[Steatosis in chronic hepatitis C: prevalence and predictive factors]. / Stéatose au cours de l'hépatite chronique C : prévalence et facteurs de risque de survenue.

BACKGROUND: Patients with hepatitis C virus seem to often have hepatic steatosis. AIM: To assess the prevalence and the predictive factors of steatosis during chronic hepatitis C. METHODS: We studied 50 HCV RNA positive subjects, who had liver biopsy performed. Steatosis was searched and patients were divided into to groups according to the presence or not of steatosis. RESULTS: On liver biopsy, 28 patients (56%) had steatosis. Multivariante analysis showed that steatosis was associated with age 58 years > 1,1 µmol/l, odds ratio 2 (95% CI 1.48 - 2.6; p= 0.02) and triglycerides level, odds ration 4,22 (95% CI 1.05 - 16.98; p = 0,03. CONCLUSION: In this study, steatosis was significantly associated with metabolic factors.

[Survival in patients with gastric lymphoma]. / Survie des patients atteints de lymphome gastrique.

BACKGROUND: Mucosa-associated lymphoid tissue lymphoma is a histological type of marginal zone non-Hodgkin's lymphoma. Its clinical features and prognosis have seldom been reported because of its indolent clinical course. AIM: To establish prognostic factors that should be considered for the staging and management of this disease. METHODS: Clinical data of 40 pathologically confirmed gastric lymphoma patients, treated during a period of 13 years, were analyzed. RESULTS: Of the 40 patients, 65% had stage IE - II1E disease and 35% had stage II2E - IV disease. A total of 18 patients received surgeries.Eighteen patients had chemotherapy and 10 patients had Helicobacter Pylori eradication therapy. The complete remission rate after treatment was 50%. The patients were followed up for a median of 26.75 months. The 5-year overall survival rate was 70%. Early stage at presentation, surgery, normal lactic dehydrogenase (LDH) levels and Helicobacter Pylori infection were associated with longer survival in univariate analysis. CONCLUSION: This study suggested that surgery might be an important factor predicting the long-term survival of patients with primary gastric lymphoma. Patients with poor prognostic factors should be treated more aggressively.

[Clinicopathologic characteristics of low grade primary gastric non-Hodgkin's lymphomas: experience from a single center]. / Caractéristiques clinico-pathologiques des lymphomes gastriques primitifs de bas grade de malignité.

AIM: To report the clinicopathological data and the treatment outcomes in patients with primary gastric low grade non-Hodgkin's lymphoma. METHODS: We carried out a retrospective analysis of 16 consecutive patients (median age 46 and range 28-75 years) who presented to our department with histopathological diagnosis of primary gastric low grade non-Hodgkin's lymphoma. We analyzed clinical manifestations, endoscopic features, pathological features,Helicobacter pylori infection and treatment. RESULTS: Common symptoms included abdominal pain (87.5%),vomiting (62.5%), and gastrointestinal bleeding (25%). Endoscopic appearances were mainly ulcers and ulcerations (93.75%).Endoscopic biopsy confirmation rate reached 87.5% when biopsies were repeated. Helicobacter pylori detection rate was 75%. A total of 9 patients received surgeries. Three patients had chemotherapy and 8 patients had Helicobacter pylori eradication therapy. The range of follow-up was 2-74 months with a median of 27 months. A complete remission was obtained in 12 cases, whereas 1 patient died and 3 were lost of view. CONCLUSION: Eradication therapy may be offered as an initial treatment option in patients with low-grade gastric lymphoma.

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

BACKGROUND: Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a biliary stent can be a solution. AIM: To prospectively analyse the usefulness of a stenting in management of biliary obstruction due to choledocolithiasis. METHODS: All patients referred to our endoscopic unit from January 2005 to January 2008, for management of bile duct stone are studied. We included patients subjected to an endoscopic insertion of a biliary stent. RESULTS: Of 414 patients with choledocolithiasis, 51 failed to have their ducts cleared with the first endoscopic retrograde cholangiopancreatography (ERCP): 25 patients (6%) were referred to surgical stone removal. Twenty six consecutive patients had endoscopic insertion of a 10 Fr biliary stent: There were 12 men and 14 women ranging in age from 35 to 102 years (median age 68 years). The indications for stent placement in common bile duct stone were mainly the endoscopic portal hypertension, elderly patients or with a short life expectancy. Twenty four patients (88%) are symptom free after stenting. Six patients (23%) had duct clearance after a median of 3 sessions at a mean of 13 months (range 3-48 months). In 3 patients endoprosthesis was inserted as a permanent therapy of biliary obstruction. Cholangitis occurred in 5 patients, early in two cases and later at a mean of 18 months (range 6-24 months) in 3 patients and was managed endoscopically by stent replacement and fluid antibiotics. CONCLUSIONS: These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones until the definitive treatment is carried out. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy.

Colorectal neoplasia in elderly versus young patients in Tunisia: analysis of colonoscopic findings.

BACKGROUND: Colorectal cancer occurs more frequently in older patients. Since the older population is increasing, a better understanding of the characteristics of colorectal neoplasm according to the age would be useful. AIM: To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. METHODS: Colonoscopy database from 2004 to 2008 was retrospectively analyzed. There were 1510 eligible patients who underwent colonoscopy with a mean age of 54 years. Patients were classified into two groups: the older age group (Group 1, aged ³ 60 years, n = 626) and the younger age group (Group 2, aged < 60 years, n = 884). Data were recorded on age, gender, colonoscopic indications, colonoscopic findings, and their related histological findings and tumor location. RESULTS: The risk of finding polyps and cancer at colonoscopy increases with age (29.4% in the older age group and 11% in the younger age group (p < 0.05). Left-sided lesions were noted to be more frequent in both age groups (66% and 67% respectively). CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly. However, both groups had the lesions predominately located in the left side.

Variceal band ligation in the prevention of variceal bleeding: a multicenter trial.

BACKGROUND/AIM: Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. PATIENTS AND METHODS: We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. RESULTS: The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. CONCLUSIONS: A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

[Autoimmune hepatitis in Tunisia. Retrospective multicenter study of 83 cases]. / L'hépatite auto-immune en Tunisie. Étude multicentrique rétrospective de 83 cas.

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory condition of the liver of unknown etiology. Its epidemiological and anatomoclinical characteristics and its outcome were unknown in Tunisia. AIM: To analyse epidemiological, anatomoclinical, immunological and histological aspects of AIH and to determine factors predicting relapse after treatment and death of this disease in Tunisia. METHODS: Patients presenting with AIH between January 1996 and December 2004 were evaluated in retrospective multicentric study. The diagnosis of AIH was established according to the criteria of the revised score of the international autoimmune hepatitis group (1999) RESULTS: Eighty three patients were identified (70 female; mean age=49+17.9 years). 63% presented probable AIH and 37% presented definite AIH. Thirty two percent presented with the acute pattern. Eighty three per cent of cases were type I AIH and 5 % of cases were type II HAI. Fifty seven percent of the patients were cirrhotic at presentation. Associated autoimmune diseases was seen in 27 patients, dominated by diabetes, autoimmune thyroiditis and Sjögren's syndrome. An overlap syndrome was diagnosed in 25% of cases; primary biliary Cirrhosis-AIH in 20% of cases and primary sclerosing cholangitis-AIH in 5% of cases. Fifty patients were treated by glucocorticoids as monotherapy or in combination with azathioprine. Complete remission was achieved in 90% of cases. Fourteen percent relapsed within a median time of 12 months. Factors associated with relapse were: treatment with Azathioprine<18 months, absence of lobular necrosis and anti-nuclear antibody (+) profile. Mortality was observed in 17 % of cases. Factors associated with death were encephalopathy as an independent factor and treatment with Azathioprine<18 months. CONCLUSION: In Tunisia, epidemiological and clinical characteristics of AIH were similar to those reported in the literature but with a higher frequency of cirrhosis at presentation. Treatment with Azathioprine < 18 months was the main factor associated with relapse and represented with encephalopathy a factor associated with death.

Plummer-Vinson syndrome.

BACKGROUND: Plummer - Vinson syndrome is one of the names given to the constellation of dysphagia, iron- deficiency anemia, and esophageal webbing. It is a rare affection which affects mainly white women. AIM: The purpose of this study is to precise epidemiological, clinical, paraclinical and therapeutic features of the affection. METHODS: We report a retrospective study enrolled over 6 years (2002 - 2008). Were studied the age, the sex, the main symptoms and the biological parameters (full blood cell, albumin, hepatic, renal and lipidic balance sheet). Patients were explored by an upper endoscopy. RESULTS: Ten patients with the diagnosis of Plummer-Vinson syndrome were collected. There were 9 women, the average age was 57 years old. Dysphagia was the main symptom, observed in 100% of the cases. Fifty per cent of our patients had iron-deficiency anemia. Iron supplementation was indicated each time there is an iron- deficiency anemia. All the patients were treated with endoscopic dilatation and three of them needed multiple session of endoscopic dilatation. Eighty per cent had a favorable evolution. The malignancy was observed in 2 cases. CONCLUSION: Dysphagia is the main symptom of the Plummer-Vinson syndrome, which must indicate an upper endoscopy. This syndrome is known to be associated with an increased risk of squamous cell carcinoma of the upper airway tract, so the patients should be followed closely. Endoscopic dilatation is the procedure of choice in the treatment of cervical web of the esophagus.

Helicobacter pylori and gastric cancer.

BACKGROUND: Patients infected with Helicobacter pylori, a stomach colonizing bacteria, have an increased risk of developing gastric malignancies, in particular gastric carcinomas. AIM: This review was aimed to analyze the relationship between gastric carcinoma and Helicobacter pylori infection and to rule out the possibility of preventive measures. METHODS: To identify articles for this review, a PubMed search was conducted using the following key words: gastric cancer, Helicobacter pylori. RESULTS: The risk for developing cancer includes environmental, host-genetic and bacterial factors, which induce physiologic and histologic changes in the stomach. There are two major pathways for the development of gastric cancer by helicobacter pylori: the indirect action on gastric epithelial cells through inflammation leading to gastric atrophy and intestinal metaplasia and the direct action through the induction of protein modulation and gene mutation.

[Biliary stent occlusion]. / Obstruction des endoprothèses biliaires.

BACKGROUND: Endoscopic stent insertion is as a method of choice for palliative treatment of malignant biliary strictures. Two types of biliary stent were actually used plastic and metallic self-expandable. Occlusion of the stent can be observed in both. AIM: To assess the management of biliary stent occlusion. METHODS: From january 2006 to december 2007, 120 biliary stents were inserted in 97 patients. Indications of biliary stents were malignant stricture in 67% of cases. Biliary stent occlusion was defined by necessity of stent replacement. RESULTS: 118 plastic and 2 metallic self-expandable biliary stents were inserted. Obstruction of the biliary stent was observed in 12 patients, after a mean time of 5,5 months [1-15]. A recurrent biliary desobstruction was necessary in 6 patients. Stent exchange was realised in 33,3% of cases for malignant biliary stenosis and in 66,6% for benign stricture (p=0,01). Obstruction of the stent was symptomatic (cholangitis, jaundice) in more of 50% of cases. Management consisted on the stent exchange by a new plastic stent for clogging plastic stent and on insertion of plastic stent inside the metallic one for the occluded metallic stent. CONCLUSION: Obstruction can occur for the two types of biliary stent. Survival of the patient, cost of the stent guide the choice of the stent will be used.

Ciclosporin for severe refractory colitis.

BACKGROUND: Intravenous ciclosporin is a promising alternative, rapidly effective, for patients with severe steroid-refractory colitis previously facing only surgical options, however its use is controversial because of the frequency of adverse effects and the doubt about the long-term response. AIM: This review will provide information on clinical pharmacology, clinical indications for use, methods of dose adjustment, monitoring of metabolites for efficacy and for potential side effects and the adverse event profile of ciclosporin in severe refractory colitis. METHODS: Literature review. RESULTS: Toxicity is dominated by opportunistic infections. Renal and neurotoxicity are also recognized. Risks of toxicity can be reduced by using lower doses, by oral microemulsion or by monotherapy without corticosteroids. The drug should not be continued for more than 3 to 6 months. As a bridge to other maintenance therapy such as azathioprine or 6-mercaptopurine ciclosporin can be an effective treatment. CONCLUSION: CSA is a viable alternative to emergency colectomy in severe UC in the short term. Although these benefits are not maintained in all patients, more than a half will also avoid colectomy in the longer term. Careful selection and monitoring of patients, use of lower doses, and oral therapy will help to reduce side effects.

[Psoas abscess as the initial manifestation of Crohn's disease. Report of 3 cases]. / Abcès du psoas révélant une maladie de Crohn. A propos de 3 observations.

BACKGROUND: Psoas abcess complicating Crohn's disease is a rare condition. Diagnosis remains difficult, especially when it is the first sign of Crohn's disease. AIM: We report here 3 patients presenting with psoas abcess as the initial manifestation of the disease, among 118 patients with Crohn's disease seen between 1990 and 2006. CASES REPORT: Symptoms and signs were fever, lower abdominal quadrant pain or tenderness and psoitis. Diagnosis was confirmed in all cases by computed axial tomography. In 2 cases, psoas abcess secondary to a periappendicular abcess or a colonic neoplasm were suspected, and the etiology was made correctly only after operation. Effective therapy included antibiotics, drainage and bowel resection.

Management of the hepatocellular carcinoma.

BACKGROUND: The hepatocellular carcinoma, is detected sooner due to the progress of the hepatic ultrasound scan allowing an accessibility to curative treatment. This cancer treatment still remains difficult in Tunisia. AIM: To show the difficulties in the management of the hepatocellular carcinoma in Tunisia. METHODS: Patients hospitalized in the gastroenterology department of Habib Thameur Hospital, from 2002 until 2007, for a cirrhosis follow-up or for a hepatocellular carcinoma treatment were studied retrospectively. The data was summarized by descriptive statistics and analysed with SPSS version 10. RESULTS: Fifty-seven patients were registered in this study. There were 40 males with an average age of 66 years. The cirrhosis was post-viral C in 28 cases. The discovery of the carcinoma was systematic in 16 cases. Treatment was prescribed in only fifteen patients, in the other patients, treatment was not made because of the multifocal character of the hepatocellular carcinoma. Complications were cirrhosis decompensation (n=3), fever (n=3), portal thrombosis (n=1) and pleurisy (n=1). CONCLUSION: Regardless of the improvement of diagnostic and therapeutic means, 17.5% of our patients having a hepatocellular carcinoma were subjected to a curative treatment. An additional effort must be unfolded.