Clinical practice standards for colonoscopy.

Colonoscopy is considered as the most effective tool for preventing, screening, and diagnosing colorectal lesions. Effectiveness of colonoscopy was identified as a major priority, and it strictly depends on quality measures. Therefore, international guidelines were formulated on quality indicators for colonoscopy, aiming to reduce the rate of interval cancers related to missed lesions during colonoscopy. Quality indicators are divided into 3 time periods: preprocedure, intraprocedure, and postprocedure.  The main pre-procedural indicators are the assessment of the appropriateness of indication of colonoscopy and the prescription of adequate bowel preparation during a consultation prior to colonoscopy. Per-procedural criteria include all technical aspects of the procedure, which are "endoscopist-dependent" factors, particularly cecal intubation, detection of adenomas and withdrawal time. The main post-procedure indicators are the rate of complications, patient experience and optimal surveillance intervals following removal of colorectal polyps. The implementation of key performance measures in endoscopy practice is increasingly important as it can help improving our care of patients and optimize outcomes. In this review, the "Club d'endoscopie digestive" (CED) presented a summary of the main colonoscopy quality indicators, and suggested recommendations that took into account the particularities of our local conditions.

Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. METHODS: A retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). RESULTS: One hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3-40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272-0.979], an intra-diverticular papilla OR 0.179 [0.035-0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068-0.385] and a stenosis of the common bile duct OR 0.068 [0.008-0.605]. The success rate of the second line treatment was 73%. CONCLUSION: Endoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.

Hepatitis B and C viral infections screening in a Tunisian IBD population under immunosuppressive therapies.

BACKGROUND: Immunosuppressive drugs have become a mainstay of therapy for the inflammatory bowel diseases (IBD). These treatments expose to a risk of hepatitis B and C reactivation. OBJECTIVE: The aim of this study was to assess the prevalence of hepatitis B and C viruses in Tunisian IBD patients on immunosuppressive treatments. MATERIALS AND METHODS: Patients with inflammatory bowel disease were consecutively recruited over a 2 years period (2017-2018). Prevalence of viral hepatitis B and C as well as clinical, biological and virological presentation, management and outcome were assessed. Factors associated to hepatitis B and C were also analyzed (SPSS software, p value <0.05). RESULTS: Seventy four patients with IBD were included: 38 women and 36 men. Among them 62 (83.8%) had CD and (16.2%) had UC. Mean age was 43.5±14.2 years. Six patients (8.1%) had at least one positive HVB marker. Hepatitis C infection was found in 4% patients. HBs Ag was positive in only one patient (1.3%) with positive HBV DNA. Anti HBc and anti HBs antibodies were positive respectively in 6 and 4 patients. Vaccination against hepatitis B was proposed for 22% of our patients with negative anti HBc antibodies and HBs Ag. Two patients presented non-severe acute hepatitis C with sustained virological response after antiviral treatment. IBD did not relapse under antiviral treatment. A 3rd patient had chronic hepatitis C infection. She was treated with Pegylated Interferon alpha and Ribavirine. No cases of viral reactivation have been reported. Noassociated factors to hepatitis B and C viral infections were identified in our study. CONCLUSION: The prevalence of hepatitis B infection in IBD patients under immunosuppressive therapy was similar to the general population, while the hepatitis C prevalence was higher than the national prevalence. Screening for hepatitis B and C viral infections is mandatory in inflammatory bowel disease patients. Vaccination against hepatitis B is highly recommended.

Hepatitis B and C viral infections screening in a Tunisian IBD population under immunosuppressive therapies / Detección de infecciones virales de hepatitis B y C en una población de EII de Túnez sometida a terapias inmunosupresoras

ABSTRACT Background : Immunosuppressive drugs have become a mainstay of therapy for the inflammatory bowel diseases (IBD). These treatments expose to a risk of hepatitis B and C reactivation. Objective: The aim of this study was to assess the prevalence of hepatitis B and C viruses in Tunisian IBD patients on immunosuppressive treatments. Materials and methods : Patients with inflammatory bowel disease were consecutively recruited over a 2 years period (2017-2018). Prevalence of viral hepatitis B and C as well as clinical, biological and virological presentation, management and outcome were assessed. Factors associated to hepatitis B and C were also analyzed (SPSS software, p value <0.05). Results : Seventy four patients with IBD were included: 38 women and 36 men. Among them 62 (83.8%) had CD and (16.2%) had UC. Mean age was 43.5±14.2 years. Six patients (8.1%) had at least one positive HVB marker. Hepatitis C infection was found in 4% patients. HBs Ag was positive in only one patient (1.3%) with positive HBV DNA. Anti HBc and anti HBs antibodies were positive respectively in 6 and 4 patients. Vaccination against hepatitis B was proposed for 22% of our patients with negative anti HBc antibodies and HBs Ag. Two patients presented non-severe acute hepatitis C with sustained virological response after antiviral treatment. IBD did not relapse under antiviral treatment. A 3rd patient had chronic hepatitis C infection. She was treated with Pegylated Interferon alpha and Ribavirine. No cases of viral reactivation have been reported. Noassociated factors to hepatitis B and C viral infections were identified in our study. Conclusion : The prevalence of hepatitis B infection in IBD patients under immunosuppressive therapy was similar to the general population, while the hepatitis C prevalence was higher than the national prevalence. Screening for hepatitis B and C viral infections is mandatory in inflammatory bowel disease patients. Vaccination against hepatitis B is highly recommended.

RESUMEN Antecedentes : Los fármacos inmunosupresores se han convertido en un pilar de la terapia para las enfermedades inflamatorias del intestino (EII). Estos tratamientos exponen al riesgo de reactivación de la hepatitis B y C. Objetivo: El objetivo de este estudio fue evaluar la prevalencia de los virus de la hepatitis B y C en pacientes tunecinos con EII que reciben tratamientos inmunosupresores. Materiales y métodos : Los pacientes con enfermedad inflamatoria intestinal fueron reclutados consecutivamente durante un período de 2 años (2017-2018). Se evaluó la prevalencia de las hepatitis virales B y C, así como la presentación, el tratamiento y los resultados clínicos, biológicos y virológicos. También se analizaron los factores asociados a la hepatitis B y C (software SPSS, valor de p<0,05). Resultados : Se incluyeron 74 pacientes con EII: 38 mujeres y 36 hombres. Entre ellos, 62 (83,8%) tenían EC y (16,2%) CU. La edad media fue de 43,5 ± 14,2 años. Seis pacientes (8,1%) tenían al menos un marcador HVB positivo. Se encontró infección por hepatitis C en el 4% de los pacientes. HBs Ag fue positivo en sólo un paciente (1,3%) con ADN del VHB positivo. Los anticuerpos anti-HBc y anti-HBs fueron positivos respectivamente en 6 y 4 pacientes. Se propuso la vacunación contra la hepatitis B para el 22% de nuestros pacientes con anticuerpos anti-HBc negativos y Ag HBs. Dos pacientes presentaron hepatitis C aguda no grave con respuesta virológica sostenida tras el tratamiento antiviral. La EII no recayó con el tratamiento antiviral. Un tercer paciente tenía infección crónica por hepatitis C. Fue tratada con interferón alfa pegilado y ribavirina. No se han notificado casos de reactivación viral. En nuestro estudio no se identificaron factores asociados a las infecciones virales por hepatitis B y C. Conclusión : La prevalencia de infección por hepatitis B en pacientes con EII bajo terapia inmunosupresora fue similar a la población general, mientras que la prevalencia de hepatitis C fue mayor que la prevalencia nacional. La detección de infecciones virales de hepatitis B y C es obligatoria en pacientes con enfermedad inflamatoria intestinal. Se recomienda encarecidamente la vacunación contra la hepatitis B.

Digestive manifestations in COVID-19: Prevalence and prognostic impact.

BACKGROUND: Since its declaration in december 2019, a novel coronavirus, the SARS-CoV-2 was rapidly responsible for a major pandemic. COVID-19 is mainly manifested by respiratory symptoms,however, digestive manifestations have been reported, raising the hypothesis of the viral digestive tropism. AIMS: Specify the digestive manifestations due to the SARS-CoV-2, and their impact on the disease prognosis and describe the COVID-19 effect in patients with underlying digestive disease. METHODS: Ageneral review of the medical literature was conducted via Medline® database, through various combinations of the following keywords :SARS-CoV-2, COVID-19, gastrointestinal tract, digestive system, inflammatory bowel diseases, liver, liver injury, chronic liver disease, neoplasms. The most relevant articles were selected. RESULTS: The SARS-CoV-2 tropism for the digestive tract has been confirmed by the identification of the enterocyte as a target cell of the virus. Viral particles and RNA detection in stool of infected patients has raised the potential for feco-oral transmission of the virus. Gastrointestinal manifestations were frequent and may even be revealing or isolated. Diarrhea was the most characteristic symptom. Frequent liver involvement is associated with a more severe form of the disease. Patients with digestive cancer and chronic liver disease are at risk for a severe form of SARS-CoV-2 infection. CONCLUSION: The clinician is required to know this type of manifestations in order to limit the delay in diagnosis and to better assess the prognosis.

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.

Prognostic factors of survival during hepatocellular carcinoma.

INTRODUCTION: Despite advances in diagnostic and therapeutic means,mortality of hepatocellular carcinoma (HCC) on liver cirrhosis remainsheavy in the absence of curative treatment. AIM: To evaluate survival and to identify prognostic factors during HCC. METHODS: A mono centric retrospective study over a period of13 years (January 2002-October 2015), including all patients with HHConcirrhotic liver was performed. Survival analysis was performed accordingto the Kaplan-Meier method. The prognostic factors of survival weredetermined by the Log Rank test. RESULTS: Ninety four patients wereincluded (meanage 66.18 years, sexratio 1.65). Cirrhosiswassecondary to hepatitis B or C in 73.6%). Twentytwo patients responded to the MILAN criteria. Cirrhosiswasrated Child A,B and C in 30.9%, 46.8% and 22.3% of patients, respectively. A Curativetreatment was possible for only 10 patients (11.2%). In our study, meansurvival was 15.1 months and overall survival at 1 year and 2 years were25.5% and 21.3%, respectively. Nine factors associated with shortersurvival were identified : a Child-Pugh stage B or C; the absence ofscreening; an AFP level of> 400ng / ml; the existence of vascularthrombosis; a CHC evolved according to the classification of Milan; anOKUDA III score; CLIP score ≥ 3; a BCLC stage C or D; palliative orsymptomatic treatment. CONCLUSION: Although the best treatment of HCC remainspreventive, theuse of new prognostic scores couldimprove the management of patientsifintegrated in therapeuticalgorithms.

Expression of epidermal growth factor receptor (EGFR) in colorectal cancer: An immunohistochemical study.

BACKGROUND AND STUDY AIM: The epidermal growth factor receptor (EGFR) plays an important role in tumourigenesis and tumour progression of colorectal cancer (CRC) and leads to the activation of intracellular signaling pathways. The use of anti-EGFR-targeted therapy has increased for patients with metastatic CRC. Today, the clinical utility of immunohistochemistry has remained somewhat inconclusive. It is based on EGFR screening methods using paraffin-embedded tumour specimen to select patients eligible for treatment. There is still lack of agreement on reproducible scoring criteria for EGFR immunohistochemistry has in various clinical trials. PATIENTS AND METHODS: We retrospectively reviewed 36 CRC patients who underwent surgeries during 2011 in Habib Thameur hospital in Tunis. We analyzed the immunohistochemical overexpression of EGFR using a score based on immunostaining intensity. In addition, we analyzed the correlation between this overexpression and patients' clinicopathologic parameters. RESULTS: The positive expression rate of EGFR was 78% (28/36). Using the immunoreactivity score, 21 cases were considered low grade expression and 15 tumours were high grade. Immunohistochemical expression of EGFR showed a significant difference with tumour's location (p = 0.034) and vascular invasion (p = 0.03). This expression was not significantly associated with age, gender, tumour size, histological type, grade, TNM staging and perineural invasion. CONCLUSIONS: EGFR expression by immunohistochemistry in CRC is variably correlated with clinicopathological parameters. Its assessment by this method has still not proved its predictive value.

Systematic gastric biopsy in iron deficiency anaemia.

BACKGROUND AND STUDY AIMS: Gastric biopsies are recommended in patients with iron deficiency anaemia to identify atrophic gastritis. However, in practice, only duodenal biopsies are routinely performed. The aim of our study was to determine the value of gastric biopsies in iron deficiency anaemia. PATIENTS AND METHODS: A prospective study including all patients referred for gastrointestinal endoscopy for iron deficiency anaemia from May 2008 to September 2014 was performed. All patients having endoscopic lesions which may explain occult bleeding were excluded, as well as patients using non-steroidal anti-inflammatory drugs or anticoagulation treatment. Two fundic biopsies, two antral biopsies, and one biopsy from the lesser curve were taken in all patients. Following entities were particularly looked for: chronic gastritis, Helicobacter pylori infection, intestinal metaplasia, endocrine hyperplasia and villous atrophy. In cases where intestinal metaplasia was present in the fundus and associated with endocrine hyperplasia and glandular atrophy, immunohistochemical study was performed to confirm autoimmune gastritis. RESULTS: One hundred seventy-seven patients (mean age 50 years, range: 15-90) were included. Chronic gastritis was found in 149 cases (84%). Infection by Helicobacter pylori was found in 107 cases (60%). Fundic intestinal metaplasia was observed in 25 patients (14%) and was associated with Helicobacter pylori infection in 52% of cases. Atrophic gastritis was observed in 14 cases (8%) and autoimmune gastritis was confirmed in 5 cases by immunohistochemical study. One patient had on gastric biopsy a carcinoma with signet ring cells. CONCLUSION: Intestinal metaplasia was frequently observed and was mostly related to Helicobacter pylori infection. These patients require monitoring, especially if they are young because it represents a pre neoplastic condition. However, in our study autoimmune gastritis often described in the literature in case of iron deficiency anaemia was rarely seen raising the question of relative cost-efficiency of fundic biopsies during iron deficiency anaemia.

Known, new and emerging risk factors of hepatocellular carcinoma (review).

Hepatocellular carcinoma (HCC) is the commonest primary cancer of the liver and is a leading cause of cancer-related death worldwide. And despite effective treatment of hepatitis B and C infection which is the prominent factor associated with HCC, the prevalence of this malignancy continues to rise probably due to other factors. So that, identifying risk factor of HCC is essential and effective surveillance programs are necessary in order to maximize patient outcomes. This article summarizes the known, new and emerging risk factors of HCC.

Theses defended at Tunis Faculty of Medecine from 2004 to 2005: Scientific become and predictive factors of publications.

INTRODUCTION: Several theses are supported, every year, in the Faculty of Medicine of Tunis but their scientific become is this day unknown. The most part of specialities have not bibliometric data. OBJECTIVES: This work had for objectives to study the still unknown future of theses of Tunis Faculty of Medecine during 2004-2005, in terms of publication in indexed reviews and to determine the predictive factors of their publication. METHODS: This was a descriptive bibliometric study of theses supported at the Tunis Faculty of Medicine between January 1st, 2004 and december 31st, 2005. The data collected concerned :number of theses, involved specialities, discipline, type of theses, type of study, number of studied cases (<25 ou  25), methodology of the work, identity of the student, the director as well as the number and the rank of one or several directors. The productivity of the various specialities was estimated by two indicators: Ratio thesis-teacher and index of becoming theses. The publication of the theses has been sought in engines "Medline" and "scopus. Predictive factors for publication were sought. RESULTS: Six hundred and thirteen theses were supported, including 57.7% belonged to the medical disciplines. The attributed mention was "very honorable with the congratulations of the jury" in 71,0% of cases and "very honorable with the congratulations of the jury and the proposal at the price of thesis " in 24,0% of the cases. Thirteen comma four pourcent (13.4%) was the rate of publication. These theses were published when the attributed mention was "very honorable with the congratulations of the jury and the proposal at the price of thesis "(p=0.05), when the discipline was community (p <10-3), and when the study was of epidemiological type (p=0.05).The ratio theses-teacher- year was lower than 1 in 70% of cases and the index of becoming theses varied from 0 and 18.7 across all disciplines. The thesis were published in half of the cases in the the review"La Tunisie Médicale". The median of citation was 2 [0-66 citations]. The publication was found thanks to the name of the student which appeared as author in 61.0% of the theses. The student was first author in 12 cases (24.5%). CONCLUSION: The rate of publication of theses of Tunis Faculty of Medecine during 2004-2005 aws little raised by 13.4%. This rate should be considered as a basic figure with regard to wich will be compared the future impact of courses made at present in our Faculty.

Immunohistochemistry in the diagnosis of dysplasia in chronic inflammatory bowel disease colorectal polyps.

BACKGROUND AND STUDY AIMS: Development of cancer is the most significant complication in inflammatory bowel disease (IBD). Distinguishing true dysplasia from reactive atypia in polyps is difficult, leading sometimes to the unsatisfactory diagnosis of "indefinite for dysplasia". Therefore, there is a need for the development of markers that can help improve diagnosis. We evaluated the diagnostic value of the expression of AMACR, Ki67 and p53 by immunohistochemistry in the diagnosis of dysplasia in polyps developed on IBD. PATIENTS AND METHODS: Forty colorectal polyps in IBD were studied. These had been diagnosed over a period of 11years. Dysplasia was classified according to the Vienna Classification (version 2000). Immunohistochemistry was performed using anti-AMACR, anti-Ki67 and anti-p53 antibodies. RESULTS: Polyps were classified as follows: 21 negative for dysplasia (ND), 10 indefinite for dysplasia (IFD), 6 low-grade dysplasia (LGD), 1 high-grade dysplasia (HGD) and 2 adenocarcinomas (ACA). AMACR positivity was observed in all polyps with HGD and ACA, 5 of the 6 LGD polyps and 3 of the 10 IFD (p=0.007). p53 immunostaining showed nuclear staining in the basal part of the crypts in 8 of the 10 IFD lesions. In ACA and HGD polyps, p53 positivity was typically observed in all epithelial cell layers (p=0.004). ACA and HGD showed diffuse and scattered staining of Ki67 along the full length of the crypts. Five lesions with LGD had extension of Ki-67 positive cells up to and into the surface epithelium. Ki67 staining in all IFD lesions was restricted to the basal third of the crypt (p<0.001). By combining the three markers, a relationship with dysplasia was statistically significant (p<0.001). Sensitivity ranged from 66.7% to 88.9% and specificity from 71.4% to 100%. The positive predictive value (PPV) for detecting dysplasia using these different antibodies ranged from 66.7% to 100% and the negative predictive value (NPV) for excluding dysplasia ranged from 85.7% to 93.3%. CONCLUSIONS: The high degree of sensitivity and specificity of AMACR, p53 and Ki67 for dysplasia in IBD suggests that these antibodies, when combined, may be useful to detect neoplastic epithelium in this condition.

[Cutaneous metastasis of a ring cell gastric adenocarcinoma]. / Métastases cutanées d'un adenocarcinoma gastrique à cellules indépendantes.

INTRODUCTION: Cutaneous metastasis of gastric tumors are very rare. Their topography is generally near to the primitive tumor, in the abdominal wall but rarely in cervical region. AIM: the aim of our study was to describe the topography and the clinic-pathological characteristics of cutaneous metastasis of ring cells gastric adenocarcinoma. Observation1: Our first patient is aged of 33 years has epigastralgias and vomiting. Gastric adenocarcinoma with independent cells was diagnosed by gastroscopy and gastric biopsy made for gastric pain and loss of weigh. During hospitalization, he developed 4 cutaneous nodes localized in cervical region. Cutaneous biopsy with histological examination confirmed the metastatic nature of the nodes. Patient was addressed in oncology unit in order to begin palliative systemic chemotherapy. Observation 2: Our second patient is a women aged of 4 3years who had surgical resection for independent cell gastric carcinoma diagnosed by gastroscpy and biopsy for gastric pain and loss of weigh. She had total gastrectomy without any complications and was addressed in oncology unit for adjuvant chemotherapy. After 2 years, she developed peritoneal carcinosis and cutaneous abdominal nodes. Cutaneous metastasis were confirmed by histological examination of cutaneous biopsy and the patient died within one month. CONCLUSION: Cutaneous metastasis of gastric cancer and especially ring cell adenocarcinoma are rare but do occur. They must be early diagnosed because they modify therapeutic options. Their prognosis remains poor.

Microbiological study and antimicrobial susceptibility of bile in biliary therapeutic endoscopy.

BACKGROUND: Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The reported incidence of infectious complications may reach up to 10%. Nevertheless, no antibiotic prophylaxis is administered routinely, prior to endoscopic therapeutic procedures. AIM: To investigate the presence and degree of biliary bacterial colonization during endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient. METHODS: Forty-four patients with biliary obstruction who underwent an ERCP with biliary drainage were prospectively included. The primary indication of ERCP was choledocholithiasis (48%), followed by benign biliary strictures (32%) and malignant bile duct obstruction (18%). Bile cultures were obtained by means of bile aspiration via the cannulation catheter. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for different antibiotics was performed. RESULTS: The overall positive rate of bile culture was 93%. The organisms cultured were Escherichia coli (26.8%), Enterococcus (17%), Klebsiella (14.6%), Enterobacter (14.6%) and Pseudomonas (9.7%) in decreasing order. In-vitro testing of different antibiotics was carried out in these 41 isolates. Imipenem showed the best antimicrobial activity (sensitivity, 100%), followed by colistin (94%), tobramycin (93%), amikacin (89.6%), gentamycin (85.2%) and ceftazidin (82%). Amoxicillin/clavulanic acid and ofloxacin were less sensitive (66% and 60% respectively). Ceftazidin was the most effective antibiotic on Escherichia coli (sensitivity 83%). Multi-resistant organisms were noted in 22% of the cases. CONCLUSIONS: Escherichia coli was found to be the pathogen most frequently detected in bile following endoscopic interventions in the biliary tract. Enterococci and Klebsiella were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, amoxicillin/clavulanic acid or quinolons are not suitable antibiotics for the prophylaxis of biliary infections. Moreover, Gram-positive bacteria such as Enterococcus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

Hypogammaglobulinemia associated with nodular lymphoid hyperplasia of the intestine and pernicious anaemia.

BACKGROUND: Nodular lymphoid hyperplasia of the gastrointestinal tract, recurrent acute pulmonary infections and autoimmune disease are well-recognized complications of common variable immunodeficiency. AIM: We aimed to focus on clinical presentation and differential diagnosis of diffuse nodular lymphoid and hyperplasia of the gastrointestinal tract coexisting with hypogammaglobulinemia. CASE-REPORT: We report the case of nodular lymphoid hyperplasia associated with pernicious anaemia in a young man with hypogammaglobulinemia and a long history of pulmonary infections. CONCLUSION: The considerable point was a mismatch primary clinical diagnosis of familial adenomatous polyposis, due to prominent polyplike endoscopic appearance of the lesions throughout the digestive tract.

Epidemiological evolution of epidemiology of the inflammatory bowel diseases in a hospital of Tunis.

BACKGROUND: The epidemiological studies showed that the incidence of the inflammatory bowel diseases describes a gradient North-South. Besides, concerning the evolution according to the time,recent studies noted an increase of the incidence of the Crohn's disease at the expense of the one of the ulcerative colitis. AIM: To determine the evolution of the epidemiology of the inflammatory bowel diseases across the time. METHODS: The study included inpatients followed for Crohn's disease, ulcerative colitis and indeterminate colitis, in the department of gastroenterology of Habib Thameur hospital. For every patient were collected the sex, the age and the year of the diagnosis, the type of inflammatory bowel disease and the initial location. We compared the evolution of the frequency of the inflammatory bowel diseases,them type and their initial location according to 5 periods of 3 years. RESULTS: During this period, 202 cases of inflammatory bowel disease were diagnosed (55,5% of Crohn's disease, 41,5% of ulcerative colitis, 6% of indeterminate colitis). For the first period,we noted 21 cases of inflammatory bowel disease, for the 5th period, we noted 43 cases. The frequency of the Crohn's disease passed from 8 cases in the 1st period to 23 cases in the 5th one. The frequency of the ulcerative colitis passed from 12 cases in the 1st period to 17 cases in the 5th one. The number of indeterminate colitis was 1 in the 1st period and 3 in the 5th one. These differences did not been significant. The distribution of initial locations of the Crohn's disease and the ulcerative colitis increased in a proportional manner for each period. The average age to the diagnosis was 32 years in the 1st period and 35 years in the 5th period and comparable whatever the inflammatory bowel disease type. CONCLUSION: Although we cannot amount the exact incidence, we noted an increase of the frequency of the inflammatory bowel diseases, with a more marked elevation for the Crohn's disease.