastro-enterology department at Sahloul hospital in Sousse. RESULTS: Thirty six cases were grouped over the period of the study. They were all women. The mean age was 54.5 years (28-79). The disease was symptomatic at the moment of diagnosis in 75% of the cases. The functional signs revealing the disease were principally asthenia, present in 69.4% of the cases, followed by jaundice and prurit. Cholestasis was constant in all the patients, stage III of scheuer was the most frequent in the patients (25%) followed by stage IV (22%). OS was present in 1/3 of the patients; the treatment is based on the prescription of urso-desoxycholic Acid associated with corticoids and with immunosuppressors in the case of OS. The average survival of the patient having PBC and OS was comparable. It was respectively of 61.8 and 55.9 months. CONCLUSION: Our results as well as the literature reveal the rarety of this disease and its predominance in women. PBC has to be diagnosed at an early stage to guarantee a better response and a better survival of the patients.

Management of anal fistulas in Crohn's disease after failure of Infliximab.

INTRODUCTION: Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. AIM: Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab. METHODS: A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded. RESULTS: Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated. CONCLUSION: Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.

Predictive factors of recurrence in spontaneous bacterial peritonitis in Tunisian patients with cirrhosis.

Introduction: Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. Aim: To assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Materials & methods: We conducted a retrospective study including patients with cirrhosis having a first episode of SBP. Results: A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. The mean time to onset of the first SBP recurrence from the first episode was 32 days. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score. Conclusion: There was no impact on survival of recurrent SBP compared with the first SBP episode.

Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. The aims of this study were to assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Thus, we conducted a retrospective study including patients with cirrhosis having a first episode of SBP. A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score.

Exploring work productivity loss in patients with inflammatory bowel disease.

Aim: We aimed in this study to evaluate the impact of inflammatory bowel disease (IBD) on patients' professional life and to determine predictors of severe work productivity loss (WPL). Materials & methods: A cross sectional study including patients with a confirmed diagnosis of IBD. Work productivity was evaluated with the work productivity and activity impairment score. Results: Severe absenteeism and WPL were found in respectively 7 (5.1%) and 54 (39.1%) patients. In multivariate analysis, the following features were found to be independently associated with severe WPL: penetrating Crohn's disease (p: 0.001, OR: 6), anemia (p: 0.031, OR: 3.23), diarrhea (p < 0.001, OR: 11.23) and a secondary level of education (p: 0.003, OR: 1.95). Conclusion: Our results show that IBD have a substantial effect on patients' professional life.

Inflammatory bowel diseases (IBD) are chronic conditions that cause inflammation in the digestive system. We wanted to know how IBD affects people's ability to work and what factors contribute to work difficulties. We asked adults with IBD about their education, work conditions and medical history. We found that a significant number of patients experience severe work productivity loss and absenteeism. Factors such as certain types of IBD, anemia, diarrhea and lower education level were linked to more severe work problems. These findings emphasize the impact of IBD on work life and highlight the importance of addressing these challenges in patient care.

Recurrent primary hepatic VIPoma treated with a combination of surgical resection and loco-regional therapy.

Vasoactive intestinal peptide (VIP) secreting tumors (VIPomas) are insidious functional neuroendocrine tumors originating mainly from pancreatic islet cells. Hepatic localization is considered exceedingly rare as only few cases have been reported in the literature. Diagnostic and therapeutic management of this tumor is still not clearly codified and therefore represents a real challenge for clinicians. Herein we report a unique case of a primary hepatic VIPoma recurrence in a female patient 22 years after curative resection. The patient had two sessions of transarterial chemoembolization. Complete symptomatic improvement was achieved since the first day after the first session. This case highlights that long-term follow-up for patients with hepatic VIPoma is mandatory as recurrence could occur several years after curative surgical treatment.

VIPomas are rare tumors secreting a hormone that is vasoactive in the intestine causing severe diarrhea. The majority of VIPomas arise within the pancreas. The hepatic localization is extremely rare. We report a case of a very late recurrence of a primary hepatic VIPoma surgically treated 20 years ago. The case was managed with therapeutic radiology by blocking the blood supply to the tumors after administering anticancer drugs in the vessels near them.

The natural history of hepatitis B virus cirrhosis after the first hepatic decompensation in Tunisia.

AIM: To define the natural long term course of viral B cirrhosis after the onset of hepatic decompensation and to determine the predictive factors of death. METHODS: Retrospective longitudinal study including 77 cases of viral B cirrhosis among 192 consecutive patients with cirrhosis, hospitalized between 1997 and 2005 for the first hepatic decompensation. All those patients were followed- up until death or until December 2006. The probability of survival after the first hepatic decompensation was calculated using the Kaplan Meier method. The predictive factors of death were determined through univariate and multivariate analyses with the Cox regression model. RESULTS: Fifty four men and 23 women with an average age of 54±14.9 years were hospitalized for the first decompensation of the viral B cirrhosis. The 77 patients had been under observation for an average period of 24.2 ±21.1 months. During that time 64% among them died. The probability of survival after decompensation was 47% in 2 years and 22 % in 5 years. During follow- up, ascites was the most frequent decompensation (85%) followed by hepatic encephalopathy (38 %), variceal hemorrhage (34 %), jaundice (30%), hepato renal syndrome (27%), hepatocellular carcinoma (21%), and spontaneous bacterial peritonitis (14%). At univariate analysis four factors were predictive of death: Child Pugh C score (p=0.009), hepatocellular carcinoma (p=0.01), rate of serum gammaglobulin superior to18g / l (p=0.008) and prothrombin time inferior to 50 % (p=0.02). According to the multivariate analysis only the rate of serum gammaglobulin superior to 18g /l was an independent predictive factor of mortality (p=0,001) with IC (95 %) [1.623 - 5.88]. CONCLUSION: In Tunisia, the prognosis of viral B cirrhosis after the first decompensation is bad, because a patient on 5 only was able to survive beyond 5 years. Ascites is the most frequent decompensation. Only the rate of serum gammaglobulin superior to 18g / l is an independent predictive factor of mortality.

Effect of Helicobacter pylori eradication therapy on the response of MALT-Gastric lymphoma.

INTRODUCTION: The link between gastric mucosa-associated lymphoid tissue lymphoma (LG-MALT) and chronic Helicobacter Pylori (HP) infection had led to a real revolution in the management of the disease. AIMS: To study the results of the HP eradication therapy and to clarify its place in the tumor response. METHODS: A descriptive retrospective bicentric study, between January 2007 and December 2016, including patients with LG-MALT treated in the gastroenterology departments of Sahloul hospital in Sousse and Habib Bougtafa hospital in Bizerte, and having received treatment for eradication of HP. RESULTS: Sixty-three patients were included. The male/female sex ratio was 1.42. The average age was 58 years. The symptomatology was dominated by epigastric pain (96.8%). On digestive endoscopy, the most frequent location and appearance were gastric antrum (39.6%) and ulcerations (89%). The lymphoma was classified as stage IE and IIE1 in 81% and 19% of cases, respectively. The HP status was positive in all patients. The HP eradication rate was 82.5% after three anti-HP treatment courses. Complete remission of lymphoma was obtained in 81% of patients at 18 months. Non-response to HP eradication therapy was observed in 19% of patients. Non-responder patients had a longer diagnostic delay (p=0.02), more diffuse endoscopic involvement (p=0.001) and a more frequent appearance of large gastric folds (p=0.001). CONCLUSION: The course of LG-MALT is determined by the treatment for the eradication of HP. Its success promotes remission of lymphoma.

Massive hematochezia due to jejunal varices successfully treated with coil embolization.

We report a case of hematochezia with hemodynamic instability due to jejunal varices in a cirrhotic patient with no prior history of surgery. The patient was managed with coil embolization via the portal vein. After which, the patient did not present any hemorrhage recurrence and maintained a stable hemoglobin level.

Predictors of postoperative recurrence in a cohort of Tunisian patients with Crohn's disease.

Background: The aim of our study was to evaluate the frequency and risk factors of clinical postoperative recurrence in Tunisian patients with Crohn's disease (CD). Methods: Clinical data of 86 patients with CD who underwent ileocolonic resection at University Hospital of Sahloul in Tunisia were retrospectively reviewed. Continuous data are expressed as median (interquartile range), and categorical data as frequencies and percentages. Multivariate Cox proportional hazard regression analysis was conducted to identify the risk factors of postoperative clinical recurrence. Results: A total of 86 patients with CD were included in this study. During follow-up, 21 patients (24.4%) had clinical recurrence. The cumulative clinical recurrence rate was 9.3% at 1 year and 20.9% at 5 years. In univariate analysis, predictive factors of postoperative clinical recurrence were active preoperative smoking (p = 0.008), ileal location of the disease (p = 0.01), active CD [Crohn's Disease Activity Index (CDAI) > 150] (p = 0.04), duration of disease before first surgery <9.5 months (p = 0.027), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.005). In multivariate analysis, only smoking (p = 0.012), duration of disease before first surgery <9.5 months (p = 0.048), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.046) were confirmed to be independent factors of clinical relapse. Conclusion: Smoking, duration of disease before first surgery <9.5 months, and limited resection margins (<2 cm) from macroscopically diseased bowel were independent risk factors for clinical recurrence. Based on these factors, patients could be stratified in order to guide postoperative therapeutic options.

Spectrum of acute hepatitis and its clinical outcome in a central region in Tunisia.

INTRODUCTION: given the lack of studies on acute hepatitis (AH) in Tunisia, we carried out this study to find the etiological spectrum and clinical profile of AH and to investigate the impact of viral etiology on the outcomes of AH. METHODS: retrospective descriptive study collecting all patients with AH from 2010 to 2017. The data were compared between two groups (viral AH and non-viral AH). RESULTS: one hundred and three patient´s files were included. The average age of our patients was 30.15 years. An etiology was found in 92 patients (89.3%). The viral etiology was found in 70 patients (76.1%). Hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV) and cytomegalovirus (CMV) were in the cause in 52, 16, 1 and 1 patient respectively. Elsewhere, it was toxic hepatitis in 10 patients (10.9%) including 7 of drug-related AH. Budd-Chiari syndrome and autoimmune hepatitis with acute onset were reported in 3 (3.3%) and 7 (7.6%) patients, respectively. Patients with viral AH were younger than those with non-viral AH (p = 10-3). There was more recourse to hospitalization for non-viral AH. Patients with viral AH had a higher mean aminotransferase (ALT) level than those with non-viral AH. The liver damage was more severe in the non-viral AH group with lower PT. There was more severe form, more transition to chronicity and more deaths in the non-viral AH group. Conclusion: the results found in our study concerning the distribution of the etiologies of AH as well as their evolutionary aspects are consistent with the data in the literature.

[The particularity of Helicobacter pylori chronic gastritis in the west center of Tunisia]. / Les particularités de la gastrite chronique a Hélicobacter pylori au centre ouest de la Tunisie.

BACKGROUND: The Helicobacter pylori (HP) is strongly associated with chronic gastritis. The aim of our study was to determine prevalence of the HP chronic gastritis in the west center of Tunisia and to clarify the clinical and the histological particularities of this infection. METHODS: it is a prospectif study carried out from September 2002 to July 2005 and had included 352 patients. All the patients had an upper endoscopy in which five gastric biopsies were taken for a histological study. The biopsy specimens were fixed in 10% buffered formol and then included in paraffin. The specimens were cut at 4 microm and stained with Hematoxyline Eosine, modified Giemsa and Alcian bleu SAP. The histological examination revealed HP specimens, the lymphoplasmocytic infiltration, the gastritis activity, the gastric atrophy and the intestinal metaplasia according to Sydney system. RESULTS: They were 162 men and 190 women,with a mean age of 48.3 years. The erythematous antral gastritis was the most frequent at endoscopy (26.7%). The prevalence of HP chronic gastritis was 89% in patients with endoscopic lesions. The activity of the gastritis was 89.7% in the antrum and 52.2% in the fundus. The activity mean score in the antrum was 2, 1.8 and 0.3 respectively in the case of duodenal ulcer and gastric adenocarcinoma vs 0.68, 1.1 and 0.16 in gastric fundus. The prevalence of gastric atrophy was 35%. The atrophy was found in the antrum in 98% of cases. The prevalence of intestinal metaplasic was 11%. CONCLUSION: the HP chronic gastritis is very frequent in the west center of Tunisia. Its prevalence is found elevated since the adolescence. It predominate the gastric antrum. It is often associated with a duodenal ulcer rather than gastric cancer.

Synchronous Hepatocellular Carcinoma in a Patient with Primary Gastric Cancer: An Exceptional Association.

Hepatocellular carcinoma (HCC) is the most frequent type of liver cancer. Liver cirrhosis of any etiology is considered the main risk factor for the development of HCC. However, HCC in noncirrhotic livers remains an uncommon finding. The association of HCC with a primary gastric adenocarcinoma was described in the literature as part of a hepatoid adenocarcinoma which is a special type of primary gastric carcinoma characterized by histologic similarities to HCC with excessive production of α-fetoprotein. Herein, we report the case of a 50-year-old male patient, with no history of pre-existing liver disease, who was admitted due to epigastric pain and vomiting. He was diagnosed with HCC in noncirrhotic liver associated with primary gastric adenocarcinoma. To our knowledge, this is the first case report of synchronous HCC and gastric cancer with no hepatoid adenocarcinoma features in Tunisia.

Cirrhotic cardiomyopathy.

The presence of cardiocirculatory dysfunction in liver cirrhosis has been described since 1960 and it was exclusively attributed to alcoholic cardiomyopathie. Only in the last two decades, the term of cirrhotic cardiomyopathy (CCM) was introduced to describe cardiac dysfunction in patients with cirrhosis. This entity is currently underdiagnosed because the disease is usually latent and manifests when the patient is under stress. However, overt cardiac failure has been described after transjugular intrahepatic portosystemic shun and liver transplantation. The diagnosis of CCM is still difficult to determine because of the lack of specific diagnosis tools. CCM is characterized by systolic dysfunction, diastolic dysfunction and electrophysiological abnormalities. At present, there is no specific treatment outside liver transplantation in the light of increased mortality and postoperative complications.Our review provides an overview of CCM, its definition, prevalence, pathogenic mechanisms, clinical presentation, various explorations and management in light of the most recent published literature.

Vogt-Koyanagi-Harada syndrome and Crohn's disease: an exceptional association.

Vogt-Koyanagi-Harada disease (VKH) is a rare, multisystem disease of melanocyte-containing organs. It is characterized by diffuse, granulomatous inflammation involving various organs. It has been reported to occur in association with other autoimmune disorders. We report the case of a female patient who was diagnosed with VKH at the age of 4 years and who was treated with corticosteroids until the age of 16. Twenty years later, Crohn's disease was diagnosed, with a severe flare-up. Three cases of VKH associated with ulcerative colitis have previously been reported anecdotally but, to our knowledge, this is the first case occurring in association to Crohn's disease.

[Predictive factors of recurrence after surgery in severe attacks of hemorrhagic ulcerative proctocolitis]. / Facteurs prédictifs de recours à la chirurgie dans la rectocolite ulcéro hémorragique en poussée grave.

AIM: The purpose of our study was to determine clinical, biological or endoscopic factors that predict surgery after a glucocortico steroid treatment failure in severe attacks of ulcerative colitis. METHODS: Sixty one patients were analyzed. A therapeutic response for glucocorticosteroid was defined as the absence of resort to surgery within the first 30 days after hospitalization. Predictive factors were assessed using univariate and multivariate analysis. RESULTS: Fifteen patients (24.6%) had a medical response. In univariate analysis, predictive factors of surgery were: male sex, tobacco, number of colitis attacks in case history, temperature over 38 degrees C, erythrocyte sedimentation rate over 30 mm, systolic blood pressure below 11, deep and wide ulcers. During the course, bowel movements/day over 7, pulse over 90/mn, temperature over 38 degrees C on day 3 after treatment initiation as well as passage of blood on day 5 were identified as predictors of surgery. In multivariate analysis, bowel movements over 7/day on day 3 of hospitalization was independently predicted a surgery. CONCLUSION: Bowel movements/day over 7 on day 3 of hospitalization was the only independently predictive factor of surgery after glucortico steroid treatment failure

[Stromal tumors of the digestive tract: three small bowel localisation]. / Tumeurs stromales du tube digestif: trois cas localises au niveau du grêle.

BACKGROUND: Stromal tumors of the digestive tract are undifferenciated connective tissue tumors, identified as stemming of "pace-maker" cells of Cajal related to the immunohistochimical characterization of the phenotype. AIM: Report three new cases CASE REPORT: We report three observations of the small bowel stromal tumors reveal by anemia in one case and mass formation in two cases. The aim of this study was to discuss the anatomo-clinical, prognosis and management of these tumors.

[Epidemiologic profile of gastric carcinoma: study of 140 cases]. / Profil epidémiologique de l'adénocarcinome gastrique: Etude de 140 cas.

The authors make a retrospective study of a series of 140 patients aged 59 years in average, followed up from 1995 to 2002 for adenocarcinoma of the stomach. Surgical resection was performed in 79 percent of the patients with total gastrectomy in 15.4%, partial gastrectomy in 50.6%. Resection was considered as curative in 66%. Lymph node metastases were present in 42, 9 percent of the patients. Margins of resection were involved in 24, 5% of the specimens. The mean survival rate was 26.5 months, 13 months and 5 months after curative resection, palliative resection and without resection.