Monitoring of hepatocellular carcinoma.

Screening for hepatocellular carcinoma in patients at risk is an evidence-based approach; however, adherence to the monitoring protocol recommended by international guidelines is difficult. Hence, there is a need to use the best scr-eening options and refine the selection of patients at risk in the future.

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.

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.

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.

Unusual case of duodenobiliary fistula complicating Crohn's disease successfully treated with Adalimumab.

Crohn's disease (CD) is characterized by transmural inflammation of the gastrointestinal tract, which predisposes to the formation of fistula. Duodenal involvement occurs in less than 5% of cases and often leads to clinically relevant strictures. However, fistula formation in the duodenum is exceptional. Herein, we report an unusual case of duodenobiliary fistula due to CD occurring in a 65-year-old patient who was successfully treated by anti-tumor necrosis factor (TNF) agents. This case report highlights the efficacy of anti-TNF alpha agents in the treatment of a bilioenteric fistula because it increases the probability of clinical remission and mucosal healing and therefore reduces the need for surgical treatment which may be associated morbidity.