[Steatosis in chronic hepatitis C: prevalence and predictive factors]. / Stéatose au cours de l'hépatite chronique C : prévalence et facteurs de risque de survenue.

BACKGROUND: Patients with hepatitis C virus seem to often have hepatic steatosis. AIM: To assess the prevalence and the predictive factors of steatosis during chronic hepatitis C. METHODS: We studied 50 HCV RNA positive subjects, who had liver biopsy performed. Steatosis was searched and patients were divided into to groups according to the presence or not of steatosis. RESULTS: On liver biopsy, 28 patients (56%) had steatosis. Multivariante analysis showed that steatosis was associated with age 58 years > 1,1 µmol/l, odds ratio 2 (95% CI 1.48 - 2.6; p= 0.02) and triglycerides level, odds ration 4,22 (95% CI 1.05 - 16.98; p = 0,03. CONCLUSION: In this study, steatosis was significantly associated with metabolic factors.

[Survival in patients with gastric lymphoma]. / Survie des patients atteints de lymphome gastrique.

BACKGROUND: Mucosa-associated lymphoid tissue lymphoma is a histological type of marginal zone non-Hodgkin's lymphoma. Its clinical features and prognosis have seldom been reported because of its indolent clinical course. AIM: To establish prognostic factors that should be considered for the staging and management of this disease. METHODS: Clinical data of 40 pathologically confirmed gastric lymphoma patients, treated during a period of 13 years, were analyzed. RESULTS: Of the 40 patients, 65% had stage IE - II1E disease and 35% had stage II2E - IV disease. A total of 18 patients received surgeries.Eighteen patients had chemotherapy and 10 patients had Helicobacter Pylori eradication therapy. The complete remission rate after treatment was 50%. The patients were followed up for a median of 26.75 months. The 5-year overall survival rate was 70%. Early stage at presentation, surgery, normal lactic dehydrogenase (LDH) levels and Helicobacter Pylori infection were associated with longer survival in univariate analysis. CONCLUSION: This study suggested that surgery might be an important factor predicting the long-term survival of patients with primary gastric lymphoma. Patients with poor prognostic factors should be treated more aggressively.

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

BACKGROUND: Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a biliary stent can be a solution. AIM: To prospectively analyse the usefulness of a stenting in management of biliary obstruction due to choledocolithiasis. METHODS: All patients referred to our endoscopic unit from January 2005 to January 2008, for management of bile duct stone are studied. We included patients subjected to an endoscopic insertion of a biliary stent. RESULTS: Of 414 patients with choledocolithiasis, 51 failed to have their ducts cleared with the first endoscopic retrograde cholangiopancreatography (ERCP): 25 patients (6%) were referred to surgical stone removal. Twenty six consecutive patients had endoscopic insertion of a 10 Fr biliary stent: There were 12 men and 14 women ranging in age from 35 to 102 years (median age 68 years). The indications for stent placement in common bile duct stone were mainly the endoscopic portal hypertension, elderly patients or with a short life expectancy. Twenty four patients (88%) are symptom free after stenting. Six patients (23%) had duct clearance after a median of 3 sessions at a mean of 13 months (range 3-48 months). In 3 patients endoprosthesis was inserted as a permanent therapy of biliary obstruction. Cholangitis occurred in 5 patients, early in two cases and later at a mean of 18 months (range 6-24 months) in 3 patients and was managed endoscopically by stent replacement and fluid antibiotics. CONCLUSIONS: These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones until the definitive treatment is carried out. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy.

Colorectal neoplasia in elderly versus young patients in Tunisia: analysis of colonoscopic findings.

BACKGROUND: Colorectal cancer occurs more frequently in older patients. Since the older population is increasing, a better understanding of the characteristics of colorectal neoplasm according to the age would be useful. AIM: To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. METHODS: Colonoscopy database from 2004 to 2008 was retrospectively analyzed. There were 1510 eligible patients who underwent colonoscopy with a mean age of 54 years. Patients were classified into two groups: the older age group (Group 1, aged ³ 60 years, n = 626) and the younger age group (Group 2, aged < 60 years, n = 884). Data were recorded on age, gender, colonoscopic indications, colonoscopic findings, and their related histological findings and tumor location. RESULTS: The risk of finding polyps and cancer at colonoscopy increases with age (29.4% in the older age group and 11% in the younger age group (p < 0.05). Left-sided lesions were noted to be more frequent in both age groups (66% and 67% respectively). CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly. However, both groups had the lesions predominately located in the left side.

Plummer-Vinson syndrome.

BACKGROUND: Plummer - Vinson syndrome is one of the names given to the constellation of dysphagia, iron- deficiency anemia, and esophageal webbing. It is a rare affection which affects mainly white women. AIM: The purpose of this study is to precise epidemiological, clinical, paraclinical and therapeutic features of the affection. METHODS: We report a retrospective study enrolled over 6 years (2002 - 2008). Were studied the age, the sex, the main symptoms and the biological parameters (full blood cell, albumin, hepatic, renal and lipidic balance sheet). Patients were explored by an upper endoscopy. RESULTS: Ten patients with the diagnosis of Plummer-Vinson syndrome were collected. There were 9 women, the average age was 57 years old. Dysphagia was the main symptom, observed in 100% of the cases. Fifty per cent of our patients had iron-deficiency anemia. Iron supplementation was indicated each time there is an iron- deficiency anemia. All the patients were treated with endoscopic dilatation and three of them needed multiple session of endoscopic dilatation. Eighty per cent had a favorable evolution. The malignancy was observed in 2 cases. CONCLUSION: Dysphagia is the main symptom of the Plummer-Vinson syndrome, which must indicate an upper endoscopy. This syndrome is known to be associated with an increased risk of squamous cell carcinoma of the upper airway tract, so the patients should be followed closely. Endoscopic dilatation is the procedure of choice in the treatment of cervical web of the esophagus.

[Biliary stent occlusion]. / Obstruction des endoprothèses biliaires.

BACKGROUND: Endoscopic stent insertion is as a method of choice for palliative treatment of malignant biliary strictures. Two types of biliary stent were actually used plastic and metallic self-expandable. Occlusion of the stent can be observed in both. AIM: To assess the management of biliary stent occlusion. METHODS: From january 2006 to december 2007, 120 biliary stents were inserted in 97 patients. Indications of biliary stents were malignant stricture in 67% of cases. Biliary stent occlusion was defined by necessity of stent replacement. RESULTS: 118 plastic and 2 metallic self-expandable biliary stents were inserted. Obstruction of the biliary stent was observed in 12 patients, after a mean time of 5,5 months [1-15]. A recurrent biliary desobstruction was necessary in 6 patients. Stent exchange was realised in 33,3% of cases for malignant biliary stenosis and in 66,6% for benign stricture (p=0,01). Obstruction of the stent was symptomatic (cholangitis, jaundice) in more of 50% of cases. Management consisted on the stent exchange by a new plastic stent for clogging plastic stent and on insertion of plastic stent inside the metallic one for the occluded metallic stent. CONCLUSION: Obstruction can occur for the two types of biliary stent. Survival of the patient, cost of the stent guide the choice of the stent will be used.

[Psoas abscess as the initial manifestation of Crohn's disease. Report of 3 cases]. / Abcès du psoas révélant une maladie de Crohn. A propos de 3 observations.

BACKGROUND: Psoas abcess complicating Crohn's disease is a rare condition. Diagnosis remains difficult, especially when it is the first sign of Crohn's disease. AIM: We report here 3 patients presenting with psoas abcess as the initial manifestation of the disease, among 118 patients with Crohn's disease seen between 1990 and 2006. CASES REPORT: Symptoms and signs were fever, lower abdominal quadrant pain or tenderness and psoitis. Diagnosis was confirmed in all cases by computed axial tomography. In 2 cases, psoas abcess secondary to a periappendicular abcess or a colonic neoplasm were suspected, and the etiology was made correctly only after operation. Effective therapy included antibiotics, drainage and bowel resection.

Retrobulbar optic neuritis associated with infliximab in a patient with Crohn's disease.

BACKGROUND AND AIM: : Infliximab is a chimeric human-murine monoclonal antibody with a high affinity and specificity for tumor necrosis factor α, which is nowadays widely used in Crohn's disease. An exacerbation of demyelinating disease as an adverse effect of this treatment is rare. The aim of this study was to discuss the relationship between infliximab and optic neuritis. CASE REPORT: : We describe a 55-year old man with Crohn's disease who developed retrobulbar optic neuritis of the left eye after the infusion of infliximab. The outcome was favorable after systemic steroid treatment. CONCLUSION: : Although the relationship between the onset of visual symptoms and the infusion of infliximab may have been coincidental, we believe that this case report underscores the clinical awareness of the possible association, especially in light of the increasing use of this cytokine inhibitor.

Management of the hepatocellular carcinoma.

BACKGROUND: The hepatocellular carcinoma, is detected sooner due to the progress of the hepatic ultrasound scan allowing an accessibility to curative treatment. This cancer treatment still remains difficult in Tunisia. AIM: To show the difficulties in the management of the hepatocellular carcinoma in Tunisia. METHODS: Patients hospitalized in the gastroenterology department of Habib Thameur Hospital, from 2002 until 2007, for a cirrhosis follow-up or for a hepatocellular carcinoma treatment were studied retrospectively. The data was summarized by descriptive statistics and analysed with SPSS version 10. RESULTS: Fifty-seven patients were registered in this study. There were 40 males with an average age of 66 years. The cirrhosis was post-viral C in 28 cases. The discovery of the carcinoma was systematic in 16 cases. Treatment was prescribed in only fifteen patients, in the other patients, treatment was not made because of the multifocal character of the hepatocellular carcinoma. Complications were cirrhosis decompensation (n=3), fever (n=3), portal thrombosis (n=1) and pleurisy (n=1). CONCLUSION: Regardless of the improvement of diagnostic and therapeutic means, 17.5% of our patients having a hepatocellular carcinoma were subjected to a curative treatment. An additional effort must be unfolded.

[Chylous ascites after pelvic irradiation for urologic malignancy]. / Ascite chyleuse après irradiation pelvienne pour une tumeur maligne de l'urètre.

CASE: A 74-year-old woman had a history of transitional papillary carcinoma of the urethra, treated with brachytherapy and radiation therapy. She was hospitalized for exploration of chylous ascites. After a work-up, we concluded it was due to chyloperitoneum caused by a post-radiation lymphatic opening. Conservative treatment, including a low-fat high-protein diet, together with medium-chain triglycerides, led to the drying of the ascites. DISCUSSION: Development of chylous ascites after radiation therapy requires first of all a search for a tumor recurrence. Nonetheless, radiation induction must be considered; its course is usually benign with good response to conservative treatment.

[Celiac disease associated with Budd-Chiari syndrome]. / Maladie coeliaque associée à un syndrome de Budd-Chiari.

INTRODUCTION: Budd-Chiari syndrome is a rare disease defined by obstruction of the hepatic portal vein. Its association with celiac disease is rare. CASE: We report the case of a 28-year-old woman who presented with celiac disease associated with Budd-Chiari syndrome for which no cause could be found. A gluten-free diet and antivitamin K treatment led to a favorable outcome. DISCUSSION: This case and a review of the literature suggest that the pathogenesis of these two disorders is linked.

When will we change treatment in the care of patients with chronic hepatitis B?

BACKGROUND: The treatment by the standard interferon is at present the only treatment recommended in Tunisia in the care of the chronic infection B. PURPOSE: Estimate the biochemical and virological answer of the patients reached by a chronic hepatitis B, treated by standard interferon. METHODS: All the patients, having a chronic hepatitis B confirmed histological, hospitalised in the service of hepatho-gastroenterologie of the hospital Habib Thameur between 1990-2005, were respectively included. The studied parameters were the age, the sex, the transaminases levels meadow and post therapeutic, the viral HVB DNA, the degree of activity and fibrosis according to the score of Metavir. The biochemical answer was defined by the normalization of transaminases at the end of treatment. The virological answer was defined by the seroconversion Ag Hbe for the patients Ag Hbe + and by the negativation of the HBV DNA for all patients. RESULTS: Fifty-one patients of an average age of 31.38 +/- 12.42 years [range: 12-68 years] were included. Twenty-five patients (49%) were treated. Sixteen of them (31%) were Ag Hbe-. The biochemical answer was observed in four cases. A seroconversion was observed in two cases. No negativation of the HBV DNA has been noted. CONCLUSION: The results of the standard interferon in the treatment of the chronic hepatitis B are disappointing in this series. The introduction of new therapeutic molecules adorned necessities in the care of such patients.

Virological response of Tunisians patients treated by peginterferon plus ribavirin for chronic hepatitis C: a preliminary study.

BACKGROUND: Peginterferon plus ribavirin is actually the most effective therapy for chronic hepatitis C. AIM: This study was designed to evaluate the efficacy and safety of peginterferon and ribavirin combination therapy in Tunisian patients with chronic hepatitis C and to identify predictors of response to treatment. METHODS: Fifty patients with chronic HCV infection recruited from the gastroenterology department of Habib Thameur hospital between January 2003 and March 2006 were prospectively included. All patients received peginterferon alpha 2a or alpha 2b subcutaneously respectively at a dose of 180 microg or 1.5 microg/Kg once weekly plus oral ribavirin given in two divided doses per day at a dose of 1000 mg/day for patients weighing 75 Kg or less and 1200 mg/day for those weighing more than 75 Kg. The clinical endpoints were the end of treatment response (EOT) and the sustained virological response (SVR) defined as an undetected serum HCV RNA 6 months after the end of treatment (< 600 IU/ml). Items associated with the main dependant variable (virological response (EOT and SVR) such us sex, age, body mass index, pretreatment viral load, pretreatment ALT quotient, pretreatment histologic degree of fibrosis, activity, steatosis, and HCV genotype (1 vs. non-1) were studied in an unvaried analysis. RESULTS: A total of 50 patients were included in the study. The mean age of patients was 47.64 +/- 8.54 years. Thirty three patients were infected by HCV genotype 1 (66%) and 15 patients by HCV genotype 2 (30%). Forty five patients (90%) had normal ALT values at the end of treatment. At the end-of-treatment 82% of patient had virologic responses. Seventy three percent of patients with HCV genotype 1 had an end-of-treatment (EOT) virologic response and 52% had sustained virologic response (SVR). In patients with HCV genotypes 2 or 3, EOT and SVR were obtained respectively in 100%and 81% of patients. Only one patient infected by HCV genotype 4 was included in this study, she achieved an EOT virologic response whereas the SVR wasn't assessed. Among the 41 patients with EOT virologic response, 3 patients (7.31%) relapses during the 6 months after the end of therapy. Nine patients didn't achieve virologic response. Treatment was well-tolerated for 80% of patients. Laboratory abnormalities were observed in 12 of the 50 included patients (24%) and 7 patients experienced severe adverse events during the treatment period. CONCLUSION: Combination therapy with peginterferon plus ribavirin for HCV infection was effective and safe. Careful monitoring of treatment-associated adverse events is necessary to avoid withdrew of therapy and to maintains a reasonable quality of life.

Autoimmune diseases in coeliac disease: effect of gluten exposure.

INTRODUCTION: the prevalence of autoimmune diseases is increased in patients with coeliac disease. Duration of gluten exposure seems to predispose adolescents with coeliac disease to autoimmune diseases. AIM: In a retrospective cohort study, we assessed the relationship between autoimmune disorders and actual gluten exposure in patients with coeliac disease. PATIENTS AND METHODS: the frequency of autoimmune disorders was evaluated in 64 patients (53 females, 11 males, mean age 29 years, range 16-63) with coeliac disease. The effect of age at the end of follow up, age at diagnosis of coeliac disease, actual gluten-exposure time, gender and diagnostic delay was assessed. RESULTS: the prevalence of autoimmune diseases was 17%. Mean duration of gluten exposure was 26 and 25 years for patients with and without autoimmunity, respectively. Logistic regression showed that a longer mean follow up (P»0.044) was related to the prevalence of autoimmune disorders while actual gluten exposure was not predictive. CONCLUSION: in this study, the prevalence of autoimmune diseases in patients with late coeliac disease diagnosis does not correlate with duration of gluten intake. Confirmatory prospective, multicentre studies of the effect of gluten-free diet are needed in adults.

[Surveillance for hepatocellular carcinoma: does it work?]. / Faut il encore depister le carcinome hepatocellulaire chez le cirrhotique? Etude prospective a propos de 110 cas.

BACKGROUND: The surveillance of cirrhotic patients for early detection of hepatocellular carcinoma is recommended but its efficacy is now discussed. The aim of our study was to present the results of a screening program in 110 patients. METHODS: it is a retrospective study that included 110 patients with cirrhosis in a screening program of hepatocellular carcinoma, based on the realization of abdominal ultrasound exam and the determination of alpha-fetoprotein amount every 6 months in 95 patients and every 3 months in 15 patients. RESULTS: the mean duration of the surveillance was 36 months. A hepatocellular carcinoma was diagnosed in 13 patients. Curative treatment was done in only 3 cases and consisted in a hepatic resection in 1 patient and an alcoolisation in 2 cases. Ten patients had new treatment : for 8 patients the discussed was very agressive and 2 patients had a server hepotic failure. The cost of this study was 37.500 Tunisian dinars. CONCLUSIONS: systematic screening for hepatocellular carcinoma offer a limited cost effectiveness ratio.

[Prognostic factors for survival in cirrhosis]. / Facteurs pronostiques de survie chez le cirrhotique.

BACKGROUND: Assessment of prognosis in patients with cirrhosis is important so as to plan their management as well as the choice of major procedures. The aim of the present study was to determine the survival rates and to identify indicators associated with shorter life expectancy in Tunisians patients with cirrhosis. METHODS: This is a retrospective study of patients with cirrhosis admitted during 14-years period. We studied clinical and biochemical characteristics of all patients and the occurrence of decompensation or complication (gastro-intestinal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, hepatocellular carcinoma). The overall survival, mortality rate and causes of death were reviewed. Univariate and multivariate analysis was performed on all variables to identify parameters associated with a lower life expectancy. RESULTS: We studied 85 patients (50 females/35 males) with a mean age of 57 years. Mean follow up was 31 months. The overall survival was 47% at 5 years. With univariate analysis, 13 variables were associated with a poor prognosis: male sex, jaundice, ascites, and decompensation at admission, increased serum gammaglobulin, gammaGT, bilirubine and ASAT levels, Child-Pugh C, occurrence of spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome and hepatocellular carcinoma. With multivariate analysis, 2 variables were independently correlated with survival:male sex and elevated gammaGT. CONCLUSION: In our study, male sex, increased serum gammaGT and gammaglobulin are uncommon parameters that may predict survival in cirrhotic patient. The Child-Pugh score was a good index for assessing the prognosis.