Management of anal fistulas in Crohn's disease after failure of Infliximab.

INTRODUCTION: Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab. AIM: Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab. METHODS: A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded. RESULTS: Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated. CONCLUSION: Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.

Enhancing proficiency in ascites puncture through procedural simulation: an audit type study investigating medium-term skill retention.

INTRODUCTION: Medical simulation has become an essential teaching method for all health professionals. It not only allows to acquire technical and non-technical knowledge, but also helps the maintenance of acquired knowledge in the medium and long term. Ascites puncture is part of the basic technical procedures learned by medical students during their internship. OBJECTIVES: To evaluate the role of simulation-based learning of ascites puncture on the improvement of theoretical knowledge and maintenance of skills at 3 months. METHODS: We conducted an audit type study with two cycles of data collection at the simulation center at the Faculty of Medicine of Sousse between November 2020 and June 2021. We included learners in their third year of medical studies who had a hospital internship in the gastroenterology department at Sahloul Hospital in Sousse. All learners attended the initial simulation session on ascites fluid puncture. Thereafter, they were free to accept or refuse participation in the evaluation session that was scheduled after 3 months, depending on their availability. RESULTS: Forty learners participated in the procedural simulation of the ascites fluid puncture technique. Thirty-four (85%) were female and six (5%) were male. In our study, we showed that following procedural simulation training of ascites puncture, there was a significant improvement in the theoretical knowledge of the learners (p < 0.000). Objective assessment of technical skills after 3 months showed the benefit of performance maintenance (p < 0.000). CONCLUSION: Our study confirmed the benefit of simulation-based learning on the improvement of theoretical knowledge and the maintenance of technical performance in the medium term.

Exploring work productivity loss in patients with inflammatory bowel disease.

Aim: We aimed in this study to evaluate the impact of inflammatory bowel disease (IBD) on patients' professional life and to determine predictors of severe work productivity loss (WPL). Materials & methods: A cross sectional study including patients with a confirmed diagnosis of IBD. Work productivity was evaluated with the work productivity and activity impairment score. Results: Severe absenteeism and WPL were found in respectively 7 (5.1%) and 54 (39.1%) patients. In multivariate analysis, the following features were found to be independently associated with severe WPL: penetrating Crohn's disease (p: 0.001, OR: 6), anemia (p: 0.031, OR: 3.23), diarrhea (p < 0.001, OR: 11.23) and a secondary level of education (p: 0.003, OR: 1.95). Conclusion: Our results show that IBD have a substantial effect on patients' professional life.

Inflammatory bowel diseases (IBD) are chronic conditions that cause inflammation in the digestive system. We wanted to know how IBD affects people's ability to work and what factors contribute to work difficulties. We asked adults with IBD about their education, work conditions and medical history. We found that a significant number of patients experience severe work productivity loss and absenteeism. Factors such as certain types of IBD, anemia, diarrhea and lower education level were linked to more severe work problems. These findings emphasize the impact of IBD on work life and highlight the importance of addressing these challenges in patient care.

Predictive factors of recurrence in spontaneous bacterial peritonitis in Tunisian patients with cirrhosis.

Introduction: Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. Aim: To assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Materials & methods: We conducted a retrospective study including patients with cirrhosis having a first episode of SBP. Results: A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. The mean time to onset of the first SBP recurrence from the first episode was 32 days. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score. Conclusion: There was no impact on survival of recurrent SBP compared with the first SBP episode.

Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. The aims of this study were to assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Thus, we conducted a retrospective study including patients with cirrhosis having a first episode of SBP. A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score.

Recurrent primary hepatic VIPoma treated with a combination of surgical resection and loco-regional therapy.

Vasoactive intestinal peptide (VIP) secreting tumors (VIPomas) are insidious functional neuroendocrine tumors originating mainly from pancreatic islet cells. Hepatic localization is considered exceedingly rare as only few cases have been reported in the literature. Diagnostic and therapeutic management of this tumor is still not clearly codified and therefore represents a real challenge for clinicians. Herein we report a unique case of a primary hepatic VIPoma recurrence in a female patient 22 years after curative resection. The patient had two sessions of transarterial chemoembolization. Complete symptomatic improvement was achieved since the first day after the first session. This case highlights that long-term follow-up for patients with hepatic VIPoma is mandatory as recurrence could occur several years after curative surgical treatment.

VIPomas are rare tumors secreting a hormone that is vasoactive in the intestine causing severe diarrhea. The majority of VIPomas arise within the pancreas. The hepatic localization is extremely rare. We report a case of a very late recurrence of a primary hepatic VIPoma surgically treated 20 years ago. The case was managed with therapeutic radiology by blocking the blood supply to the tumors after administering anticancer drugs in the vessels near them.

Massive hematochezia due to jejunal varices successfully treated with coil embolization.

We report a case of hematochezia with hemodynamic instability due to jejunal varices in a cirrhotic patient with no prior history of surgery. The patient was managed with coil embolization via the portal vein. After which, the patient did not present any hemorrhage recurrence and maintained a stable hemoglobin level.

Predictors of postoperative recurrence in a cohort of Tunisian patients with Crohn's disease.

Background: The aim of our study was to evaluate the frequency and risk factors of clinical postoperative recurrence in Tunisian patients with Crohn's disease (CD). Methods: Clinical data of 86 patients with CD who underwent ileocolonic resection at University Hospital of Sahloul in Tunisia were retrospectively reviewed. Continuous data are expressed as median (interquartile range), and categorical data as frequencies and percentages. Multivariate Cox proportional hazard regression analysis was conducted to identify the risk factors of postoperative clinical recurrence. Results: A total of 86 patients with CD were included in this study. During follow-up, 21 patients (24.4%) had clinical recurrence. The cumulative clinical recurrence rate was 9.3% at 1 year and 20.9% at 5 years. In univariate analysis, predictive factors of postoperative clinical recurrence were active preoperative smoking (p = 0.008), ileal location of the disease (p = 0.01), active CD [Crohn's Disease Activity Index (CDAI) > 150] (p = 0.04), duration of disease before first surgery <9.5 months (p = 0.027), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.005). In multivariate analysis, only smoking (p = 0.012), duration of disease before first surgery <9.5 months (p = 0.048), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.046) were confirmed to be independent factors of clinical relapse. Conclusion: Smoking, duration of disease before first surgery <9.5 months, and limited resection margins (<2 cm) from macroscopically diseased bowel were independent risk factors for clinical recurrence. Based on these factors, patients could be stratified in order to guide postoperative therapeutic options.

Spectrum of acute hepatitis and its clinical outcome in a central region in Tunisia.

INTRODUCTION: given the lack of studies on acute hepatitis (AH) in Tunisia, we carried out this study to find the etiological spectrum and clinical profile of AH and to investigate the impact of viral etiology on the outcomes of AH. METHODS: retrospective descriptive study collecting all patients with AH from 2010 to 2017. The data were compared between two groups (viral AH and non-viral AH). RESULTS: one hundred and three patient´s files were included. The average age of our patients was 30.15 years. An etiology was found in 92 patients (89.3%). The viral etiology was found in 70 patients (76.1%). Hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV) and cytomegalovirus (CMV) were in the cause in 52, 16, 1 and 1 patient respectively. Elsewhere, it was toxic hepatitis in 10 patients (10.9%) including 7 of drug-related AH. Budd-Chiari syndrome and autoimmune hepatitis with acute onset were reported in 3 (3.3%) and 7 (7.6%) patients, respectively. Patients with viral AH were younger than those with non-viral AH (p = 10-3). There was more recourse to hospitalization for non-viral AH. Patients with viral AH had a higher mean aminotransferase (ALT) level than those with non-viral AH. The liver damage was more severe in the non-viral AH group with lower PT. There was more severe form, more transition to chronicity and more deaths in the non-viral AH group. Conclusion: the results found in our study concerning the distribution of the etiologies of AH as well as their evolutionary aspects are consistent with the data in the literature.

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.

Effect of low dose albumin administration in spontaneous bacterial peritonitis on renal function and survival.

BACKGROUND AND STUDY AIMS: Current guidelines favour albumin administration during spontaneous bacterial peritonitis (SBP). However, its use is limited in clinical practice and low doses are preferred. The aim of our study was to determine the effect of low dose albumin perfusion during SBP on mortality and prevention of hepatorenal syndrome (HRS) in cirrhotic patients. PATIENTS AND METHODS: A retrospective study including consecutive patients with SBP hospitalized from 2002 to 2015 was performed. All patients were treated by intravenous empiric antibiotics associated with albumin infusion (30 g/day the first and third day) irrespective of patient's weight. The diagnosis of HRS was assessed according to the International Ascites Club criteria. The survival, the frequency of HRS and any disturbance in renal function were recorded. RESULTS: Fourty nine patients (sex ratio = 0.81, mean age 60.6 years [23-89]) were included. Main cause of cirrhosis was hepatitis B and C in 42.9% of cases. 63.3% were of Child Pugh C score%. The first line intravenous antibiotic treatment was based on cefotaxime in 87.8% of cases, followed by ofloxacin in 6.1% of cases. The outcome was favourable in 85.7% of cases. HRS was observed in 9 patients (18.3%) within 18 months [1-55]. Otherwise, 10 patients (20.4%) experienced an increase in creatinine level despite of albumin perfusion. The immediate mortality was 4%, and the six months survival was of 81.8%. CONCLUSION: Despite even a low dose administration of albumin during SBP, renal dysfunction and HRS occurred less than described in literature. These results associated with cost considerations could suggest to use such an intervention during SBP or to select high risk patients who must receive albumin perfusion during SBP.

Effect of long-term proton pump inhibitors on bone mineral density.

BACKGROUND: Proton pump inhibitors (PPIs) are widespread nowadays. Recent concerns haveemerged about possible bone complications of their long-term use, as lowbone mineral density (BMD) and an increased risk of fractures. AIM: To evaluate the effect of long-term use of PPIs on boneby estimating the frequency of osteopenia andosteoporosis, and determining the risk factors associated to these complications. METHODS: A prospective study including consecutive patients taking PPI for at least one year. All patients underwent bonedensitometry, and  FRAXscore was calculated to estimate the risk of osteoporotic fracture. RESULTS: We included 52 patients with a mean age of 49.5 years and a male-femaleratio of 0,48. Mean duration of PPI intake was 45 months. The most frequentindication was gastroesophageal reflux disease.  PPI prescription wasappropriate in 94% of cases. The calculated daily calcium intake was in majority insufficient (94%).  Approximately half of patients had at least three risk factors. Osteopenia and osteoporosiswere observed in 52% and 19% respectively. Predictive factors of low BMD were an age≥50 years, menopause, calcium intake ≤550mg/day and a PPI use duration≥30 months. FRAX score was significantly higher when BMD was lower. The multivariate analysis could not be undertaken because of co linearity of the factors. CONCLUSION: Long-term PPI use is associated with risk of bone complications, especiallyamong patients at risk for osteoporosis. It seems reasonable to be more vigilantin prescribing PPIs and to use the lowest effective dose for patients with appropriateindications.

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.

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.

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.

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.

[Nocturnal gastroesophageal reflux. About a pH metric series]. / Le reflux gastro-oesophagien acide nocturne pathologique. A propos d'une série pHmétrique.

BACKGROUND: Nocturnal gastroesophageal reflux has been shown to be associated with the more severe forms of gastroesophageal reflux disease (GERD), particularly with extraesophageal manifestations as well as complications of mucosal damage. AIM: To determine the frequency of nocturnal gastro esophageal reflux disease on 24-hour esophageal pH monitoring in patients with digestives or extra-digestives symptoms and to evaluate the clinical and pHmetric characteristics of nocturnal reflux in these patients. METHODS: We conducted a retrospective study based on results of 24- hour esophageal pH monitoring during a 11-year period in patients with or without digestive symptoms of gastroesophageal reflux disease. The nocturnal gastroesophgeal reflux was defined. RESULTS: We studied 696 patients (299 men, 397 women; mean age: 34.05 years). Gastroesophageal reflux was found in 350 patients (50%). Nocturnal reflux was observed in 240 patients (34.3%), mostly in association with pathological reflux in the total period (223 cases). Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes (21.9±27.4 vs 67.4±5.,1 ; p<0.0001), more longer duration of reflux episodes (24.4±37.9 minutes vs 13.9± 17.5 minutes ; p<0.001), and a lower symptomatic correlation (26% vs 45% ; p=0.0005). CONCLUSION: Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by longer reflux episodes, less number of reflux episodes and less symptomatic correlation.