Norethisterone-induced cholestasis: A case report.

Case presentation This case report concerns a 49-year-old woman who developed cholestasis (build-up of bile in the liver) two months and a half after initiating norethisterone, progestin-only pills, which resolved after the withdrawal of these pills.

Squamous cell carcinoma of the rectum cured after chemoradiation.

The primary squamous cell carcinoma of the rectum is a rare tumor that presents epidemiological, etiopathogenic and evolutionary characteristics different from those of adenocarcinoma . We report the case of a primary squamous cell  carcinoma well  differentiated  from medium-high   rectal junction in a 59 year old patient treated with a chemoradiation first ,followed by surgical resection. However, the anatomical examination of the  surgical specimen did not show tumoral tissue.

Successful treatment of massive ascites due to lupus peritonitis with hydroxychloroquine in old- onset lupus erythematosus.

Systemic lupus erythematous (SLE) is an auto-immune disease with multiple organ involvements that occurs mainly in young women. Literature data suggest that serositis is more frequent in late-onset SLE. However, peritoneal serositis with massive ascites is an extremely rare manifestation. We report a case of old-onset lupus peritonitis treated successfully by Hydroxychloroquine. A 77-year-old Tunisian woman was hospitalized because of massive painful ascites. Her family history did not include any autoimmune disease. She was explored 4 years prior to admission for exudative pleuritis of the right lung without any established diagnosis. Physical examination showed only massive ascites. Laboratory investigations showed leucopenia: 3100/mm3, lymphopenia: 840/mm3 and trace protein (0.03 g/24 h). Ascitic fluid contained 170 cells mm(3) (67% lymphocytes), 46 g/L protein, but no malignant cells. The main etiologies of exudative ascites were excluded. She had markedly elevated anti-nuclear antibody (ANA) titer of 1/1600 and a significantly elevated titer of antibody to double-stranded DNA (83 IU/mL) with hypo-complementemia (C3 levl was at 67 mg/dL). Antibody against the Smith antigen was also positive. Relying on these findings, the patient was diagnosed with SLE and treated with Hydroxychloroquine 200 mg daily in combination with diuretics. One month later, there was no detectable ascitic fluid and no pleural effusions. Five months later she remained free from symptoms while continuing to take chloroquine. This case was characterized by old age of onset of SLE, the extremely rare initial presentation with lupus peritonitis and massive painful ascites with dramatic response to only hydroxychloroquine treatment.

[Serodiagnosis of acute hepatitis in adults patients: results of a prospective study in a central region of Tunisia]. / Sérodiagnostic des hepatitis aiguës de l'adulte: résultats d'une etude prospective dans une region du centre tunisien.

UNLABELLED: PRÉREQUIS: Viral hepatitis is a public health problem in many parts of the globe. In Tunisia, the respective responsibility of five viruses (HAV, HDV, HBV, HCV and HEV) in the genesis of acute hepatitis in adults is only roughly indicated in the absence of suitable serological studies, given as important to plan appropriate preventive strategies. OBJECTIVES: To approach the role of viral hepatitis in all adult with acute hepatitis, identify the current share of each virus A, B, C and E in the genesis of hepatitis and to study the epidemiological and evolution of these diseases. METHODS: We conducted a prospective study over two years including patients aged from 15 to 65 years old, with clinical and / or biological acute hepatitis. Data were collected through a standard questionnaire wich covered sociodemographic charactereristics and risk factors. Blood samples were collected and were tested for IgM anti-HAV, IgM anti-HEV, HBsAg, IgM anti-HBc, anti-HCV antibodies .When serological tests were negatives, further explorations including immunological test, search for HCV RNA and a pharmacovigilance survey was conducted. Statistical analysis was performed by SPSS version 10.0 RESULTS: 105 patients were included. Acute viral hepatitis was diagnosis in 70 patients (67%). The proportion of patients with acute viral hepatitis A, B, C and E was 51.5% , 38.5%, 4.3% and 5.7% respectively. The risk factors of viral hepatitis A was drinking of untreated water and poor socioeconomic status. In the HBV group, the notion of sexual contact risk was found in 30% of cases. The small numbers of acute hepatitis E and C does not permit us to draw conclusions. CONCLUSION: Our study confirms the shift in age of onset of hepatitis A to the age of adolescence and young adulthood. The respective responsibilities of the different viruses studied in the genesis of acute hepatitis in adults in our area brings us closer of western populations where HAV infection predominates followed by HBV.

Appropiateness of colonoscopy in the university hospital center of monastir. Interest and applicability of criteria established by the European panel on the appropriateness of gastrointestinal endoscopy.

AIM: 1) To assess the applicability of EPAGE criteria in there first version (EPAGE I) in clinical practice, 2) to assess colonoscopy appropriateness using EPAGE I criteria, 3) to compare colonoscopy appropriateness and findings. METHODS: Four hundred and eighty-seven consecutive diagnostic colonoscopies were included. The appropriateness of the indication of colonoscopy was appreciated using a scoring system on the basis of the EPAGE criteria in there first version (EPAGE I). RESULTS: Appropriateness were applied in 86,4% of the colonoscopies. Fifty-one percent were appropriate, 14% uncertain and 18% inappropriate. The difference of 17% represented the procedures indicated for hematochezia and for witch an appropriateness score can not be attributed because of lack of clinical information. The probability of finding a clinically significant lesion was significantly higher in patients aged ≥ 50 years, males, inpatients, those referred by gastroenterologists and those who had the colonoscopy for "appropriate" indication according to the EPAGE I criteria. The independent variables correlated with the diagnostic yield of colonoscopy were the age, the appropriateness of indication and the health care setting. CONCLUSION: EPAGE I criteria were applicable in most patients and were correlated with significant findings. They are thereby useful to rationalize colonoscopy demand. However, they could be regularly updated.

[Epidemiological, clinical features, therapeutic results and evolution of gastrointestinal stromal tumour: about 25 cases]. / Caractéristiques épidémiologiques, cliniques, thérapeutiques et évolutives des tumeurs stromales digestives: à propos de 25 cas.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are mesenchymal tumors occuring in the majority of cases in the stomach and small intestine, rarely in rectum, colon, esophagus or mesentery. They are derived from cells of cajal or their precursor, and are typically CD117/KIT + (95%), CD34 + (70%). AIMS: is to study the epidemiological, clinical, therapeutic and evolution of gastrointestinal stromal tumors. METHODS: retrospective study including all patients with the diagnosis of GIST supported in the department of gastroenterology and surgery in universital hospital of Monastir. RESULTS: 25 patients were included, 12 men and 13 women with an average age of 60.5 years. Digestive symptomatology was dominated by gastrointestinal bleeding (n = 12) and abdominal pain (n = 12). The tumor was discovered incidentally in two patients. The small intestine was the most common site of the tumor (n = 10), followed by the stomach in 9 patients, rectum in two patients, the colon (n = 1), the bulb of water (n = 1), duodenum (n = 1) and liver in a patient. The tumor size ranged from 0.8 to 24 cm. GIST was localized in 16 patients, in whom therapeutic care based mainly on surgery and optimal broad. It was metastatic in 9 patients, in whom treatment using imatinib as first-line in 4 of them with a good response in 3 patients and the possibility of R0 surgery in one patient, initial stabilization and then a secondary exhaust in a patient. The first surgery was necessary in 5 patients in complicated situation or if diagnostic doubt. CONCLUSION: The best characterization of GIST thanks to advances in cancer research has led to improved treatment of these tumors. Surgery is the standard treatment in localized forms. Imatinib is the standard treatment in metastatic GIST first line as well as adjuvant after surgery.

[Duodenal ulcer disease and Ramadan]. / Maladie ulcéreuse duodénale et Ramadan.

Ramadan fasting is accompanied by an increase of the gastric acidity over 24 hours especially in the daytime. Gastric acidity is maximal at the end of the fasting day. So, a patient with duodenal ulcer is exposed to a high risk of disease reactivation. The frequency of ulcer complications is statistically higher during the month of Ramadan than the rest of the year. The frequency of the upper gastrointestinal hemorrhage is multiplied by 2 and perforation by 4. Helicobacter pylori eradication does not seem to play a role in the occurrence of these complications, particularly the perforation. The patient with duodenal ulcer can fast without risks while using a proton pump inhibitor if the ulcer is healed and H. pylori is eradicated. Ramadan fasting seems to us inadvisable when duodenal ulcer is active, but large prospective studies are needed.

Clarithromycin versus metronidazole in first-line Helicobacter pylori eradication. Prospective randomized study of 85 Tunisian adults.

BACKGROUND: Although primary resistance to metronidazole remains high (56,8%), it is more widely used than clarithromycin as a firstline Helicobacter pylori (H. pylori) treatment in the common Tunisian practice. AIM: To compare the eradication rate in two protocols including clarithromycin versus metronidazole in Tunisian adults. METHODS: From July 2005 to December 2007, 85 patients aged 18 to 75 years presenting with gastro-duodenal lesions with H. pylori infection and requiring its eradication were included in the study. They were randomized to receive alternatively a seven-day triple therapy including: Omeprazole + Amoxicillin + Clarithromycin (OAC group) or Metronidazole (OAM group) twice a day. A second endoscopy with new biopsies was carried out 6 weeks after treatment to control eradication. RESULTS: Eighty five patients finished the protocol. The OAC and OAM groups included 46 and 39 patients respectively. They were comparable with respect to age, gender, clinical presentation and initial lesions. The total eradication rate was 60%. It was significantly higher in the clarithromycin group (69.6%) than in the metronidazole group (48.7%): p < 0.05. CONCLUSION: Clarithromycin is more effective than metronidazole in H. pylori eradication. It should be made available in our hospital's nomenclature. This would prevent iterative eradication courses and probably reduce treatment cost.

[Chronic viral hepatitis and kidney failure]. / Hépatites virales chroniques chez les patients insuffisants rénaux.

Chronic viral hepatitis remains a major problem among patients with chronic renal failure. Hepatitis B and C viruses are frequent among dialysis patients and after renal transplantation and may significantly diminish the survival of both the patient and the graft. Hepatitis B and C viral infection in these patients is often characterized by normal transaminase levels despite viremia and progressive liver lesions. Liver biopsy remains essential for assessing the extent of liver disease. Cirrhosis is a contraindication to transplantation of only a kidney, because of elevated morbidity and mortality. A combined as liver-kidney transplantation may be considered. The best treatment of hepatitis infections is preventive: vaccination against the hepatitis B virus and attentive hygiene, especially to prevent nosocomial transmission. Among patients not awaiting transplant, antiviral treatment should be reserved for patients with active or even fibrotic liver disease. For hemodialysis patients awaiting kidney transplant: Alpha interferon is ineffective and poorly tolerated by dialysis patients. Lamivudine is effective and well tolerated, but its long-term efficacy and its optimal effective dose in dialysis patients remain unknown.