Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison.

BACKGROUND: There is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This "overuse" of colonoscopies has become a major burden for health care. OBJECTIVES: to assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria. PATIENTS AND METHODS: this cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria. RESULTS: From 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153). CONCLUSIONS: The updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.

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.

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.

[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.

Duodenal adenocarcinoma presenting as a mass with aneurismal dilatation.

Duodenal adenocarcinoma is frequent. Aneurysmal dilatation of the small bowel is reported to be a lymphoma characteristic imaging finding. A 57-year-old male was found to have a duodenal adenocarcinoma with aneurismal dilatation on imaging which is an exceptional feature. On laparotomy, the wall thickening of the dilated duodenum extended to the first jejunal loop, with multiple mesenteric lymph nodes and ascites. Segmental palliative resection with gastro-entero-anastomosis was done. Histopathology revealed a moderately differentiated adenocarcinoma with neuro-endocrine differentiation foci. Wide areas of necrosis and vascular emboli were responsible for the radiological feature of the dilated duodenum with wall thickening.

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.

[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.

[Renal amyloidosis complicating Crohn's disease: report of two cases and review of literature]. / Amylose renale compliquant la maladie de Crohn: a propos de deux cas et revue de la littérature.

Secondary amyloidosis is caused by the extracellular store of the fragment AA of the circulatory protein in serum amyloid-A. It can complicate diseases such as family mediterranean fever, rheumatoid arthritis or Crohn's disease. Renal amyloidosis is a rare but serious complication of Crohn's disease. We report two cases of Crohn's disease associated with a nephrotic syndrome due to renal amyloidosis. It is important to recognize this complication, especially since Colchicine has been proposed as a possible treatment. So, the search for proteinuria seems to be important for an early diagnosis of renal amyloidosis in Crohn's disease.

[Predictive factors of intestinal stenosis in Crohn's disease]. / Facteurs prédictifs de l'apparition de sténose intestinale au cours de la maladie de Crohn.

UNLABELLED: The aim of our study was to determine demographic, clinical, biological or endoscopic factors that predict intestinal stenosis in Crohn's disease. PATIENTS AND METHODS: One hundred and twenty one patients were retrospectively analyzed during 10 years. The diagnosis of stenosis were determined by morphologic and endoscopic exams independently of appearance of symptoms. The studied characteristics were age at appearance of symptoms, sex, geographical origin, tobacco addiction, symptoms revealing Crohn's disease, extra-digest and auto-immune signs associate and seat of disease. Biological values studied were: haemoglobin, white cells, platelet, erythrocyte sedimentation rate, C- reactive protein and albumin. Predictive factors were assessed using univariate and multivariate analysis. RESULTS: Forty-seven patients (38,8%) had a stenosis. In univariate analysis, predictive factors of stenosis were a young age and ileum site of Crohn's disease. In multivariate analysis, none of these variables was independently associated of appearance of stenosis in Crohn's disease. CONCLUSION: This study didn't identify the presence of predictive factors of intestinal stenosis in Crohn's disease that could allow an early specific therapy.

[Importance of vaccination chronic hepatitis B]. / Interet de la vaccination au cours de l'hepatite chronique B.

Weak therapeutic responses and weak immune cytotoxic CD8 and CD4 response in chronic hepatitis B emphasize the necessity to find new therapeutic strategies especially as specific immunotherapy. Vaccination, whose principle was to widen immune repertoire, was used as a curative treatment of chronic hepatitis B. It would be the therapeutic procedure with the lowest cost and the potentially greatest benefit. Our purpose was to enhance the interest of therapeutic vaccination in chronic hepatitis B in order to debate later its usefulness in developing countries.