[Management of complicated Barrett's esophagus. Observational study carried out in a regional hospital]. / Prise en charge de l'œsophage de Barrett compliqué. Étude observationnelle réalisée dans un centre hospitalier régional.

The incidence of Barrett's esophagus, complication of gastroesophageal reflux disease, is rising in western countries. It is the same for esophageal adenocarcinoma, of which it is the main contributing factor. This retrospective study seeks to report the incidence of these pathologies observed in a regional hospital center and to describe their management. In 5 years, 354 Barrett's esophagus are detected and 34 of them are complicated by high-grade dysplasia or adenocarcinoma. Endoscopic resection is performed in 24 of these patients. The histological analysis of which leads to the conclusion of adenocarcinoma in 20 patients and high-grade dysplasia in the 14 others. The complications of endoscopic and surgical resections are detailed. Their frequency and severity remain low, comparable to data in the literature.

L'incidence de l'œsophage de Barrett, complication du reflux gastro-œsophagien, est en croissance dans les pays occidentaux. Il en est de même de l'adénocarcinome œsophagien dont il est le principal facteur favorisant. Cette étude rétrospective s'attache à rapporter l'incidence de ces pathologies, observées dans un centre hospitalier régional, et à détailler leur prise en charge. En 5 ans, 354 œsophages de Barrett sont détectés et 34 d'entre eux sont compliqués de dysplasie de haut grade ou d'adénocarcinome. Une résection endoscopique est réalisée chez 24 de ces malades. Les analyses histologiques permettent de conclure à un adénocarcinome chez 20 malades et une dysplasie de haut grade chez les 14 restants. Les complications des résections endoscopiques et chirurgicales sont détaillées. Leur fréquence et leur gravité restent faibles, comparables aux données de la littérature.

[Efficacy of macro-clips for perforations and fistulas following endoscopic or surgical procedures. Retrospective analysis of 25 consecutive cases]. / Les macro-clips utilisés dans la suture endoscopique des perforations et fistules compliquant des procédures chirurgicales et endoscopiques Résultats d'une étude monocentrique, rétrospective des 25 premiers cas.

OBJECTIVE: The aim of our retrospective study is to analyse the results of endoscopic macro-clips used for closing intestinal breaches in the real life. Post-endoscopic, spontaneous perforations and surgical fistulas are included. Our results are compared with principal published series. METHODS: Between 2010 and 2015, 25 consecutive patients underwent an endoscopic suture with macro-clips to seal a breach resulting from endoscopic perforation, surgical fistula, invasive medical procedure or spontaneous perforation. RESULTS: The endoscopic efficacy was immediate for all patients whose perforation was of endoscopic aetiology. None of them required surgery. Secondary complementary endoscopic treatment was only used in 6/25 patients. All of them had non-endoscopic aetiology for their perforation. The survival at 1 month was 84 % and at 3 months of 76 %. CONCLUSION: Our results confirm the high efficiency of macro-clips in the treatment of endoscopic breaches in a regional hospital center. The use of macro-clips seems less convincing for the closure of some postoperative fistula. The suture with macro-clips associated with endoscopic and medical treatments allowed to avoid surgical redo in some cases.

Objectifs : Le but de notre étude est d'analyser rétrospectivement les résultats obtenus en utilisant les macro-clips pour réaliser des sutures endoscopiques dans la vie réelle. Les perforations spontanées, postendoscopiques et post-chirurgicales sont incluses. Nos résultats sont comparés à ceux des principales séries publiées. Méthodes : Entre 2010 et 2015, 25 patients consécutifs ont bénéficié d'une suture endoscopique à l'aide de macro-clips utilisés pour fermer des larges brèches transmurales apparues après procédures endoscopiques, procédures chirurgicales ou invasives et, également, lors d'une perforation spontanée. Résultats : La fermeture endoscopique a été immédiate chez tous les patients dont la perforation avait pour origine une procédure endoscopique. Aucun de ces patients n'a requis d'intervention chirurgicale. Un second traitement endoscopique, complémentaire, a été réalisé chez 6/25 patients pour lesquels l'origine de la perforation n'était pas endoscopique. La survie globale à 1 mois était de 84 % et à 3 mois de 76 %. Conclusion : Nos résultats confirment l'efficacité remarquable des macro-clips dans le traitement des perforations endoscopiques rencontrées dans un centre hospitalier régional. Leurs résultats sont moins convaincants lorsqu'ils sont utilisés dans la fermeture des fistules post-chirurgicales. Ces macro-clips, utilisés dans une stratégie associant des traitements médicaux, radiologiques et endoscopiques complémentaires, permettent de réduire le recours à la reprise chirurgicale à de très rares cas.

[Acute cytomegalovirus proctitis in a immunocompetent patient]. / Rectite aiguë à cytomégalovirus chez un patient immunocompétent.

Cases of CMV proctitis are frequently reported in immunocompromised patients. However, some cases of CMV proctitis are linked to a CMV primary infection and to unprotected anal intercourse in immunocompetent patients. The most common symptom is bloody diarrhea (hemorrhagic colitis). The endoscopic exam can present in distincts forms. The diagnostic is based on a set of clinical, biological, endoscopic and histological arguments. The prognosis of the disease is favorable. The treatment is supportive. A research on other sexually transmitted diseases must be conducted.

Des cas de rectite à cytomégalovirus (CMV) sont fréquemment rapportés chez des patients immunodéprimés. Cependant, certains cas de rectite à CMV sont associés à une primo-infection à CMV et des rapports anaux non protégés chez une personne immunocompétente. La diarrhée hémorragique est le symptôme le plus fréquent. La présentation endoscopique est variée. Le diagnostic repose sur un faisceau d'arguments cliniques, biologiques, endoscopiques et histologiques. Le pronostic de l'affection est favorable. Le traitement est simplement supportif. Une recherche d'autres maladies sexuellement transmissibles doit être réalisée.

[Incidence and treatment of complications observed after endoscopic mucosal resection of superficial digestive tumours in a regional general hospital]. / Incidence et traitement des complications observées après résections endoscopiques muqueuses des tumeurs digestives superficielles dans un Centre Hospitalier Régional.

Superficial digestive tumours resection by endoscopic mucosal resection and sub-mucosal dissection causes very few complications according to the results obtained in expert centers. This work reports the rate of complications observed in a regional hospital, also comparing the results of their therapeutic management. The first 100 patients treated by endoscopic mucosal resection and sub-mucosal dissection, conducted by conventional techniques, were studied. The usual complications (stenosis, bleeding, perforation) were identified and details of their treatment reported. The overall complication rate was 16 %. Symptomatic stenoses are observed in 4 % of patients. Secondary bleeding occurs in 5 % of cases. Endoscopic management of these complications is effective in all cases, when it is attempted. Perforations complicate 7 % of the procedures. Two patients were assigned to surgery, successfully, the other 5 patients were treated by endoscopic sutures without damage. The complication rates observed in our department are comparable with results reported by the reference western centers. Their endoscopic management is usually successful and rescue surgery is unfrequent.

La résection par mucosectomie et dissection sous-muqueuse des tumeurs digestives superficielles n'entraîne que très peu de complications selon les résultats obtenus dans les centres experts. Ce travail rapporte le taux de complications observé dans un centre hospitalier régional, comparant également les résultats de leur prise en charge. Les 100 premiers patients ayant été traités par mucosectomie et dissection sous-muqueuse, effectuées selon les techniques classiques, ont été étudiés. Les complications habituelles (sténoses, hémorragies et perforations) ont été répertoriées ainsi que les détails de leur traitement. Le taux global de complications est de 16 %. Les sténoses symptomatiques affectent 4 % des patients. Les hémorragies secondaires surviennent dans 5 % des cas. La prise en charge endoscopique de ces complications est efficace dans tous les cas, lorsqu'elle est tentée. Les perforations compliquent 7 % des procédures. Deux patients ont été confiés à la chirurgie, avec succès, les 5 autres patients ont été traités par sutures endoscopiques sans séquelle. Le taux de complications observé dans notre service est comparable aux résultats rapportés par les centres occidentaux de référence. Leur prise en charge endoscopique est régulièrement efficace et le recours à la chirurgie est peu fréquent.

[Ulcerated duodenitis revealing Henoch-Schönlein purpura]. / LE CAS CLINIQUE DU MOIS. Duodénite ulcérée révélant un purpura rhumatoïde.

Inflammation and duodenal ulcers can meet many etiologies. We report the case of a young adult with an ulcerated duodenitis revealing Henoch-Schönlein purpura. The abdominal symptoms preceded the emergence of the classical cutaneous signs of the disease.

[Hypercalcemia and acute renal failure: a case report of vitamin D intoxication]. / Le cas clinique du mois. Hypercalcémie et insuffisance rénale aiguë: un cas clinique d'intoxication à la vitamine D.

Vitamin D (VTD) deficiency has become a topical issue leading to screening with frequent supplementation. The latter can be dangerous and exceptionally causes overdoses. We report the case of a 20 year old patient with abdominal pain in the setting of hypercalcemia due to intoxication by VTD. This case offers the opportunity to describe the differential diagnosis of hypercalcemia and to brownse through the literature in search of clinical practice recommendations for VTD supplementation.

[When genetics spices up a severe flare of chronic inflammatory bowel disease]. / Quand la génétique pimente une poussée sévère de maladie inflammatoire chronique intestinale.

The simultaneous occurrence of pneumomediastinum, peridural emphysema, subcutaneous emphysema and pneumothorax is extremely rare. We report the case of a young man with severe chronic inflammatory bowel disease presenting with voluminous spontaneous pneumomediastinum complicated by subcutaneous emphysema as well as peridural emphysema and pneumothorax. A genetic disorder is suspected.

Treatment of a nephrotic syndrome by endoscopic removal of a villous adenoma of the duodenum.

We report the case of a patient diagnosed with a villous adenoma of the duodenum showing high degree dysplasia who developed a nephrotic syndrome (NS) due to a membranous nephropathy (MN), demonstrated by renal biopsy. Only the endoscopic resection of the duodenal adenoma could control the NS. The first manifestation of a MN is often the development of a NS. Up to 20% of patients older than 65 years who develop a MN have cancer. Tumours most often identified are those of lung, prostate and digestive tract. A renal biopsy is required to identify this type of nephropathy. If a diagnosis of MN is made, an associated tumour should be looked for.

[Paradox: when a prothrombotic disorder is responsible for an upper gastrointestinal bleeding. Case report of hepatoportal sclerosis]. / Paradoxe: lorsqu'un état prothrombotique est responsable d'une hémorragie digestive. Observation d'un cas de sclérose hépatoportale.

Variceal bleeding is frequently the initial presentation of a previously unknown cirrhosis. Portal hypertension and its complications without liver cirrhosis should raise the possibility of presinusoidal portal hypertension, and the diagnosis of hepatoportal sclerosis. These patients need to be investigated for coagulation disorders. A hypercoagulable state is often associated. Risks and benefits of anticoagulation should be further investigated in these patients.

Safe treatment of thiopurine S-methyltransferase deficient Crohn's disease patients with azathioprine.

Thiopurine S-methyltransferase (TPMT) deficient patients develop life threatening haematotoxicity (for example, pancytopenia) when treated with a standard dose of azathioprine (AZA) and 6-mercaptopurine (6-MP) due to excessive accumulation of cytotoxic metabolites. At present, it is generally recommended that these patients should not receive AZA or 6-MP treatment for inflammatory bowel disease. We report for the first time that Crohn's disease patients with TPMT deficiency can be successfully treated with AZA. We illustrate this with three cases where treatment has been successful and toxicity has been avoided by carefully titrating the drug dose. Thus very low TPMT activity demands pharmacogenetically guided dosing.

[Risk of contamination by hepatitis C of endoscopes utilized in gastroenterology hospital service]. / Risques de contamination par le virus de l'hépatite C des endoscopes utilisés dans un service hospitalier de gastroentérologie.

UNLABELLED: Transmission of hepatitis C virus by gastrointestinal endoscopy has been suggested especially therapeutic procedures. The aim of this study was to investigate the frequency of contamination of the endoscopes by hepatitis C virus and to assess the efficacy of a semi-automatic disinfection procedure. METHODS: In 19 patients with chronic replicative hepatitis C, upper gastrointestinal endoscopy with different invasive procedures was performed. Cleaning and disinfection were carried out according to the recommendation of the belgian "Conseil Supérieur de l'Hygiène": cleaning with detergent solution, rinsing, disinfection with a disinfectant solution for 10 minutes and again rinsing. Before the procedure (T0), a blood sample was collected to detect the presence of hepatitis C virus RNA. Immediately after the endoscopic procedure, the operating channel of the endoscope was flushed with water and was sterilely collected (T1); after cleaning (T2) and after disinfection (T3, T3EC), the same procedure was repeated. The collected samples were analysed by PCR in order to detect hepatitis C virus RNA. RESULTS: All the samples were positive at T0. Virus C RNA was found in 10 out the 19 patients at T1 (53%). The results were negative in all the samples both after cleaning (T2) and disinfection (T3-T3 EC). CONCLUSIONS: Our study confirmed the presence of hepatitis C virus in the operating channel after invasive upper gastrointestinal endoscopy. The contamination rate of the endoscope is high. Our cleaning and disinfection procedure seems to be effective in regard of hepatitis C virus RNA clearance.

Incidence of inflammatory bowel disease in the province of Liège (Belgium). La Société de Gastroentérologie Liègeoise.

UNLABELLED: Up to now, as there is no national registry of patients with inflammatory bowel disease (IBD) in Belgium, the study of IBD epidemiology in our country is only possible through institutional or regional series. Therefore we conducted a prospective epidemiologic study of IBD in the Province of Liège (1 million inhabitants). METHODS: 29 (out of 47) private and public gastroenterologists completed a standard questionnaire for each patient consulting for the first time with clinical symptoms compatible with IBD between 1/06/1993 and 31/05/1994. RESULTS: During that period 104 cases of IBD were recorded: 56 (54%) Crohn's disease (CD), 36 (35%) ulcerative colitis (UC) including 7 proctitis (19% of UC) and 12 (11%) unclassified colitis. The annual incidence was 5.5 per 100.000 for CD and 3.5 for UC. The sex ratio F/M was 1.7 for CD and 0.7 for UC. The median age at the time of diagnosis was 33.5 yrs for CD and 40 yrs for UC. The highest age specific incidence rate for CD and UC was between 20 and 29 yrs : 13.6 and 6.1, respectively. CONCLUSIONS: This first Belgian prospective study has shown an incidence rate for CD comparable with that seen in north European studies but lower than that seen for UC. These results were similar to those observed in the northern part of France. Belgium appears to be a privileged country to undertake a national register and to study epidemiological aspects of IBD.

[Effect of a serotonin S2 receptor antagonist on portal hypertension due to cirrhosis. Preliminary results of a heart and liver hemodynamic study]. / Effects d'un antagoniste des récepteurs S2 de la sérotonine sur l' hypertension portale de la cirrhose. Résultats préliminaires d'une étude hémodynamique cardiaque et hépatique.

In 10 cirrhotic patients, with two balloon catheters introduced in the right internal jugular vein, the following parameters were measured before and after injection of ketanserine (0.1 mg/kg): cardiac output using the thermo-dilution method, free supra-hepatic pressure, wedged supra-hepatic pressure at rest and during cough, right atrial pressure, pulmonary capillary and arterial pressures. After 30 minutes, the following modifications were recorded: the cardiac output goes from 8.0 +/- 2.4 l/min to 8.7 +/- 2.5 l/min (p less than 0.05); the mean arterial pressure goes from 107.0 +/- 18.8 mmHg to 94.7 +/- 25.9 mmHg (p less than 0.02); the wedged supra-hepatic pressure, during coughing goes from 85.2 +/- 36.1 mmHg to 64.6 +/- 23.1 mmHg (p less than 0.005). As in non-cirrhotic patients, ketanserine causes a drop in the mean arterial pressure and a transient elevation of the cardiac output. Ketanserine is able to lower portal pressure of cirrhotic patients at rest as well as during coughing. These results seem to indicate that the activation of serotonin S2 receptors may play a role in determining the portal hypertension in cirrhotic patients.

[Effects of sotalol on blocked suprahepatic pressure in cirrhotic patients]. / Effets du sotalol sur la pression sus-hépatique bloquée de malades cirrhotiques.

With the use of two balloon catheters inserted in the right jugular vein, the following parameters were measured before and after injection of sotalol (1.5 mg/kg): cardiac output with the thermodilution method, hepatic output with the indocyanin green perfusion method, free sub-hepatic pressure, blocked sub-hepatic pressure recorded at rest and during coughing. After 30 minutes, the following modifications were recorded: the cardiac output goes from 6.8 +/- 2.1 to 5.9 +/- 1.9 L/min (NS), the hepatic output goes from 1.9 +/- 1.1 to 1.5 +/- 0.6 L/min (NS), the hepatic pressure gradient goes from 18.2 +/- 6.1 to 11.5 +/- 5.4 mmHg (p less than or equal to 0.0005); the blocked sus-hepatic pressure at rest goes from 25.0 +/- 7.8 to 19.8 +/- 8.0 mmHg (p less than or equal to 0.025); the blocked sus-hepatic pressure during coughing goes from 92 +/- 32 to 82 +/- 39 mmHg (NS). This study demonstrates: a) that the drop in the hepatic pressure gradient induced by a dose of sotalol is more important than that observed by Westaby et al. with propranolol: 37% vs 31% (NS); b) that sotalol cannot lower the blocked sub-hepatic pressure during coughing. This result suggests that the potential protective effect of sotalol toward esophageal varices rupture disappears during coughing.

[The effect of sotalol on cirrhotic portal hypertension. Results of a preliminary study of cardiac and hepatic hemodynamics]. / Effet du sotalol sur l'hypertension portale du cirrhotique. Résultats préliminaires d'une étude hémodynamique cardiaque et hépatique.

Using two balloon-tipped flotation catheters introduced through the jugular vein, systemic and hepatic hemodynamic measurements were made in nine cirrhotic patients before and 15, 30, 45 and 60 minutes after intravenous injection of 1.5 mg/kg of sotalol. At 30 minutes, the occluded sus-hepatic pressure fell from 23.6 +/- 6.4 mm Hg to 16.7 +/- 5.7 mm Hg (P less than 0.025); the sus-hepatic pressure gradient decreased from 16.2 +/- 3.8 mm Hg to 8.1 +/- 2.7 mm Hg (P less than 0.0005) whereas cardiac output failed to show any significant change (6.8 +/- 2.4 l/minute prior to drug versus 5.7 +/- 2.1 l/minute). These results suggest that sotalol, a non selective beta-adrenoceptor blocking drug with weaker negative inotropic effects than propranolol is effective in lowering portal pressure. The decrease of the sus-hepatic pressure gradient induced by the dose we used (50.2 +/- 20.0%) is statistically greater than that observed by Westaby et al. with intravenous propranolol (31.0 +/- 8.2%). The absence of hepatic metabolism of the drug which is excreted untransformed by the kidney should facilitate the selection of the optimal oral dose. The rather long half-life should also allow administration of one single daily dose which improves patients' compliance. The long term oral efficacy remains to be demonstrated in further studies, but in view of the advantages that sotalol possesses over propranolol, these studies are deemed justified.