Estimation of the prevalence of obstructive sleep apnea in non alcoholic fatty liver disease.

INTRODUCTION: The prevalence of non alcoholic fatty liver disease is increasing in parallel with the epidemic of obesity and metabolic syndrome. Recent data have shown frequent association between non alcoholic fatty liver disease (NAFLD) and obstructive sleep apnea. AIM: To estimate the prevalence of sleep disorders, to search an obstructive sleep apnea syndrome by conducting a ventilator polygraphy and to search the particularities of obstructive sleep apnea when its exists, in patients with NAFLD. METHODS: A prospective study, conducted over a period of 6 months, including patients followed for non-alcoholic fatty liver disease. We performed in all patients a Berlin questionnaire that assesses the risk of obstructive sleep apnea syndrome, an Epworth score that estimates the degree of daytime sleepiness and a ventilator polygraphy. RESULTS: We collected 37 patients. The mean age was 50,41±13,7 years. The sex ratio (M/F) was 0,42. Type 2 diabetes mellitus, arterial hypertension or dyslipidemia were recorded respectively in 37,8%, 40,5% and  37,8% of cases. Snoring was noted in 75,7%  of cases and excessive daytime sleepiness in 34,2% of cases. Obesity was observed in 73% and metabolic syndrome in 43,2% of cases. The Berlin Questionnaire was positive in 64,9% of cases. The average score of Epworth scale was 9,22±4,02 and 43,2% of patients had a score> 10. Ventilatorypolygraphy was positive in 13 cases (35,1%) with a mean AHI of  7,02±10,08.In these patients, obstructive sleep apnea was mild, moderate and severe in respectively 61,5%, 15,4% and 23,1% of cases. In univariate analysis, subjects with positive ventilator polygraphy had a significantly higher waist circumference (118,00 versus 109,58, p=0,05). Arterial hypertension was significantly associated with increased daytime sleepiness (p=0,018). In multivariate analysis, the only independent variable associated with excessive daytime sleepiness was arterial hypertension (OR=5,33 p=0,021). CONCLUSION: In our study, the prevalence of obstructive sleep apnea syndrome is high in patients with non alcoholic fatty liver disease. The only independent variable associated with excessive daytime sleepiness was arterial hypertension.

Hyponatremia in cirrhosis: Risk factors and prognostic value.

Background Hyponatremia is the most common electrolyte abnormality encountered in cirrhotic patients. Recent studies have shown that hyponatremia was correlated with severity of cirrhosis and associated with increased risk of complications and mortality. However this relationship is still unclear. The aims of the present study were to search predictive factors for hyponatremia in cirrhosis and to assess its prognostic value. Methods We performed a retrospective study, including consecutive cirrhotic patients admitted to our department between January 2011 and April 2014. Patients and cirrhosis characteristics were studied. Serum sodium levels were determined at admission. The cutoff level of 130 mmol/l was chosen because it is widely accepted to define hyponatremia in patients with cirrhosis. Predictive factors of hyponatremia development and its impact on the outcome (cirrhosis complications and survival) were evaluated. Results We included 143 cirrhotic patients: 67 females (46.9%) and 76 males (53.1%) with a mean age of 58 years. Etiology of cirrhosis was mainly viral (56.7%). Child-Pugh stage was B in 41.2% and C in 25.9%. Mean MELD score was 15 [6-40]. The prevalence of dilutional hyponatremia as defined by a serum sodium concentration ≤130 mmol/L or ≤135 mmol/L was 10.5% and 31.4% respectively. Serum sodium level ≤130 mmol/L was strongly associated with severity of liver function impairment as indicated by Child-Pugh C (OR=7.84;p<0.001), and MELD score> 16 (OR=6.76; p=0.001). Survival without complications was reduced in patients with hyponatremia but was only significant if a serum sodium concentration ≤135 mmol/L was considered (p=0.012). Survival without hepatic encephalopathy and without hepatorenal syndrome was significantly reduced in patients with hyponatremia (p<0.001 for both). Global survival was also reduced in patients with hyponatremia at 1 year: 22.5% versus 68.7%, as well as mean global survival: 8.3 versus 32.8 months (p<0.0001). Conclusion Low serum sodium level was correlated with severity of cirrhosis.  Hyponatremia was a negative prognostic factor associated with increased short-term morbi-mortality.

Prognosis of refractory ascites in cirrhosis.

BACKGROUND: Ascitic decompensation is a common major complication of cirrhosis and is associated with a poor outcome. In 5-10% of patients, ascites become resistant to treatment (either do not respond to a high dose of diuretics or because these drugs induce complications), which is called refractory ascites (RA). RA is associated with poor survival: 20-50% at 1 year. The aim of this study was to investigate the outcome of RA. METHODS: Retrospective study including consecutive cirrhotic patients admitted for controlling ascites between January 2010 and April 2013. Patients and cirrhosis characteristics were studied. Development of RA during follow-up was investigated. The impact of RA on the outcome (cirrhosis complications and survival) was evaluated. RESULTS: We included 124 cirrhotic patients: 59 females (47.6%); mean age was 58 years. Ascites was grade 3 in 38.5% and was the first episode in 45.1% of patients. Etiology of cirrhosis was mainly viral (57.3%). Child-Pugh score was B in 39.5% and C in 28.2%. Mean MELD score was 16 [6-40]. During follow-up, 27 patients developed RA, meaning a prevalence of 21.8%. RA type was diuretic intractable in all cases. Survival without complications was significantly reduced in patients with RA (4 vs 17 monthsp<10-3). RA was an independent predictive factor of global complications, spontaneous bacterial peritonitis and hepatic encephalopathy. Global survival was reduced in patients with RA (12 vs 16 months, p=0.069). One year survival was 45% for patients with RA vs 63% for other cirrhotics. In multivariate analysis, only Child-Pugh score, but not RA was an independent prognostic factor. CONCLUSION: In this Tunisian sample we confirm that RA reduces survival and increases risk of cirrhosis complications, especially hepatic encephalopathy and spontaneous bacterial peritonitis. Therefore, these patients should be promptly listed for liver transplantation, over and above the MELD score.

Does protein energy malnutrition affect the outcome in Tunisian cirrhotic patients?

BACKGROUND: Malnutrition is commonly seen in cirrhotic patients and has been shown to adversely affect outcome. However, it remains associated with the severity of cirrhosis. Therefore, its role as an independent prognostic factor is still under debate. The aims of our study were to determine the prevalence of malnutrition in cirrhotic patients and determine whether this condition was an independent prognostic factor. PATIENTS AND METHODS: We prospectively analyzed the nutritional status of 104 consecutive patients with cirrhosis Subjective global nutritional assessment (SGA) and anthropometry [dry body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC)] were used for the evaluation of the nutritional status. Complications of cirrhosis during follow-up and patient's survival were recorded. Global survival and survival without complications was studied by Kaplan Meier method and using Log Rank test. RESULTS: Prevalence of malnutrition ranged from 16.3 and 62.5% according to the method of nutritional assessment used. Survival without complications was reduced in malnourished patients. This difference was significant when assessing malnutrition by dry BMI (p=0.001). In multivariate analysis, malnutrition defined by dry BMI<18.5 kg/m2 was an independent predictor of complications (p<0.001; RR 3.2) especially hepatic encephalopathy (p=0.001; RR 2.66). In univariate analysis, global survival was worse in malnourished patients (by BMI and SGA; p=0.03 and p=0.0014 respectively), but this trend was lost in multivariate analysis. CONCLUSION: In our study, malnutrition was an independent predictor of complications in cirrhosis. However, it did not appear as an independent prognostic factor for global survival. These results raise again difficulties to clarify whether malnutrition influence itself the prognosis of cirrhosis or if it is only related to the severity of cirrhosis.

Cardiovascular risk estimation in non alcoholic fatty liver disease.

BACKGROUND: Nonalcoholic fatty liver disease is rising to the growing epidemic of metabolic syndrome. Recent data suggest that this liver disease may represent a real marker of cardiovascular risk. The aim of our study was to calculate cardiovascular risk and to estimate the frequency of subclinical coronary artery disease by conducting an exercise testing. METHODS: This is a prospective study conducted over a period of one year including all patients followed for non alcoholic fatty liver disease. We realized in all patients an exercise testing and we calculated the ACC / AHA score that estimates the risk of developing atherosclerotic cardiovascular disease. This risk is considered very high if the score> 7.5. RESULTS: We included 103 patients. The mean age was 52 years. The sex ratio (M/F) was 0.3. Diabetes, dyslipidemia and hypertension were present respectively in 45.6%, 48.5% and 38.8% of cases. Obesity was noted in 69.9% of our patients. Metabolic syndrome was found in 78.6% of patients. The ACC / AHA average score was 8.03 ± 9 and a score> 7.5 was noted in 35.9% of cases. The exercise testing was positive in 12 patients (11.65%). Of these, 11 underwent coronary angiography which was normal in 10 cases and showed a coronary artery infiltration without significant stenosis in only one case, and 2 patients underwent coro-scanner which was without significant anomalies. In univariate analysis, the presence of metabolic syndrome (p = 0.05), waist circumference ≥ 94 cm in men and ≥ 80 cm in women (p = 0.019), diabetes (p = 0.03) were associated with a high risk of developing cardiovascular events. In multivariate analysis, the only independent variable associated with a positive exercise testing was diabetes (OR 4.5, p = 0.03). CONCLUSION: During non alcoholic fatty liver disease, there is an increased cardiovascular risk. It would be necessary to consider this excess risk in the surveillance of patients followed for non alcoholic liver disease to early detection of any cardiovascular disease.

Complete radiological response after sorafenib treatment for advanced hepato-cellular carcinoma.

INTRODUCTION: Sorafenib, an oral multikinase inhibitor, has recentlybeen shown to improve overall survival in patients with advanced hepatocellular carcinoma (HCC) but only a handful of reports of complete remission on sorafenib have been issued. CASE REPORT: We report an intriguing case of advanced HCC complicating HCV infection with cirrhosis, in which the patient achieved complete remission by prolonged administration of sorafenib. CONCLUSION: Identifying factors that could be associated with good response to this therapy are needed.

Percutaneous treatment versus hepatic resection for the treatment of small hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is the first liver tumor worldwide. Therefore, it is a matter of debate whether surgical treatment or percutaneous treatment should be preferred for the treatment of patients with small hepatocellular carcinoma. The aim of our study was to compare the long-term outcome and the survival between surgically and percutaneously treated small hepatocellular carcinomas. MATERIAL AND METHODS: A retrospective study was performed in the department of hepatology during a period of 2009-2012. The study included all patients carrying small hepatocellular carcinoma which were divided in: group 1 including patients who underwent surgical treatment, and group 2 including patients who underwent percutaneous treatment. RESULTS: Among the 63 patients who were diagnosed for hepatocellular carcinoma, 28 carried a small hepatocellular carcinoma with a mean age of 63 years and sex-ratio of 0.64. Etiology of cirrhosis was viral in 96% cases. Surgical treatment (hepatic resection) was performed in 54% cases while percutaneous treatment was proposed for 46%: radiofrequency ablation in 69% and alcoholic injection in 31%. No major complications for both surgical and percutaneous treatment occurred in our study. The corresponding 6 months and 1- year overall survival rates for the surgical resection group and the percutaneous treatment group were 100%, 100%, 20%, and 52%, respectively (p=0,04). The disease free survival were not significantly different. CONCLUSION: Our results showed the efficacy and safety of percutaneous ablation treatments (radiofrequency ablation and ethanol injection) in patients with small hepatocellular carcinoma.

Quality indicators for colonoscopy in a Tunisian endoscopy unit.

BACKGROUND: Colonoscopy is a powerful tool for prevention and early diagnosis of colorectal cancer. However, the effectiveness of colonoscopy is dependent on the quality of the procedure, which is assessed by a number of key quality indicators. Among them, cecal intubation and adenoma detection rate are historically the most commonly used indicators of quality of colonoscopy. The aim of our study was to evaluate these two indicators of quality of colonoscopy in a Tunisian endoscopy center. METHODS: We conducted a retrospective study from January 2009 to March 2013. Data were collected from colonoscopies reports. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The quality of bowel preparation was subjectively classified at the time of the examination by each endoscopist as good, fair, or poor. Procedure related quality indicators considered for analysis were: cecal intubation rate (CIR) and polyp detection rate. RESULTS: During the period of the study, 859 colonoscopies were performed without sedation. The average age was 54.76 ± 17.5 years. Males represented the majority of our population (50.2%). Colic preparation was judged good, fair and poor in respectively 24 %, 61% and 15% of cases. The cecal intubation rate was 61.1 %. Causes of incomplete colonoscopy were especially poor preparation (47.3%) and poor tolerance (34.4%). Univariate analysis disclosed 3 predictive factors of CIR : the quality of bowel preparation (good vs fair or poor( (67.2 % vs 31.3%, p = 0.0001,OR: 4.5, 95% CI: 3.3-6), the screening indication (72.9% vs 60.1% , p = 0.03, OR: 1.7, 95% CI: 1-3) and the presence of alarming signs (55% vs 43%, p=0.04; OR: 1.1, 95% CI:0.9-2.5). By multivariate analysis, the factors influencing independently the CIR were the quality of bowel preparation (p=10-3, OR=2.23, 95% CI: 1.47-3.3) and the screening indication (p=0.02, OR: 1.9, 95% CI: 1.1-3.4). The polyp detection rate was 21% and was correlated, in univariate analysis with: age over 47 years (p=10-3, OR:3.2, 95 % CI:2-4.9), male gender (25.1% vs 16.8%, p=0.001, OR:2.36, 95% CI: 1.4-4), the quality of the preparation (26.5% vs 19.1%, p=0.03 OR:1.4, 95% CI:0.9 -2), the presence of colorectal cancer (50.9% vs 18.2%, p=0.0001, OR:4.6, 95% CI: 2.6-8) and the screening indication (35.7% vs 19%, p=0.001 OR: 2.36, 95% CI: 1.4- 4). By multivariate analysis, 3 independent factors associated with polyp detection rate were identified: age over 47 years (p=10-3, OR: 3.5 95% CI:2-5.9), bowel preparation (p=10-3 OR=5, 95% IC:2.7-9.6) and the screening indication( p=0.01, OR 2.5, 95% IC 1.4-4.7). CONCLUSION: In our cohort, the quality of bowel preparation, tolerance of the procedure, age and the indication of colonoscopy were significantly associated with the indicators of quality. Bowel preparation and tolerance are targets on which we should act to improve performance.

[Solitary rectal ulcer syndrome. A Tunisian monocentric Survey]. / Le syndrome d'ulcère solitaire du rectum. A propos d'une série Tunisienne monocentrique.

BACKGROUND: Solitary rectal ulcer syndrome is an uncommon and benign defecation disorder. Occidental series are scarce and to our knowledge, Tunisian data are not available. AIMS: The aim of this study was to evaluate the clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome. METHODS: All the patients diagnosed with solitary rectal ulcer syndrome from January 2001 to 2012 were included in the study. The medical records were reviewed retrospectively to evaluate the clinical spectrum of the patients along with the endoscopic, histological and therapeutic findings. RESULTS: A total of 15 patients were evaluated: 7 males; mean age 42.6 years. Bleeding per rectum was present in 66% and dyschezia in 73%. Endoscopically, solitary lesion was present in 66% patients. The most frequent dynamic abnormalities shown by defecography were of rectal intussusception (53%). Anorectal manometry was performed in seven cases disclosing dyssynergia in 2 cases. Thirty patients underwent surgery, always after failure of medical treatment and one patient was treated with biofeedback. Rectopexy was the most utilized technic. After a mean follow-up of 29 months, total regression of symptoms was noted in 50% of patients who underwent surgery. CONCLUSION: In this cohort, diagnostic and therapeutic spectrum of solitary rectal ulcer syndrome was comparable to occidental features. Nevertheless, accesses to manometry and defecography as well as biofeedback were limited.

Appropriateness of indication for upper gastrointestinal endoscopy in a Tunisian endoscopy unit.

BACKGROUND: Upper gastrointestinal endoscopy (UGE) is an increasing and reliable procedure. Given the high costs and potential risks, appropriate indication of UGE may be facilitated by referring to qualifying criteria such as those devised by the European Panel (EPAGE). This prospective study evaluates the applicability and efficacy of these criteria in clinical practice. METHODS: Cross sectional study. Consecutive patients were referred to our unit endoscopy for diagnostic upper gastrointestinal endoscopy between January 2011 and June 2011. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The appropriateness of UGE was assessed based on EPAGE II criteria before the procedure. RESULTS: EPAGE criteria were applicable in 89.1% of cases. They were 78 men (48.1%) and mean age was 49 years [14 - 91]. Indications for UGE were extremely appropriate, appropriate, inappropriate and uncertain in 21.6%, 47.4%%, 8.8% and 22.2% respectively. Among patients with clinically significant lesions detected by UGE, 70.7% had an appropriate indication. Clinically significant lesions were disclosed in 59% of the appropriate group and 54% of the inappropriate group. All cancers were observed in patients with appropriate indications. Patients with appropriate indication were older than patients belonging to the inappropriate group (53.6 years versus 39.9 years, p =0,0001). CONCLUSION: In this present study, EPAGE criteria were applicable in 89.1% and indication was judged appropriate in more than two-third of cases. However, clinical significant lesions were observed in a proportion of patients with inappropriate indication, and in some relevant clinical situations EPAGE criteria were not applicable. Therefore, even if these criteria are helpful for decision-making, final decision must however rely upon practitioner. Qualifying criteria for an appropriate selection of endoscopical procedure adapted to our population are advisable.

[Minimal hepatic encephalopathy: a better diagnostic to improve prognostic]. / Encéphalopathie hépatique minime : un diagnostic précoce pour améliorer le pronostic.

BACKGROUND AND AIMS: Minimal hepatic encephalopathy (MHE) is the mildest form of the spectrum of hepatic encephalopathy that impairs health-related quality of life. The aim of this study is to evaluate the prevalence of MHE in patients with liver cirrhosis and analyze risk factors. METHODS: Between September 2011 and December 2012, consecutive cirrhotic patients seen in our department were evaluated. Patients included were screened by the psychometric hepatic encephalopathy score (PHES) battery comprising 5 tests: number connection test A and B, line tracing test, serial dotting test and digit symbol test. Patients included were regularly followed-up for the development of overt hepatic encephalopathy, driving accidents, falls and death. RESULTS: We included 45 cirrhotic patients. Etiology of cirrhosis was viral in half of cases. Child-Pugh score was A in 55.6 %, B in 26.7 % and C in 17.8 %. Median Meld score was 14. According to the PHES score, MHE was detected in 44.4 % of patients. Univariate analysis identified 4 variables significantly associated with the presence of MHE: age ≥ 55 years (P=0.031), poor educational status with years of study< 9 years (P=0.007), MELD score ≥ 15 (P=0.002) and Child-Pugh ≥ 7 (P=0.001). At multivariate analysis, the only independent risk factor of MHE was a MELD score≥15 (OR=15.4; P<0.001). During the follow-up, patients with MHE developed more often overt encephalopathy, falls and driving accidents, and had a lower survival, although the difference was not statically significant. CONCLUSION: In this preliminary small series, prevalence of MHE in Tunisian cirrhotic patient was 44.4 %. A MELD score ≥ 15 was the only independent risk factor. MHE had a negative impact on the outcome, justifying an early diagnostic. Adequate therapy may improve cognitive function.

Percutaneous treatment versus hepatic resection for the treatment of small hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is the first liver tumor worldwide. Therefore, it is a matter of debate whether surgical treatment or percutaneous treatment should be preferred for the treatment of patients with small hepatocellular carcinoma. The aim of our study was to compare the long-term outcome and the survival between surgically and percutaneously treated small hepatocellular carcinomas. METHODS: A retrospective study was performed in the department of hepatology during a period of 2009-2012. The study included all patients carrying small hepatocellular carcinoma which were divided in: group 1 including patients who underwent surgical treatment, and group 2 including patients who underwent percutaneous treatment. RESULTS: Among the 63 patients who were diagnosed for hepatocellular carcinoma, 28 carried a small hepatocellular carcinoma with a mean age of 63 years and sex-ratio of 0.64. Etiology of cirrhosis was viral in 96% cases. Surgical treatment (hepatic resection) was performed in 53.5% cases while percutaneous treatment was proposed for 46.5%: radiofrequency ablation in 69% and alcoholic injection in 31%. No major complications for both surgical and percutaneous treatment occurred in our study. Overall survival was significantly lower in the surgical resection group. The corresponding 6 months and 1-year overall survival rates for the surgical resection group and the percutaneous treatment group were 100%, 100%, 20%, and 52%, respectively (p=0,04). The disease free survival were not significantly different. CONCLUSION: Our results showed the efficacy and safety of percutaneous ablation treatments which were better than those of surgical treatment in patients with small hepatocellular carcinoma.

Risk factors of psychological disorders in inflammatory bowel disease in a tunisian survey. Results of a cross-sectional study.

BACKGROUND: Little is known in inflammatory bowel disease (IBD) regarding risk factors for psychological distress. The aims of our work were to evaluate the frequency of anxiety and depression among patients with IBD and to determine the factors associated with these psychological disorders in Tunisian patients. METHODS: From June 2012 to April 2013, 60 consecutive patients with IBD answered a questionnaire about psychological and socioeconomic factors and adherence to treatment. In this study we focused the analysis on the characteristics of IBD (type, localization, severity, treatment) and socioeconomic factors (professional, educational, and marital status). Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). RESULTS: According to the HADS, 25 patients (41.6%) were anxious while 4 (6.6%) were depressed. Three had anxiety and depression at the same time. Twelve patients had a probable anxiety, 2 patients had a probable depression and 3 patients had a probable depression and anxiety at the same time. By univariate analysis, factors associated with anxiety and depression were: female gender (p<0.03), rent (p<0.03), high school graduation (p<0.009), IBD type ulcerative colitis (p<0.05). By multivariate analysis, independent factors associated with these emotional disorders were: female gender (p=0.005, OR 11.3), the high school graduation (p=0.004, OR 12.1). CONCLUSION: In our cohort, risk factors for anxiety and depression were the high school graduation and IBD type ulcerative colitis. Consequently, psychological interventions would be useful when these factors are identified.

Gender difference in patients with hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma represents the fifth most common cancer worldwide and account for approximately 90% of primary liver cancer. Men have a higher prevalence than women; the sex ratio varies between 2:1 and 4:1, depending on the geographic region. AIM: To determine the influence of gender on the clinicopathologic characteristics and survival of patients with hepatocellular carcinoma. METHODS: A retrospective analysis of medical records was performed in 63 patients with hepatocellular carcinoma and their clinicopathologic features and survival were compared in relation to gender. The data was summarized by descriptive statistics and analysed with SPSS version 11.5. RESULTS: Among these patients, 36 were men (57.1%) with male-to female ratio of 2:1.5, the mean female age was 59.8 years (p=0.054). Serum albumin level was significantly lower in women (p=0.0061).The average size of the tumor was 45.8mm and the difference was not significant (p=0.638). Hepatocellular carcinoma was significantly more prevalent among 16 men with post viral B cirrhosis (p=0.04). The main reason for therapeutic abstention was multifocal character of the hepatocellular carcinoma. The median survival time (6.52 months) was not different between the 2 groups. CONCLUSION: At diagnosis, men were younger than women. The viral C etiology was statistically more frequent in women than in men. Hepatocellular carcinoma was more aggressive in male but median survival time was not significant between groups. Screening and early treatment can limit this problem.

The Budd-Chiari syndrome.

BACKGROUND: The Budd-Chiari syndrome is a rare disease, often fatal if not treated optimally. It is characterized by a blocked hepatic venous outflow tract. aim: This review attempted to present pathophysiology, aetiologies,diagnosis and therapeutic modalities of the Budd-Chiari syndrome. METHODS: Review of literature. RESULTS: Budd-Chiari syndrome is a complex disease with a wide spectrum of aetiologies and presentations. Hematologic abnormalities, particularly myeloproliferative disorders, are the most common causes of the Budd-Chiari syndrome. The clinical presentation is governed by the extent and rapidity of the hepatic vein occlusion. Doppler-ultrasound, computed tomography or magnetic resonance imaging of hepatic veins and inferior vena cava are usually successful in demonstrating non-invasively the obstacle or its consequences. A therapeutic strategy has been proposed where anticoagulation, correction of risk factors, diuretics and prophylaxis for portal hypertension are used first; then angioplasty for shortlength venous stenosis; then Transjugular Intrahepatic Portosystemic Shunt (TIPS); and ultimately liver transplantation. Treatment progression is dictated by the response to previous therapy. This strategy has achieved 5-year survival rates approaching 70%. Medium-term prognosis depends on the severity of liver disease. CONCLUSION: The diagnosis of the Budd-Chiari syndrome must be considered in any patients with acute or chronic liver disease. Management of this syndrome should follow a step by step strategy.

[Bowel preparation : what's new ?]. / Préparation colique : Quoi de neuf?

BACKGROUND: The efficiency of bowel preparation directly affects the quality and the reliability of total colonoscopy. Inadequate bowel cleansing is a common cause of incomplete colonoscopy with a risk of ignoring pre-neoplastic lesions represented primarily as adenomas with a size below centimetre. Due to the numerous factors interfering with preparation, an adapted choice of the type of preparation and the follow-up of diverse methods to optimize bowel preparation allows to improve diagnostic accuracy and to reduce costs while guaranteeing to the patient good tolerabilty and safety. AIM: To report the news about the terms of the bowel preparation for colonoscopy quality and to propose practical ways to optimize it. METHODS: Review of literature and lecture of recommendations. RESULTS: The pre-colonoscopy consultation, prescription of a split dose bowel preparation and a brief time between the last dose of preparation and colonoscopy are the means currently available to optimize bowel preparation. CONCLUSION: A better understanding of terms of bowel preparation and the factors influencing the degree of preparation improve the diagnostic efficacy of colonoscopy especially in the detection and treatment of colorectal cancer.