Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy.

INTRODUCTION: Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. METHODS: This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. RESULTS: Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. CONCLUSIONS: Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.

[Dysphagia and recurrent esophageal stenosis associated with intramural pseudodiverticulosis of the esophagus. A case report]. / Dysphagie et sténose oesophagienne récidivante associée à une pseudodiverticulose intramurale de l'oesophage. A propos d'un cas clinique.

Intramural pseudodiverticulosis of the esophagus is a rare benign disease of the eosphageal wall, with dilation of the submucosal glands, and the predominant symptom is dysphagia. This disorder may be associated with gastroesophageal reflux, motility disorders, candidiasis and alcoholism. Inflammation, resulting in periductal fibrosis and compression of the duct orifices, may be a causative factor. Good and long-lasting therapeutic success can be achieved by bouginage of the stenosis with concomitant treatment of the associated esophageal diseases. Esophageal intramural pseudodiverticulosis is a differential diagnosis in cases of dyspagia and/or esophageal strictures if no other causes are found.

[Autoimmune hepatitis and CREST syndrome]. / Hépatite auto-immune associée au syndrome de CREST.

We report the case of an autoimmune hepatitis in a 59-year old woman who was referred for a progressive jaundice. The patient had an history of CREST syndrome. The particularity of this case report is the rare association between these two autoimmune diseases.

Treatment of acute hepatitis C with interferon alpha-2b: early initiation of treatment is the most effective predictive factor of sustained viral response.

AIM: To evaluate the efficacy of early interferon alpha-2b in non-post-transfusion acute hepatitis C virus: a prospective study with historical comparison. PATIENTS: Group A: 28 patients prospectively treated for acute hepatitis C virus with daily regimen of interferon 5 million units for 2 months. Group B: historical series of 16 patients with untreated acute hepatitis C virus. RESULTS: There was no significant difference between the two groups with regard to gender, age, icterus, alanine aminotransferase, or genotypes. In group B, hepatitis spontaneously resolved in three of 16 (19%) patients (follow-up 1-7 years). In group A, 21 of 25 patients became sustained viral responders (75%; P = 0.0003 vs. group B). Factors include not predictive of sustained viral response: age, gender, sources of infection, presence of icterus, alanine aminotransferase peak, bilirubin peak, incubation period, presence of hepatitis C virus antibodies at presentation, or genotypes. The time from presentation to the start of therapy was, however, significantly shorter in sustained viral responders (43 +/- 31 days) than in relapsers or non-responders (88 +/- 52 days) (P = 0.016). CONCLUSIONS: Early treatment of acute hepatitis C virus with interferon prevents chronicity. A short waiting time from presentation to treatment appears as the most relevant predictive factor for sustained response.

[Lactose and gluten intolerance: which to suscept?]. / Les intolérances au lactose et au gluten: quand faut-il y penser?

Lactose intolerance affects millions of people world-wide and should be suspected specially when evaluating gastrointestinal symptoms in ethnic populations in which it is prevalent. Fortunately, once a diagnosis is made, management is fairly straightforward. The authors discuss symptoms and methods of detection and offer their recommendations for helping patients with this common disorder. Coeliac disease is the end result of 3 processes that culminate in intestinal damage: genetic predisposition, environmental factors, and immunological based inflammation. Epidemiological studies based on serologic tests suggest that the prevalence of coeliac disease has been significantly underestimated. The classic sprue syndrome of steatorrhea and malnutrition may be less common than more subtle and often monosymptomatic presentations of the disease. The authors discuss the diagnostic criteria and the clinical utility of serologic tests.

Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage.

Varices of the entire colon are very rare. This rare cause of massive lower gastrointestinal hemorrhage is almost invariably associated with cirrhosis of the liver and consequent hypertension or portal venous obstruction. We report about a patient with massive lower gastrointestinal bleeding from extensive colonic varices. Despite extensive investigation and a follow-up of 3 years, the etiology of the colonic varices could not be determined. Only a few cases of apparent idiopathic (familial or non-familial) colonic varices have been described. Recognition of this abnormality is important, however, because colonic varices may be the cause of recurrent, frequently massive lower gastrointestinal hemorrhage. A misleading endoscopic diagnosis can lead to inappropriate biopsies, resulting in major bleeding.

[New viral hepatitis]. / Les nouvelles hépatites virales.

Viral hepatitis are essentially caused by 5 types of viruses which differ in way of transmission and their evolution to chronicity or not. Like the virus causing hepatitis A, the E-virus-discovered en 1983-is a virus with oral-fecal transmission, responsible only for acute hepatitis which may be fulminant, notably in pregnant woman. Responsible for epidemics in Asia and Africa, the E-virus is nearly non-existent in our regions. Just like the B, C and D viruses, the G-virus is a RNA-virus with intravenous transmission. Notwithstanding a high prevalence, its pathogenic role remains hypothetical so that some hesitate to consider it as a virus causing clinical hepatitis. Etiological viral or non-viral agents for the cryptogenic hepatitis which can appear as acute, fulminant, post-transfusional or chronic illness, remain to be discovered.

Omeprazole-based antimicrobial therapies: results in 198 Helicobacter pylori-positive patients.

AIM: To compare the efficacies of omeprazole-based antimicrobial therapies in Helicobacter pylori-positive patients. PATIENTS AND METHODS: We report the results of seven therapeutic trials combining omeprazole, clarithromycin, amoxycillin, colloidal bismuth subcitrate and tinidazole in 198 patients (peptic ulcer disease/non-ulcerative dyspepsia, 137/61) to eradicate H. pylori infection. The diagnosis of infection was performed by Sydney system biopsies, compliance was checked after a pill count at the end of the treatment and eradication was assessed at least 4 weeks after the end of the treatment either by the Sydney system for peptic ulcer disease or the urease breath test for non-ulcerative dyspepsia. RESULTS: When results were analysed on a protocol basis, the only significant difference in eradication (P = 0.006) was found between the total population of patients treated with amoxycillin-based combinations (27 eradications out of 48 patients) and those given a treatment that included clarithromycin (84 eradications out of 108). Forty-two patients (21%) dropped out either because of side effects (10 among patients taking clarithromycin and two taking amoxycillin) or because they were lost to follow-up (27 patients). Out of 64 patients with active ulcers, 43 (67%) were both H. pylori-negative and ulcer-free 4-8 weeks after the end of therapy, 12 out of 64 (19%) were ulcer-free but remained H. pylori-positive and nine out of 64 (14%) were H. pylori-positive and had active ulceration.

[Medical treatment of reflux peptic esophagitis: literature review]. / Traitement médical de l'oesophagite peptique de reflux: revue de la littérature.

Treatment of GO reflux and reflux oesophagitis should be based on pathophysiology, natural history, diagnostic assessment and patient expectations. Physiopathologically, GO reflux results from the balance between aggression and defence. The primary importance of motor and sphincters disturbances should make prokinetic drugs the treatment of choice; however, these drugs are unable to influence the inappropriate sphincter relaxation. The severity of symptoms and lesions is related to the duration of exposition of the oesophagus to pH < 4 explaining the superiority of omeprazole over the usual doses of H2RA. Since symptoms and lesions relapse frequently after treatment, long term prophylaxis, either by surgery or by drugs, is necessary. Comparing different therapeutic options is complicated by the absence of a precise definition of abnormal GO reflux or a gold standard; moreover, treatment results depend on the initial oesophagitis grade. Treatment will depend on the desired goal: to treat symptoms of lower grade oesophagitis or to heal lesions and prevent complications of high grade oesophagitis.

[Unusual form of esophagobronchial fistula in adults]. / Forme inhabituelle de fistule oesophago-bronchique chez l'adulte.

We describe the case of an adult patient with a benign congenital esophagobronchial fistula. The different types of congenital fistula without atresia or in H form are discussed. We formulate some hypotheses explaining the late occurrence of symptoms in a lesion present since the patient's birth.

A randomized, multi-observer, comparative evaluation of conventional fiberendoscopy and videoendoscopy in the upper GI tract.

In a comparative, histologically controlled study, no significant difference was found in the accuracy of conventional fiberendoscopy and videoendoscopy in the diagnosis of upper gastrointestinal tract lesions. Both techniques permitted accurate description of focal and/or ulcerative lesions, but videoendoscopy did not provide better sensitivity than fiberendoscopy in the diagnosis of superficial, non-ulcerative, inflammatory changes. The same results were obtained on checking the reproducibility of the macroscopic diagnosis by a delayed review of recorded videotapes.

Juxtapapillary duodenal diverticula: association with biliary stone disease.

In order to explore the relationship between duodenal diverticula and biliary stone disease, we reviewed 2231 endoscopic retrograde cholangio-pancreatography procedures. We found at least one juxtapapillary diverticulum per 239 patients (10.8%). The occurrence of duodenal diverticula increases with age. Patients with duodenal diverticula were older, had more gallbladder stones, more common bile duct stones, had undergone cholecystectomy more frequently, and experienced more frequently common bile duct stone recurrence after cholecystectomy. We thus confirm an association between the presence of diverticula of the second part of the duodenum, and biliary stone pathology, including gallbladder stones, common bile duct stones, and recurrent stones after cholecystectomy. We discuss the aetiopathogeny of this affection.

Correction of low circulating levels of 1,25-dihydroxyvitamin D by 25-hydroxyvitamin D during reversal of hypomagnesaemia.

The effect of 25-hydroxyvitamin D (25OHD), given orally during the reversal of hypomagnesaemia, was studied in five patients with hypomagnesaemic hypocalcaemia and low serum levels of 25OHD and 1,25-dihydroxyvitamin D (1,25(OH)2D). The results were compared to those obtained in five other patients with similar initial levels of magnesium, calcium, 25OHD and 1,25(OH)2D who did not receive 25OHD. Serum levels of 1,25(OH)2D in the ten hypomagnesaemic patients were lower than in ten control subjects with low serum levels of 25OHD. The reversal of hypomagnesaemia was similar in the two groups of patients and elicited a similar increase of circulating iPTH levels. The expected increase of circulating 25OHD was observed in patients supplemented with 25OHD; their circulating 1,25(OH)2D rose within 48 h to normal levels, contrasting with the delayed and poor increase of 1,25(OH)2D in patients receiving no 25OHD. The evolution of serum calcium was however identical in the two groups. Our results suggest that vitamin D deficiency was a significant factor leading to low circulating levels of 1,25(OH)2D in hypomagnesaemic hypocalcaemic patients. The biological consequences of low serum 1,25(OH)2D in these patients remain unclear, but clearly, normal levels of 1,25(OH)2D are not essential for the correction of hypomagnesaemic hypocalcaemia.

Penetration of cefoperazone into ascites.

The pharmacokinetics of cefoperazone was studied in eleven cirrhotic patients with ascites after i.v. administration of a single dose of 15 mg.kg-1 (n = 7) or after three doses of 15 mg.kg-1 given at 12 h intervals (n = 4). The concentrations of cefoperazone in serum and ascitic fluid were determined by HPLC. The peak serum cefoperazone concentration after a single i.v. injection of 15 mg.kg-1 was 96.0 mg.l-1. The serum elimination half-life was longer (5.0 h) than in normal subjects. The penetration of cefoperazone into ascites was satisfactory (32.3% and 58.3% after single and repeated injections, respectively). Ascitic fluid concentrations of cefoperazone exceeded 5.4 mg.ml-1 from 0.5 to 6 h after the single i.v. injection, levels which are well above the MIC of most pathogens found in spontaneous bacterial peritonitis. Adjustment of the dose of cefoperazone in cases of severe hepatic insufficiency does not appear to be necessary provided that renal function is normal.