Computed tomography-based virtual colonoscopy in the assessment of bowel endometriosis: The surgeon's point of view.

OBJECTIVE: To discuss the role of computed tomography-based virtual colonoscopy (CTC) in preoperative assessment of bowel endometriosis. METHODS: Retrospective study using data prospectively recorded, including 127 patients with colorectal endometriosis, having undergone CTC for bowel endometriosis. The study was conducted in a tertiary referral center during 38 consecutive months. Preoperative assessment included CTC, magnetic resonance imaging (MRI), endorectal ultrasound (ERUS) and clinical examination. Information concerning identification of deep infiltrating endometriosis (DIE) of the bowel, the length and height of colorectal involvement, stenosis of digestive lumen and associated digestive localizations were compared with intraoperative findings. RESULTS: Sensitivity and specificity of CTC for DIE of the rectum, the sigmoid colon, associated digestive localizations, and stenosis of the digestive lumen were respectively 97% and 84%, 93% and 88%, 84% and 97%, 96% and 96%. Intraoperative estimation of the length of digestive tract involved by DIE was closer to that provided by CTC than those provided by MRI and ERUS. When CTC revealed stenosis of digestive lumen, higher rates of colorectal resection (63% vs. 9.6%, < 0.001) and disc excision (25.9% vs. 11%, 0.03) were recorded. DISCUSSION: For those surgeons using various procedures for management of bowel endometriosis, accurate information on the length and height of bowel involvement, as well as the existence of bowel stenosis enables informed decision regarding the feasibility of conservative techniques versus bowel resection. Preoperative identification of associated localizations above the sigmoid colon is another major advantage related to CTC. CONCLUSIONS: CTC provides accurate data on the length and height of colorectal involvement by DIE, stenosis of digestive lumen and associated lesions of digestive tract, which impact on the choice of surgical procedure.

[Laparoscopic surgery of profund endometriosis with rectal affect]. / Chirurgia laparoscopica a endometriozei profunde cu atingere rectala.

OBJECTIVE: To present the principles of laparoscopic treatment for rectal endometriosis and to discuss possible postoperative outcomes. MATERIAL AND METHODS: Our series included women managed for rectal endometriosis during consecutive 20 months in the Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen--France. Patient's characteristics, symptoms, imaging examination results, surgical treatment and postoperative outcomes were all evaluated retrospectively. RESULTS: Sixteen patients presenting with rectal endometriosis were managed surgically, (mean age was 35.9 +/- 6.5 years). All women presented at least one severe painful symptom which was typical of a digestive involvement in 12 cases. MRI results suggested a rectal involvement in 14 cases, and endorectal ultrasound examination clearly showed rectal wall infiltration in all patients. The gynaecological stage of surgical treatment was carried out laparoscopically in 13 cases, and the digestive surgical stage in 7 cases. Two limited and 14 segmental rectal resections were performed. Transitory stoma was carried out in 9 women. The length of the surgical procedure depended on the number of endometriosis localizations with a median value of 6 h 30 min. Postoperative complications occurred in 6 women: 2 anastomosis stenosis, 1 anastomosis fistula, 1 abscess of the parietal wall and 1 bladder atonia. Complains of pain were completely or significantly improved in all cases. CONCLUSION: Surgical treatment for rectal endometriosis may be carried out laparoscopically. It should be reserved for women presenting with severe painful condition and may contribute to significant improvement. However, the balance of benefit and risks must also be assessed on a case to case basis prior to any decision for or against surgical treatment.

[Treating severe endometriosis by pregnancy: a risky business]. / Traitement de l'endométriose sévère par la grossesse: un pari risqué

We report the case of a young woman presenting with painful deep and rectal endometriosis. This condition had started long ago while the diagnosis had been delayed. Brutal colon occlusion followed the discontinuation of oral contraception. Left colectomy with terminal colostomy was carried out in emergency. The conservative surgical management of deep endometriosis was performed three months later. In women presenting deep endometriosis, the discontinuation of hormonal treatment in order to attempt a spontaneous pregnancy should not be recommended before undertaking a thorough endometriosis and fertility status investigation.

Cleft lip/palate and CDH1/E-cadherin mutations in families with hereditary diffuse gastric cancer.

We report the association of CDH1/E-cadherin mutations with cleft lip, with or without cleft palate (CLP), in two families with hereditary diffuse gastric cancer (HDGC). In each family, the CDH1 mutation was a splicing mutation generating aberrant transcripts with an in-frame deletion, removing the extracellular cadherin repeat domains involved in cell-cell adhesion. Such transcripts might encode mutant proteins with trans-dominant negative effects. We found that CDH1 is highly expressed at 4 and 5 weeks in the frontonasal prominence, and at 6 weeks in the lateral and medial nasal prominences of human embryos, and is therefore expressed during the critical stages of lip and palate development. These findings suggest that alteration of the E-cadherin pathway can contribute to human clefting.

Spontaneous passage of a dislocated esophageal metal stent: report of two cases.

Delayed transpyloric impaction is a very rare complication of esophageal metallic stent placement. Authors report different endoscopic removal techniques, but none of these has been validated yet because of their variable success, time-consuming nature, and risk of perforation and hemorrhage. We report that a "wait-and-see" approach is a safe and effective policy in patients with permeable transpyloric impacted esophageal stents.

Low levels of gastric mucosal glutathione during upper gastric bleeding associated with the use of nonsteroidal anti-inflammatory drugs.

OBJECTIVES: To investigate the glutathione concentrations in gastric mucosa from patients with acute gastric bleeding related to nonsteroidal anti-inflammatory drugs (NSAIDs), and to test the influence of nutritional status on mucosal glutathione. Glutathione protects the gastrointestinal mucosa against reactive oxygen species, and glutathione content in various tissues may be depleted during malnutrition. METHODS: Endoscopic biopsies were obtained from 39 patients. Eighteen of these (9 well-nourished, 9 malnourished) presented with gastric bleeding ulcers related to NSAIDs. Twenty-one other patients (12 well-nourished, 9 malnourished) underwent normal routine diagnostic endoscopy and served as controls. Malnutrition was defined as a loss of over 10% of normal body weight and/or plasma albumin levels below 30 g/l. Gastric biopsies were taken from the fundus and antrum (controls) and from the region of the ulcer (patients with acute bleeding) and frozen quickly until glutathione analysis by high-performance liquid chromatography (HPLC) coulometric detection. Results were expressed as nmol/mg wet tissue. RESULTS: Gastric mucosal glutathione levels were significantly (P < 0.05) lower in both the antrum (0.81 +/- 0.34 v. 1.41 +/- 0.88 nmol/mg tissue) and the fundus (1.04 +/- 0.54 v. 1.43 +/- 0.92 nmol/mg tissue, P < 0.05) in malnourished than in well-nourished control patients. Glutathione mucosal concentrations were decreased significantly in patients with NSAID-induced gastric bleeding compared with control patients (0.38 +/- 0.36 v. 1.12 +/- 0.56 nmol/mg tissue, P < 0.001), and the lowest glutathione levels were observed in malnourished patients (0.28 +/- 0.20 v. 0.48 +/- 0.15 nmol/mg tissue in well-nourished patients, not significant). CONCLUSION: Malnutrition is associated with low levels of gastric glutathione. This may contribute to the severity and the onset of haemorrhage in NSAID-induced gastric ulcers.

[Expandable metal stents in palliative treatment of malignant colorectal stricture. A report of 17 consecutive patients]. / Les prothèses métalliques expansives dans le traitement palliatif des sténoses malignes colo-rectales.

OBJECTIVE: Several endoscopic procedures have been used to avoid a colostomy in palliative treatment of occlusive colorectal cancer. The aim of this study was to evaluate in intent to treat the long term effectiveness and safety of self-expanding metal stents as a palliative treatment in patients with neoplastic colonic obstruction. PATIENTS AND METHODS: From December 1997 to June 2000, seventeen patients were treated with 21 colonic stents. Sites of obstruction were high rectum in 3, sigmoid in 11 and left colon in 3. RESULTS: Stent placement was successful in 16/17 patients (94%). Relief of bowel obstruction occurred in 13 patients (74%) in the first 48 hours. Expandable metal stent achieved an effective bowel transit until death in 9 of the 17 patients (53%). Clinical complications occurred in 6 patients (35%): 2 perforations, 2 migrations, 1 rectal bleeding and 1 dislocation of the stent. Subsequent colostomy was done in 5 patients. CONCLUSION: Colonic stenting is an alternative palliative treatment in malignant colorectal stricture. However, morbidity and need for subsequent colostomy should be taken into account.

[Upper gastrointestinal bleeding in patients treated by low-dose aspirin]. / Hémorragies digestives hautes et aspirine à faible dose.

AIM OF THE STUDY: To estimate the number of people treated by low-dose aspirin (<330 mg daily) in France and to evaluate the risk of upper gastrointestinal bleeding associated with low-dose aspirin treatment. SUBJECTS AND METHODS: One thousand six hundred and two patients with upper gastrointestinal bleeding were included between January and June 1996 in 4 French areas. Data about patients characteristics, drugs recently used, and bleeding lesions were prospectively collected. Five hundred seventy five cases were matched for sex, age and area with control people without previous upper gastrointestinal bleeding. Low-dose aspirin intake in the population was estimated from the control group. Aspirin intake in the previous 7 days in cases and in controls was compared by logistic regression, adjusted for other gastrotoxic drugs intake. RESULTS: Low-dose aspirin is taken by about 1.2 millions adults in France. In 1 602 patients, gastrointestinal bleeding was related to a peptic ulcer in 34%. Aspirin was associated with higher risk of upper gastrointestinal bleeding: OR=1.68 (1.03-2.74) with low-dose, and OR 1.42 (0.91-2.21) with higher doses. CONCLUSION: About 2.8% of the population is exposed to low-dose aspirin in France. This treatment seems to be associated with a high risk of upper gastrointestinal bleeding.

Biliary varices on endoscopic ultrasonography: clinical presentation and outcome.

BACKGROUND AND STUDY AIMS: Bile duct varices are not a well-recognized feature of portal venous obstruction. The aim of the present study was to describe the clinical and endosonographic features of biliary involvement in patients with extrahepatic portal venous obstruction (EPVO). PATIENTS AND METHODS: A retrospective study was conducted of the clinical features, outcome, and endosonographic findings (using Olympus EUM-3 or EUM-20 probes) in 21 patients with EPVO and endosonographic features of biliary varices. Biliary varices were defined as multiple, large, serpiginous, anechoic vascular channels in and/or surrounding the extrahepatic biliary tracts. RESULTS: Biliary varices have not previously been visible using conventional imaging methods (computed tomography and ultrasonography). They were identified using EUS in the wall of the common bile duct in 16 patients (76%), surrounding the common bile duct (CBD) in 11 patients (52%), and in the gallbladder in nine (43%). The varices were the cause of obstructive jaundice in three of the 21 patients (14%), but only when they were in the wall of the CBD. Two of these patients were treated using portosystemic shunting, and the other received a biliary endoprosthesis. The EUS examination also provided evidence of unrecognized pancreatic or biliary tumors in three other patients with EPVO of undetermined origin. CONCLUSIONS: EUS can serve to diagnose biliary varices in patients with EPVO and jaundice. Although biliary varices are mainly asymptomatic, they may cause obstructive jaundice when they are located in the wall of the CBD. EUS can also detect unrecognized malignant tumors in patients with EPVO of undetermined origin.

[Digestive complications of aspirin]. / Complications digestives de l'aspirine.

INTRODUCTION: This review focuses on aspirin-related gastrointestinal side-effects and the mechanism by which aspirin causes gastrointestinal damage. CURRENT KNOWLEDGE AND KEY POINTS: Aspirin causes direct gastric damage by topical irritant effects and indirect damage via systemic inhibition of cyclooxygenase synthesis and microcirculation injury. The question of a possible synergistic relation between the presence of Helicobacter pylori infection and aspirin use on gastric damage is not resolved. The pathogenesis of small intestinal and colonic damage is less well understood; an increase in intestinal permeability and free radical synthesis are suggested. Gastric damage predominates. Gastroduodenal lesions from aspirin have been documented in endoscopy studies. The lesions occur rapidly, even for low-dose aspirin. The association of aspirin consumption with upper gastrointestinal bleeding has been well established. The main risk factors are advanced age, concomitant use of nonsteroidal antiinflammatory drugs and history of ulcer. Low-dose aspirin are associated with increased risk of gastrointestinal bleeding and this risk is dose-dependant. Chronic aspirin consumption can cause iron deficiency anaemia. Uncomplicated gastric ulcer (but not uncomplicated duodenal ulcer) is associated with aspirin use, with relative risk 3. Other upper gastrointestinal complications have been reported: stenosis and perforation. Aspirin can also damage other areas of the gastrointestinal tract. Oesophageal injuries (oesophagitis and stricture) have been reported. Aspirin is associated with variceal bleeding episodes in patients with cirrhosis. The adverse effects of aspirin on the small bowel are perforation, bleeding, increasing permeability. The adverse effects of aspirin on the large intestine are perforation, bleeding, collagenous colitis and anorectal stenosis with suppositories containing aspirin. Direct clinical data regarding prophylaxis with co-administration of a protective drug are not yet available for aspirin. FUTURE PROSPECTS AND PROJECTS: Patients should be made aware of adverse gastrointestinal effects due to aspirin. Further studies regarding prophylactic therapy of low-dose aspirin induced gastroduodenal lesions, which identify a subset of patients who may be at higher risk than the low-dose aspirin population as a whole, are warranted.

Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas.

OBJECTIVE: To compare incidence rates and epidemiological characteristics of acute upper gastrointestinal haemorrhage (AUGIH) in France with those of other European studies. DESIGN: Population-based multi-centre prospective survey. SETTING: 29 public hospitals and 96 private specialists in gastroenterology in four administrative areas in France during 1996. SUBJECTS: A total of 2133 AUGIH patients 18 years and over were included in the six-month study. OUTCOME MEASURES: Incidence and mortality. RESULTS: The overall incidence in France was 143 cases per 100000 persons per year, classified as out-patients (16%), emergency admissions (59%) and in-patients (25%). The incidence rates increased with age except for in-patients, and were higher in males. Peptic ulcer (36.6%), varices (13.7%) and erosive disease (12.3%) were the most frequent diagnoses. In 677 patients (31.7%), aspirin, antiinflammatory drugs or corticosteroids were taken on the 7 days before bleeding. The overall mortality (out-patients excluded) was 14.3% (10.7% for emergency patients and 23% for in-patients). Mortality was associated with comorbidities (especially malignancies, cirrhosis, asthma or respiratory deficiency), was lower in emergency patients using non-steroid anti-inflammatory drugs, and higher in in-patients using corticosteroids. CONCLUSIONS: In France, patients with AUGIH are frequently managed as out-patients. Gastrotoxic drug use is frequently associated with AUGIH and constitutes a strategic opportunity for preventive treatment. Discrepancies between countries are not clearly explained either by demographic factors or by drug use, but this may be related to the emphasis on AUGIH in in-patients.

[Management of upper digestive hemorrhage occurring in the community: patterns of patient care in 4 French administrative areas]. / Prise en charge des hémorragies digestives hautes communautaires. Trajectoires des malades dans 4 départements français.

AIMS: To describe patterns of health care management in patients with upper gastrointestinal hemorrhage and to identify factors linked to the different patterns. PATIENTS AND METHODS: We conducted a prospective study of patients over 18 with upper gastrointestinal hemorrhage (inpatients excluded) among all public hospitals and private practice gastroenterologists in 4 French administrative areas (3 in Northern France and one in the South West). RESULTS: One thousand six hundred and two patients were included over a six-month period (1996). An endoscopic procedure was performed in 1532 patients in public (70%) or private (20.5%) hospitals, or at private office (9.5%). Hospitalization was necessary in 78.8% of the patients in university, non university public or private hospitals (38.9, 45.5 and 15.6%, respectively) with a median duration of 6.5 days. Admission was associated to old age, short delay between hemorrhage and endoscopic procedure, previous gastrointestinal bleeding, cirrhosis or cancer, bleeding from peptic ulcer or esogastric varices. Endoscopic hemostasis was performed in 21.4% of the patients, more often in university and no university public hospitals. Surgery was necessary in 4% of the patients. Death rate was 10.7%. Important geographical variations were observed concerning referral patterns. Patients' characteristics did not differ between the 4 areas. On the other hand, health care supply provided in the management of upper gastrointestinal hemorrhage was different in the four French geographical areas. CONCLUSION: a) An initial endoscopic procedure is nearly always performed in patients with an upper gastrointestinal hemorrhage in France; in 1 patient out of 10, endoscopy was performed in a private gastroenterologist office; b) hospital admission was strongly related to epidemiological and clinical criteria of severity; c) the geographical variations observed in referral patterns depend in part on health care supply; d) upper gastrointestinal haemorrhage status could be used as an indicator of the quality of health care organizations.

Low levels of glutathione in endoscopic biopsies of patients with Crohn's colitis: the role of malnutrition.

BACKGROUND AND AIMS: During active Crohn's disease, generation of free radicals is increased, and nutritional depletion is frequent. We investigated the glutathione concentration of the colonic mucosa in biopsies from patients with active Crohn's colitis depending on nutritional status. METHODS: Endoscopic biopsies were taken in 10 well-nourished control patients, and 18 patients with active Crohn's disease (11 well-nourished, seven malnourished with a recent weight loss > 10 %). Colonic biopsies were taken from healthy and inflamed mucosa and analysed for total glutathione concentration. RESULTS: Mucosal glutathione concentration (nmol/mg wet tissue) was lower in patients with active colitis both in diseased and healthy mucosa as compared with controls (1.89 +/- 0.39, 2.08 +/- 0.4 and 6.69 +/- 4. 94, respectively, P< 0.05). Mucosal glutathione was lower in healthy mucosa from malnourished versus well-nourished patients: 1.8 +/- 0.2 vs 2.3 +/- 0.37 (P= 0.02). CONCLUSIONS: Mucosal glutathione is markedly lower in active Crohn's colitis, even in healthy mucosa; glutathione depletion tends to be more severe in malnourished patients. Glutathione depletion may be related in part to malnutrition and contribute to a prolonged evolution of disease and could be a target for pharmacological and nutritional support.

[Prospective evaluation of three kits for endoscopic percutaneous gastrostomy (PEG)]. / Evaluation prospective de trois kits de gastrostomie percutanée endoscopique (GPE).

OBJECTIVES: Percutaneous endoscopic gastrostomy (PEG) is often used for long-term enteral feeding. Various PEG kits are currently available. A technical evaluation could be useful in providing a criteria of choice between the different kits. METHODS: Therefore, from January 1995 to January 1998, we prospectively performed a short- and a mid-term technical evaluation of 150 PEG kits: 106 Compat Sandoz, 37 Flocare Nutricia et 7 Sherwood. RESULTS: In 20% of the patients studied, technical problems during endoscopic insertion of the probe were observed. Only minor incidents were found for Compat Sandoz and Flocare Nutricia kits. However, major problems occurred with the Sherwood kits leading to a very difficult (4 cases) or impossible (2 cases) transcutaneous introduction of the catheter into the stomach. Mid-term outcome was evaluated in 86 of the 150 patients (57%) with a median follow-up duration of 5 months (range: 1-24). The main finding of the mid-term evaluation was a significant alteration of the Compat Sandoz tube. CONCLUSION: This prospective evaluation shows that technical improvement of the available PEG kits are needed, that the PEG polyurethane tube could be preferred for long-term enteral feeding.

[Hemorrhaging eso-gastro-duodenal ulcers: epidemiology and management. A multicenter prospective study]. / Les ulcères oeso-gastro-duodénaux hémorragiques: épidémiologie et prise en charge. Etude prospective multicentrique.

UNLABELLED: The aim of this study was to estimate the incidence, and to describe the characteristics and medical care in patients with bleeding upper gastrointestinal ulcers in the general population. PATIENTS AND METHODS: A study was performed over six months in 1996 in 4 French geographical areas: Finistère, Gironde, Seine-Maritime, and the Somme (3 million people minimum 18 years). All public or private hospitals, and specialist gastroenterologists in private practice participated in the study, based on a standardized questionnaire. RESULTS: Over 6 months 793 patients with bleeding ulcers were identified, corresponding to 27 per 100,000 inh./year or 24,000 cases in France. Most patients were men (60%) and 40.1% were 75 years and older. The ulcer was oesophageal (6%), gastric (47%), or duodenal (69%). In 406 patients (51.2%) a chronic disease was present (cancer, cirrhosis, circulatory, respiratory or cardiac disease). In 237 cases (29.9%) the ulcer occurred in patients, 453 patients (57.1%) were admitted and 103 patients (13%) were managed as outpatients. Gastrotoxic drugs were taken by 349 patients (44%): non steroidal anti-inflammatory drugs (18.7%), aspirin (21.2%, including 2/3 with doses under 330 mg/day), corticosteroids (7.8%) and 24.3% had anticoagulant therapy. Patients were managed in university hospitals (39.3%), other public or non profit hospitals (44.2%) or private hospital (16.5%) with geographical differences between the 4 areas. Therapeutic endoscopy was performed in 16.9% and a surgical procedure was performed in 5.9%. The mortality rate (outpatients excluded) was 13.5% (n = 93), but only 2% (n = 16) of death were associated with a bleeding ulcer: mortality was higher in inpatients (24.1%) than in out patients (8.1%). A chronic disease was also associated with higher mortality (17.9% versus 8.1%). CONCLUSION: Bleeding ulcers are frequent and severe, especially in inpatients or associated with chronic conditions. A gastrotoxic drug used is found in about fifty percent of the cases.