[Efficiency of endoscopic treatment with intra gastric balloon in severe to morbid obesity]. / Efficacité du traitement endoscopique par le ballon intragastrique au cours de l'obésité severe à morbide.

BACKGROUND: Obesity raises such a healthcare matter throughout the world. Its management is not only complex but also most often multidisciplinary. The medico-dietary treatment is of inconstant efficiency and the surgical treatment, though more efficient, presents a considerable morbidity-death rate. The endoscopic treatment through intra-gastric balloon avails a seducing alternative namely accounting for surgery preparation. AIM: To assess the efficiency of the endoscopic treatment through gastric balloon, both in the short and long term, and this is accounting for weight loss as well as tolerance. METHODS: We have carried out a retrospective study including the patients suffering from severe to morbid obesity and who had a gastric balloon implemented in our Endoscopy Unit between November 2005 and December 2007. RESULTS: Twenty one patients were included. The average age was 32,19 ± 12,65 years with extremes of 16 and 52 years. Fifteen patients suffered from morbid obesity. The patients' average weight was 134, 52 ± 26,46 kg (extremes 88 and 194 kg). Some co-morbidity was found out with 15 patients. Te balloon implementation (Héliosphère®) was carried out with no incidents in all patients. Six months after the balloon implementation, the average weight loss was 17,5% and the average loss of over weigh was 37%. In biological level, we noted a normalisation of fasting glycaemia in 28,6 % of cases, of the cholesterolemia in 100 %, of the triglyceridemia in 33,33%, of the uraemia in 42,8% and hepatic tests in 50 % of the cases. The metabolic syndrome disappeared in 28,57 % of cases. The assessment after a 5-year-period was marked by the need to surgical treatment in 4 patients and this is due to the loss of efficiency of endoscopic treatment. A bad tolerance of gastric balloon was observed in 34 % of the cases, dominated by sicknesses. Only one patient presented incoercible sicknesses with ionic troubles as well as deshydrating requiring the precocious extraction of the balloon after 48 hours of its implementation. CONCLUSION: The endoscopic treatment through intra gastric balloon is well tolerated but efficiently limited in time. It might be recommended in preparation for a surgical treatment or in case of contre- indication or surgery refusal.

[Epidemiological, clinical and therapeutic features of hepatocellular carcinoma in cirrhotic patients]. / Aspects épidémiologiques, cliniques et thérapeutiques du carcinome hépatocellulaire chez le cirrhotique.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most frequent primitive hepatic tumor, the fifth most common cancer in the world,and the third highest cause of cancer-related mortality. The presence of cirrhosis is the main risk factor. AIM: To describe the epidemiological, clinical and therapeutic features of HCC. METHODS: Retrospective study including all the patients with HCC occurring in cirrhotic liver followed in the gastroenterological department of Charles Nicolle hospital between 1997 and 2009. RESULTS: A hundred and one patient were enrolled; 64 men and 37 women with a median age of 65.4 years (31-88 years). Cirrhosis was due to viral hepatitis B or C in 25.7% and 62.2% of cases respectively and was classified Child Pugh A, B and C in 30.7%,50.5% and 18.8% of patients respectively. HCC was inaugural in most cases (68.3 %) and it was revealed by a tumoral syndrome in 38.6% of cases, by decompensation in 22.7% and was discovered during systematic screening when cirrhosis was already known in 19.8% of cases. Diagnosis of HCC was non invasive, relying on imaging and alphafetoprotein in most cases (95%). 84 patients(83.2%) had an advanced HCC, with vascular or extra hepatic spread in 58 (57.5%) of them. Treatment was curative in 14 cases, based on surgical resection in one case and percutaneous ablation in 13 cases.Six patients received transarterial chemoembolization as a palliative treatment. In 71 patients, only symptomatic treatment was given. The median survival time was 11 months. CONCLUSION: In the majority of the cases, HCC was diagnosed at an advanced stage and treatment was only symptomatic.

Colonoscopy in elderly: feasibility, tolerance and indications: about 901 cases.

BACKGROUND: Colonoscopy is the standard investigation for colonic disease, but clinicians often are reluctant to refer elderly patients for colonoscopy because of a perception of higher risk and a high rate of incomplete examinations. AIMS: To evaluate feasibility and tolerance of this investigation in elderly and to review the most frequent indications of colonoscopy in these patients. METHODS: A pilot retrospective study including 901 patients from January 2005 to December 2009; divided into two groups. Group (I) included patients 75 years old and more, group (II) included patients 45 years old or less. All those patients underwent colonoscopy at the gastroenterology department of Charles Nicole hospital. RESULTS: The 1st group included 231 patients, and the 2nd group included 670 one. A past history of colorectal cancer was more frequent in the group I (33.3% versus 9.90%; p<0.05) however history of chronic inflammatory bowel disease was more frequent in group II (0 versus 40.6%; p<0.05). The main indication of colonoscopy was constipation in group II (6.1% versus 27%; p<0.05) and chronic diarrhoea in group I (42.9% versus 16.4%; p<0.05). Bowel preparation was poor in 30.4% cases of the group I and 12.9% of group II (p<0.05). The tolerance was similar in the two groups. The incomplete colonoscopy rate was higher in the group I (38.3% versus 23.4%; p<0.05). The most frequent cause of colonoscopy interruption was the poor preparation in group I and the bad tolerance in group II. Diverticular disease, polyps and colorectal cancers prevailed in group I, whereas inflammatory bowel disease was current in group II. CONCLUSION: In elderly patients, colonoscopy is safe, well tolerated and offers a good diagnostic yield. Its non completion was essentially due to the poor preparation. Sedation did not seem essential. The optimisation of results of colonoscopy requires an improvement of quality preparation.

[Prevalence and risk factors of thromboembolic complications in inflammatory bowel disease]. / Prévalence et facteurs de risque des complications thromboemboliques au cours des maladies inflammatoires chroniques de l'intestin.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at increased risk of thromboembolic complications (TEC), which represent an important cause of morbidity and mortality. AIM: To assess the prevalence and risk factors of TEC in patients with IBD. METHODS: We conducted a retrospective study including all the IBD patients in the gastroenterological department of Charles Nicolle hospital between 2000 and 2010. Only thromboembolic events that had been diagnosed by an imaging procedure were counted. RESULTS: A total of 266 patients with IBD were consecutively included. TE events occurred in nine patients (3.4%); six men and three women. Their mean age was 31 years [15-64 years]. Five patients had Crohn's disease and four had ulcerative colitis. The types of TEC were deep venous thrombosis of the leg in five cases with pulmonary embolism in one of them, cerebral venous thrombosis in two cases, portal thrombosis in one case and jugular vein thrombosis in one case. Active disease was present in all cases at the time TEC occurred. CONCLUSIONS: In our study, the prevalence of TEC is 3.4% in patients with IBD. Deep venous thromboses of the leg are the most common TEC and all our cases occurs during the active phase of IBD.

Cerebral thrombosis in inflammatory bowel disease: a report of four cases.

The risk of thromboembolism is increased in inflammatory bowel disease and its symptoms may be overlooked. The commonest are deep vein thrombosis and pulmonary emboli. Cerebral thrombosis, in a particular stroke, is rare. Furthermore, its treatment can be complex. We present the cases of 4 patients with cerebral vascular involvement.

Hepatocellular carcinoma with sarcomatous change.

BACKGROUND: Hepatocellular carcinoma (HCC) with sarcomatous change is an uncommon neoplasm with a poor prognosis. AIM: To report a new case. CASE REPORT: A 72-year-old man presented with abdominal right upper quadrant pain. The diagnosis of cirrhosis was suspected on clinical and biochemical data. On abdominal computed tomography, the mass was not enhanced in the arterial phase and exhibited peripheral enhancement during portal phase which persisted in the delayed phase. The serum alpha-fetoprotein was 500 ng/ml but since the imaging features were not typical of ordinary HCC, percutaneous liver biopsy was performed and confirmed the diagnosis of HCC with sarcomatous change. CONCLUSION: Except for liver biopsy, no diagnostic method could distinguish between sarcomatous and ordinary HCC.

Correlation between liver biopsy and fibrotest in the evaluation of hepatic fibrosis in patients with chronic hepatitis C.

AIM: To assess the diagnostic value of Fibrotest in comparison with liver biopsy, for the evaluation of hepatic fibrosis in patients with chronic hepatitis C. METHODS: This prospective study included in 2 years (2006-2007), consecutive patients with chronic hepatitis C naive to treatment. Fibrotest and liver biopsy were performed. Receiver operating characteristics (ROC) curves , the sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic value of Fibrotest in comparison with the METAVIR classification. RESULTS: We recruited a total of 65 patients: 28 males and 37 females (mean age: 50 years); 92% of the patients had genotype 1. The histological fibrosis results were: 3.1% F0; 24.6% F1; 32.3% F2; 29.2% F3 and 10.8 % F4. The diagnostic value of Fibrotest in the detection of significant fibrosis (F2-F4) was 0. 87. A score > 0.5 has a sensitivity of 85. 1%, a specificity of 72. 2%, a positive predictive value of 88. 9%,and a negative predictive value of 65%. The diagnostic value of Fibrotest in the detection of cirrhosis (F4) was 0. 85. There were 13/65 cases of discordance (20%) for fibrosis, 4 cases were attributable to biopsy and 6 cases to Fibrotest. The discordance was unexplained in 3 cases. the size of biopsy< 15 mm [OR=2. 82, 95% CI, 1. 3-6. 07; p = 0. 008] and the stage of fibrosis F0, F1, F2 [OR =3. 35 , 95% CI, 1. 1-10. 2; p=0. 03] were considered as risk factors of discordance in multivariate analysis. CONCLUSION: This prospective study confirmed the good diagnostic value of Fibrotest as compared with the histological analysis of liver biopsy.

[Nephrogenic ascites: an exceptional diagnosis. About one case]. / L'ascite Nephrogenique, Un Diagnostic Rare Auquel Il Faut Penser. A Propos D'une Observation.

BACKGROUND: Nephrogenic ascites is a clinical entity that manifests as refractory and exsudative ascites with unknown etiology in patients with end stage renal disease and often undergoing hemodialysis. This entity presents in practice many diagnostic and therapeutic difficulties. AIM: The aim of this study is to focus on these difficulties through a new observation. CASE REPORT: We report one case of nephrogenic ascites in chronic renal failure related to an idiopathic neurologic bladder. It's a 38 years old patient on hemodialysis for three years who consulted for exsudative ascites with a low rate of leucocytes. CONCLUSION: We conclude that nephrogenic ascites is rare. Its diagnosis is an exclusion diagnosis based on exclusion of other causes of ascites, particularly exsudative forms with low leucocytes rate. Its management is based essentially on renal transplantation and its prognosis is very poor.

Evaluation of nutritional status in patients with liver cirrhosis.

BACKGROUND: Malnutrition is a frequently reported complication in patients with liver cirrhosis. It has a high clinical and economic impact reflected by an increased morbidity and prolonged hospital stay. AIM: This preliminary prospective study aimed to determine the prevalence of malnutrition in hospitalized cirrhotic patients and to investigate whether biological and anthropometric parameters are a valuable tool for identifying malnutrition in these patients. METHODS: The nutritional status of 44 consecutive cirrhotic patients (21 men, 23 women) was assessed according to the anthropometric measurements and biochemical analysis. The diagnosis of malnutrition was based on diminished values of Mid arm muscle circumference (MAMC) and/or Triceps skinfold thikness (TST) below the 5th percentile or less than 60%. RESULTS: The aetiology of cirrhosis was viral hepatitis in 29 patients (66%). Cirrhosis was classified Child Pugh A, B or C in respectively 9, 26 and 9 patients; 37 patients (84%) have mild or tense ascite. In this study, malnutrition was found in 35 patients (79.5%), whereas 9 patients has a good nutritional status. TST and MAMC less than 60% was found in respectively 72% and 25% of patients. No significant statistical difference in epidemiological characteristics was found between malnourished and well-nourished patients. TST and MAMC decreased significantly according to the Child score (p = 0.014 and 0.032 respectively; a positive correlation was found between these two parameters and the severity of cirrhosis. CONCLUSION: In this study, the high prevalence of denutrition was associated with the severity of cirrhosis. Anthropometric parameters are valuable tools for malnutrition diagnosis.

Endoscopic ultrasonography versus helical CT in diagnosis and staging of pancreatic cancer.

AIM: Compare the performances of EUS to helical CT in the diagnosis and staging of pancreatic adenocarcinoma. METHODS: Forty two consecutive patients (mean age 63 years; 25 men, 17 women) who had surgical exploration and histologically proved pancreatic cancer were retrospectively included. All our patients underwent with endoscopic ultrasonography (EUS) and helical computed tomography (helical CT). Data analysis compared helical CT, EUS with the surgical data with or without histological study in diagnosis, staging and resectability of pancreatic cancer. Surgical findings were used as gold standard. RESULTS: For positive diagnosis EUS was more sensitive 100% (CI:93-100) than helical CT 88% (CI:77-95). But helical CT was more specific 89% (CI:64-98) than EUS 83% (CI:58-96) for small tumors whose diameter is below 2.5 cm in witch EUS was more sensitive in their detection (100% versus 83%). In evaluating venous involvement EUS was more sensitive than helical CT (96% versus 50%; p<0.05), while CT was more specific (81% versus 75%; p<0.05). Regarding lymph nodes invasion, the two imaging technique had the same sensibility (56%) with better specificity for helical CT (83% versus 75%; p<0.05). The accuracy of EUS in identifying the T and N stages were 80% and 67% respectively, while helical CT have an accuracy of 50% and 71% respectively. EUS and helical CT correctly identified all resectable tumors while EUS was more accurate than helical CT in detecting non resectable tumors 94% versus 69%. CONCLUSION: EUS remains superior to helical CT in positive diagnosis of pancreatic adenocarcinoma especially for small tumors and also for the diagnosis of venous invasion and in identifying non resectable tumors. The two techniques have the same accuracy in the detection of lymph node involvement.

[Usefulness of endoscopic ultrasonography for diagnosis between multivesicular hydatic cyst and serous cystadenoma of the pancreas. Case report]. / Apport de l'echoendoscopie dans le diagnostic differentiel entre un kyste hydatique multivesiculaire et un cystadenome sereux du pancreas. A propos d'un cas.

Hydatid cyst of the pancreas is very rare. However, it should be suspected in every case of pancreatic cyst, especially in hydatid countries where hydatic cyst disease is endemic. In the paper we report the first case of a multivesicular hydatid cyst of the pancreas explored by endoscopic ultrasonography. Endoscopic ultrasonography is very reliable in the investigation of pancreatic cystic tumors. However it did not allow us to define semiological criteria capable of permitting a differential diagnosis between a hydatid cyst and serous cystadenoma. Per-echoendoscopic transduodenal puncture might improve the efficiency of this procedure with of hydatid cysts of the head of the pancreas.

[Place of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. Prospective study about 102 cases]. / Place de la ligature elastique dans la prevention secondaire de l'hemorragie digestive par rupture de varices oesophagiennes. Etude prospective de 102 cas.

The aim of this study was to assess the efficacy and morbidity of endoscopic variceal ligation for the prophylaxis of rebleeding from oesophageal varices. This work is a prospective study including 102 patients having had at least one episode of variceal bleeding. The mean age is 52.5 years. Oesophageal varices were eradicated in 83.3% of cases after an average of 3.5 sessions. Recurrence of oesophageal varices after eradication was observed in 22% after an average follow-up of 7 months. 10 patients died before eradication of oesophageal varices from causes unrelated to the technique. The endoscopic variceal ligation is effective for eradication of oesophageal varices, with a low morbidity. This technique appears to be a method of choice in the prophylaxis of rebleeding from oesophageal varices.

[Bone mineral density in patients with Crohn's disease. Contribution of bone densitometry in 53 cases]. / La densite minerale osseuse au cours de la maladie de Crohn: apport de l'osteodensitometrie chez 53 patients.

Fifty-three patients with Crohn disease were included in a prospective study. Bone mineral density was measured at the femoral neck and lumbar spine by dual-energy X-ray absorptiometry. Ten variables were analyzed in search of an association with bone demineralization; Age, sex, nutritional state, smoking, duration of the disease, hormonal status, inflammatory syndrome, site of disease: ileal, colic or ileocolic, accumulated doses of corticoids and intestinal resection. A bone demineralization was observed in 58.5% of cases. The ileum location and the corticothérapie were predictives of bone demineralization. Crohn disease is a disease at high risk of bone demineralization. Predictors of the bone loss were smoking, long duration of the disease, ileal site and systematic corticotherapy.

Anti-thrombomodulin antibodies and venous thrombosis.

Thrombomodulin (TM) is a cell surface endothelial glycoprotein having anticoagulant properties. It inhibits thrombin, and activates protein C, leading to the inhibition of activated factors V and VIII. TM autoantibodies could theoretically predispose to thrombosis. We have tested 83 unselected patients with deep venous thrombosis, 36 males and 47 females aged from 1 to 70 years [mean +/- standard deviation (SD), 34.2 +/- 14.5 years] for the presence of IgG anti-TM in their plasmas. Tests were performed by enzyme-linked immunosorbent assay (ELISA) using recombinant human TM kindly provided by PAION GmbH (Aachen, Germany). Results are expressed as the optical density (OD) differences between coated and un-coated wells. Plasmas from 83 normal volunteer donors were used to define the cut-off value as the mean of absorbance of the control group + 3 SDs. The median OD of normal controls group was 0.024 (mean, 0.034; SD, 0.066; range, -0.048 to 0.309). The median OD obtained with plasmas from patients was 0.048 (mean, 0.114; SD, 0.215; range, -0.039 to 1.312) and was significantly higher than that of the control group (P < 0.0001). Choosing a cut-off value of 0.232 (mean OD of the control group + 3 SDs), 11 patients are considered as positive for IgG autoantibodies to TM and three normal controls are weakly positive. Selected plasma with IgG anti-TM and purified IgG were further tested by dot blot using recombinant purified TM and were found positive. Purified IgG of positive plasmas inhibits protein C activation by TM and thrombin, suggesting that anti-TM antibodies have a procoagulant effect. Interestingly, in our study, anti-TM antibodies are found in three of six patients with Budd-Chiari syndrome and four of eight patients with cerebral venous thrombosis. In conclusion, thrombomodulin autoantibodies could be a new interesting marker of thrombophilia easily detected by ELISA.