Sporadic Burkitt lymphoma presenting with peritoneal lymphomatosis.

Burkitt lymphoma (BL) is a highly aggressive non-Hodgkin B-cell lymphoma. It has a doubling time of 24 h. Fortunately, it is highly sensitive to aggressive chemotherapy. Sporadic BL often affects the mesenteric and retroperitoneal lymph nodes. Extra-nodal involvement includes the ileocecal area, stomach, kidneys, gonads, and central nervous system. Peritoneal lymphomatosis is a rare presentation. We report a case of BL presenting with peritoneal lymphomatosis to emphasize the importance of early histological diagnosis of any peritoneal thickening.

Comparison between signet-ring cell carcinoma and non-signet-ring cell carcinoma of the stomach: clinicopathological parameters, epidemiological data, outcome, and prognosis-a cohort study of 123 patients from a non-endemic country.

BACKGROUND: Signet-ring cell carcinoma of the stomach (SRCC) is a particular gastric cancer entity. Its incidence is increasing. Its diagnosis is pathological; it corresponds to adenocarcinoma with a majority of signet-ring cells component (> 50%). These histological features give it its aggressiveness characteristics. This has repercussions on the prognostic level and implications for the alternatives of therapy, especially since some authors suggest a potential chemoresistance. This survey aimed to identify the epidemiological, pathological, therapeutic, and prognostic characteristics of SRCC as a separate disease entity. METHODS: This was a retrospective study of 123 patients admitted for gastric adenocarcinoma to Habib Thameur Hospital in Tunis over 11 years from January 2006 to December 2016. A comparative study was performed between 2 groups: the SRCC group with 62 patients and the non-SRCC (non-signet-ring cell carcinoma of the stomach) with 61 patients. RESULTS: The prevalence of SRCC in our series was 50%. SRCC affected significantly younger patients (55 vs 62 years; p = 0.004). The infiltrative character was more common in SRCC tumors (30.6 vs 14.8%; p = 0.060), whereas the budding character was more often noted in non-SRCC tumors (78.7 vs 58.1%; p = 0.039). There was no significant difference in tumor localization between both groups. Linitis plastica was noted in 14 patients with SRCC against a single patient with non-SRCC (p = 0.001). The tumor size was more important in the non-SRCC group (6.84 vs 6.39 cm; p = 0.551). Peritoneal carcinomatosis was noted in 4.3% of cases in the SRCC group versus 2.2% of cases in the NSRCC group (p = 0.570). Total gastrectomy was more often performed in the SRCC group (87 vs 56%; p = 0.001). Resection was more often curative in the non-SRCC group (84.4 vs 78.3%; p = 0.063). Postoperative chemotherapy was more commonly indicated in the SRCC group (67.4 vs 53.3%; p = 0.339). Tumor recurrence was more common in the non-SRCC group (35.7 vs 32%; p = 0.776). The most common type of recurrence was peritoneal carcinomatosis in the SRCC group (62.5%) and hepatic metastasis in the non-SRCC group (60%; p = 0.096). The overall 5-year survival in the SRCC group was lower than in the non-SRCC group, with no statistically significant difference (47.1 vs 51.5%; p = 0.715). The overall survival was more important for SRCC in early cancer (100 vs 80%; p = 0.408), whereas it was higher for non-SRCC in advanced cancer (48.1 vs 41.9%; p = 0.635). CONCLUSION: Apart from its epidemiological and pathological features, SRCC seems to have a worse prognosis. Indeed, it is diagnosed at a more advanced stage and has a worse prognosis in advanced cancer than non-SRCC. It is therefore to be considered as a particular entity of gastric adenocarcinoma requiring a specific therapeutic protocol where the place of chemotherapy remains to be more investigated.

Gastric polyps: a 10-year analysis of 18,496 upper endoscopies.

BACKGROUND/AIMS: Gastric polyps (GPs) are usually asymptomatic lesions of the upper gastrointestinal tract observed in 1-3% of esophagogastroduodenoscopies (EGD). Most GPs are benign. The aim of this study was to precise the frequency of different types of gastric polyps in our population, and to analyze their possible association with other factors. MATERIALS AND METHODS: A total of 18,496 consecutive patients undergoing EGD over a 10-year period (between 2007 and 2018) in a tertiary hospital were retrospectively reviewed. Eighty-six patients diagnosed with gastric polyps were analysed. Demographics, medical history of the patients, and indication for gastroscopy were collected. Morphological, histological characteristics of polyps, and therapeutic management data were also collected. RESULTS: GPs were found in 86 out of 18,496 (0.46%) reviewed EGD, corresponding to a total of 141 polyps. There were 64 female (74.4%) and 22 male patients (25.6%) with a sex ratio (M/F) of 0.34. The average age was 58.1 years. One hundred and forty one polyps were included, and histopathology was obtained on 127 GPs. The most common location was the fundus (59.6%) and 48.9% were smaller than 5 mm. The polyp was unique in 75.6% of cases. According to Paris classification, 80% of the polyps were sessile (Is). Hyperplastic polyps were the most common (55.9%), followed by sporadic fundic gland polyps observed in 23 patients (18.1%), 7 (5.5%) were adenomas and 4 (3.1%) were neuroendocrine tumors type 1. The following factors were associated with hyperplastic polyps: anemia (p = 0.022), single polyp (p = 0.025) and size ≥ 5 mm (p = 0.048). Comparing hyperplastic polyps' biopsies to resected polyps, no difference was found in the evolutionary profile of the 2 groups. A size less than 10 mm (p = 0.013) was associated with fundic gland polyps. Sixty polyps (47.2%) were treated by cold forceps, 19 (15%) treated by a mucosal resection and 15 (11.8%) with diathermic snare. Five procedural bleeding incidents were observed (3.9%). Only the use of anticoagulant treatment was associated with a high bleeding risk (p = 0.005). The comparative histological study between specimens of biopsied GPs and endoscopic polypectomy led to an overall agreement of 95.3%. CONCLUSION: In our study, the GPs frequency was 0.36%. Hyperplastic polyps and fundic gland are the most common in our country. The high frequency of Helicobacter pylori infection in our patients and in our area may explain the high frequency of HP.

Primary gastric squamous cell carcinoma with a bilio-gastric fistula and Krukenberg syndrome.

Primary squamous cell carcinoma of the stomach is a rare type of gastric malignancies. Diagnosis criteria are well defined but diagnosis is generally late being made at an advanced stage with metastases explaining its poor diagnosis.

Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.

With the increasing prevalence of obesity and type 2 diabetes, fatty liver disease associated with metabolic dysfunction is a global health problem, especially because it is one of the earliest consequences of obesity and it precedes diabetes development. Fatty liver disease associated with metabolic dysfunction is of particular concern in the Middle East and north Africa, where its prevalence is greater than that in the rest of the world. Despite the magnitude of the problem, no regional guidelines have been developed to address this disease. This Review describes suggestions of redefining fatty liver disease associated with metabolic dysfunction, including its terminology and criteria for diagnosis. Experts have raised serious concerns on the current nomenclature, which labels the disease as non-alcoholic fatty liver disease (NAFLD), and its diagnostic criteria. The panel reached a consensus that the disease should be renamed as metabolic-associated fatty liver disease (MAFLD) and that the disease should be diagnosed by positive criteria. The aim is now to work with authorities across the region to implement these proposed changes and reflect them in health-care policy and to improve health care for patients in this region.

An unusual case of diffuse large B-cell lymphoma complicating a Crohn's disease.

Clinicians should keep in mind that Crohn's disease may be complicated by neoplasia such as adenocarcinomas or lymphomas, especially if the disease duration is long and the patient is under immunosuppressive therapy.

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.

Gastrointestinal bleeding as an initial manifestation of gastric lipoma: Case report and review of the literature.

Gastric lipoma should be considered as a rare differential diagnosis in patients presenting with gastrointestinal bleeding. Diagnosis is mainly done by radiologic and endoscopic findings. It presents characteristic pathognomonic endoscopic signs.

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.

Prognostic significance of poorly cohesive gastric carcinoma in Tunisian patients.

BACKGROUND: While the incidence of gastric cancer has decreased worldwide in recent decades, the incidence of poorly cohesive carcinoma (PCC) is rising. The prognostic significance of gastric PCC remains a subject of debate. OBJECTIVE: To analyze the prognosis of gastric PCC in a Tunisian cohort. METHODS: A total of 122 gastric adenocarcinoma patients who underwent curative gastrectomy from 2001 to 2014 at Habib Thameur hospital in Tunis, Tunisia were included. The clinicopathological parameters and prognosis of PCC were analyzed in comparison with non PCC (NPCC). RESULTS: Sixty one patients (50%) presented PCC. Patients were younger in PCC group (p = 0,001). There was no difference in sex distribution between the two groups. PCC was more likely to be stage T4 (55.7% vs 34.4%; p = 0.033), N3 (67.8% vs 30%; p < 0.001) and have a higher metastatic lymph node ratio (p < 0.001). Hepatic metastases were more frequent in NPCC group (p = 0.031) whereas peritoneal carcinomatosis was more common in PCC group (p = 0.004). Perineural invasion was more frequent in PCC group (p = 0.001). Resection margins were more often positive in PCC group (31.1% vs 9.8%; p = 0.004). There was no difference in recurrence rate between the 2 groups (p = 0.348). The 5-year survival was similar in the NPCC and PCC (respectively 43% vs 23 %; p = 0.247). Survival rates were also comparable in early stage (100% vs 80% respectively for PCC and NPCC; p = 0.527) as well as for advanced stage (16% vs 35% respectively for PCC and NPCC; p = 0.538). PCC was not a prognostic factor for survival. Interestingly, advanced age, adjacent structures invasion, positive resection margins were specific prognostic factors for PCC. CONCLUSION: In our study PCC was not a prognostic factor for survival. Advanced age, adjacent structures invasion and positive resection margins were specific prognostic features for this histological subtype.

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.

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.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report.

BACKGROUND: Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination. CASE PRESENTATION: We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution. CONCLUSIONS: GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.