Treatment of Helicobacter pylori infection 14-day concomitant quadruple therapy versus triple therapy: A parallel double-blind randomized controlled trial.

Background and Aims: Successful Helicobacter pylori (Hp) eradication with the traditional 7-day course of proton pump inhibitor triple therapy is declining. Prolonging therapy to 14 days is associated with better eradication rates. Most learned societies recommend concomitant quadruple therapy (QC) as a first-line alternative therapy for this bacterial infection. The aim of this study is to compare the efficacy and safety of triple therapy (TT) and QC for the eradication of Hp infection. Methods: A parallel double-blind randomized controlled trial was conducted. The diagnosis of Hp infection was made by pathological examination of gastric biopsies. Patients were randomly assigned to two treatment groups: either QC (esomeprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily) or triple therapy (esomeprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses) for 14 days. The efficacy of the treatment is defined by Hp eradication attested by a negative breath test performed 6 weeks after the completion of treatment. Treatment outcomes were compared using the chi-square test, while binary logistic regression identified predictors of treatment failure. Results: Ninety-two patients were included. Forty-two patients belonged to the QC group and 50 to the TT group. No significant difference was noted between the two groups concerning the rate of Hp eradication either by intention to treat (81% vs. 72% respectively, p = 0.31) or per protocol (81.6% vs. 76.1% respectively, p = 0.54). Likewise, there was no difference between the two groups in terms of tolerance to treatment (59.5% for QC vs. 58% for TT, p = 0.88). No factor has been associated with treatment failure. Conclusion: There was no significant difference in the rate of HP eradication between the QC and the 14-day triple therapy. Neither regimen should be used topically because of their low eradication rates.

Tunisian consensus on the management of Helicobacter Pylori infection.

Helicobacter pylori infection is the most common infectious disease worldwide. It is associated with duodenal and gastric ulcer disease and the risk of gastric neoplasia. The management of helicobacter pylori infection currently represents a real challenge for clinicians, given the ever-increasing rate of resistance of Helicobacter pyolori to various antibiotics. In this consensus document, we present recommendations adapted to the Tunisian context, including indications for the detection of helicobacter pylori infection, indications for the use of different diagnostic methods, and a therapeutic strategy for the management of Helicobacter pylori infection.

Occupational exposure to hepatitis C virus infection and associated factors among healthcare workers in Fattouma Bourguiba University Hospital, Tunisia.

BACKGROUND: Healthcare workers (HCWs) are at high risk of hepatitis C virus (HCV) infection. Indeed, they are exposed to blood and body fluid which put them at an important risk of transmission of various blood borne pathogens including HCV. The goal of this study was to determine the magnitude of occupational exposure to hepatitis C virus infection as well as the factors associated to this exposure among HCWs at a Tunisian University Hospital in 2017. METHODS: A hospital-based cross-sectional study was carried out at Fattouma Bourguiba University Hospital in Monastir Governorate (Tunisia) from 01 June 2017 to 31 August 2017. Data were collected using an anonymous questionnaire. To determine factors associated with occupational exposure to hepatitis C virus infection, we performed multivariate analysis. RESULTS: Among the 1493 included participants, more than half (56.7) had at least one exposure to blood or body fluid. A history of needle stick injury was reported by 48.3% of the respondents. Exposure to blood or body fluid splash into the face was announced by 32.1% HCWs. Doctors had the highest risk of exposure (AOR = 12.425; 95% CI: [05.310-29.075]). Participants working at surgical departments were the most exposed comparing to workers at others departments (AOR = 7.440; 95% CI: [4.461-12.408]). Two exposed female HCWs were tested positive corresponding to a HCV infection prevalence of 0.13% (95% IC: [0.11-0.16%]). CONCLUSION: Occupational exposure to hepatitis C virus infection was high at the university hospital of Monastir. Despite the low magnitude of HCV infection, preventive actions should be taken to promote the safety of health care personnel.

Norethisterone-induced cholestasis: A case report.

Case presentation This case report concerns a 49-year-old woman who developed cholestasis (build-up of bile in the liver) two months and a half after initiating norethisterone, progestin-only pills, which resolved after the withdrawal of these pills.

EncephalApp Stroop Test for covert hepatic encephalopathy screening in Tunisian cirrhotic patients.

Background: Covert hepatic encephalopathy (CHE) is underdiagnosed and is difficult to detect. The EncephalApp Stroop test is validated for its screening. The aim of the study was to define Tunisian norms for the test based on healthy controls norms and to estimate the prevalence of CHE in cirrhotic Tunisian patients. Methods: A prospective, multicenter, cross-sectional study was conducted. Ambulatory or hospitalized cirrhotic patients aged 40 years and over were recruited at 11 centers. Healthy subjects aged 40 years and over were recruited at 8 centers. We used a translated Arabic version of the streamlined EncephalApp Stroop test. The task has two components: "Off" and "On" state depending on the discordance or concordance of the stimuli. Results: 142 patients were included. The mean age was 57.26 years [40-86]. 40 (28.17%) of cirrhotic patients who were included were diagnosed as having a minimal hepatic encephalopathy or CHE. Among the ineligible patients, 22 had overt hepatic encephalopathy. If we consider these patients, the overall prevalence rate of CHE was around 24.39% in cirrhotic patients. It was more frequent in women (34.21% vs 25.96%), and in patients whose level of school education is between 6 and 13 years. Its prevalence does not appear to be affected by gender, MELD score, etiology of cirrhosis and age group of patients, as these variables were independent with respective p according to the chi-square test 0.413; 0.736; 0.663 and 0.1. The stroop times (On / Off and On + Off) correlated significantly with each other, are associated significantly and positively with age (respective Pearson coefficients: 0.578; 0.567 and 0.6). The more the age increases, the more the stroop response times increases (p > 10 -3). Conclusions: EncephalApp Stroop test was an efficient screening tool for CHE in Tunisian cirrhotic patients.

The role of quantitative HBsAg in the natural history of e antigen-negative chronic hepatitis B: A Tunisian prospective study.

BACKGROUND/AIMS: During the natural course of Chronic Hepatitis B (CHB) infection, differentiation between inactive carrier (IC) and HBeAg negative CHB is a subject of ongoing debate. We studied the role of hepatitis B surface antigen (HBsAg) level as a means of differentiating between CHB and IC in a group of untreated chronic HBeAg-negative HBV-infected patients. STUDY: A total of 115 HBeAg negative carriers were enrolled and followed up for>12 months; 78 as inactive carriers (IC), and 37 as active carriers (AC). Among ACs, patients were categorized according to the highest rate of viral load: AC1 (n=23), active carriers with persistent HBV-DNA<20,000 IU/mL; AC2 (n=14), active carriers with HBV-DNA>20,000 IU/mL. RESULTS: HBsAg levels were higher in AC compared to IC patients (1607 IU/ml vs. 225 IU/ml respectively, P=0.001). Among the AC group, the 23 AC1 cases had HBsAg levels significantly lower than the 14 AC2 patients (1756 IU/mL vs. 3327 IU/mL respectively; P<10-3). HBsAg showed weak correlation with HBV-DNA in the whole cohort (r=0.44, P<0.01). The suggested cutoff value of HBsAg titer to differentiate between the two groups was 938 IU/mL. Combined single-point quantification of HBsAg (938 IU/mL) and HBV DNA (2000 IU/mL) identified IC with 87.2% specificity and 91.7% positive predictive value. CONCLUSION: This study confirms the predictability of a one-time combined HBsAg and HBV DNA measurement for true inactive carriers requiring neither strict follow-up nor antiviral treatment.

Diverticular disease of the small bowel: a rare cause of the duodenojejunal flexure obstruction (a case report).

The small bowel is the least common site for diverticula in the entire gastrointestinal tract. Chronic upper intestinal obstruction due to diverticula is very rare. We report a case of multiple small bowel diverticula causing mechanical obstruction of the duodenojejunal flexure.

Black esophagus: a case report.

INTRODUCTION: Acute esophageal necrosis, also known as black esophagus, is a rare digestive complication, frequently manifested by an upper gastrointestinal hemorrhage and occurs in patients with comorbidities. AIM: To report the case of a patient with a black esophagus revealed by an upper gastrointestinal hemorrhage. OBSERVATION: A 72-year-old patient with a history of diabetes mellitus, hypertension and ischemic heart disease was hospitalized in surgical intensive care unit for hemorrhagic shock induced by cholecystectomy. On the 7th postoperative day, the patient developed acute hematemesis. Gastroscopy showed circumferential necrosis, localized in the middle and lower third of the esophagus and stopped abruptly at the gastroesophageal junction. Gastric mucosa was strictly normal. The bulb and the first part of duodenum showed multiple superficial ulcers without signs of recent hemorrhage. The patient was placed on absolute diet and total parenteral nutrition associated with high-dose intravenous proton pump inhibitor. Second-look gastroscopy, performed six days later, showed a significant improvement in esophageal lesions. The evolution was marked by the occurrence of pneumonia complicated by septic shock which caused patient's death. CONCLUSION: Black esophagus is a rare pathology of multifactorial etiology. Treatment is based on proton pump inhibitors in combination with resuscitation measures to control comorbidities. Mortality remains high due to the seriousness of comorbid disease states often associated with this condition.

Primary biliary cholangitis : therapeutic and evolving aspects about 46 cases.

BACKGROUND: Primary biliary cholangitis (PBC) is a rare autoimmune chronic liver disease whose prevalence is increasing. Medical treatment is based on ursodeoxycholic acid. It association with autoimmune hepatitis defined the overlap syndrome (OS). AIM: It was to determine therapeutic and evolving characteristics of PBC and to compare them to those in subjects having an overlap syndrome. METHODS: This was a retrospective study of all the patients' files with PBC from hepato-gastroenterology department at Monastir hospital from April 1999 to November 2013. RESULTS: Forty six patients were included in our study: 43 women and 3 men with an average age of 55 years. OS was retained in 13 patients. Cirrhosis was retained in 21 patients. Thirty-eight patients were treated with ursodeoxycholic acid (UDCA) associated with corticosteroids and immunosuppressors in the case of OS. After an average follow-up of 50 months [13-169 months] the overall response rate to UDCA was 55%. This rate was comparable between the 2 groups isolated PBC and OS. It was lower in the cirrhosis group compared with non-cirrhotic patients (40% vs 65%, p=0,06). One patient underwent a liver transplantation. Three patients were died as a result of decompensated cirrhosis. CONCLUSION: Our study highlights the frequency of cirrhosis at the time of PBC diagnosis, which may explain the low rate of response to UDCA. There is no difference in the therapeutic and evolving aspects between patients with isolated PBC and those with SC.

Squamous cell carcinoma of the rectum cured after chemoradiation.

The primary squamous cell carcinoma of the rectum is a rare tumor that presents epidemiological, etiopathogenic and evolutionary characteristics different from those of adenocarcinoma . We report the case of a primary squamous cell  carcinoma well  differentiated  from medium-high   rectal junction in a 59 year old patient treated with a chemoradiation first ,followed by surgical resection. However, the anatomical examination of the  surgical specimen did not show tumoral tissue.

Unusual presentation of severely disseminated and rapidly progressive hydatic cyst: Malignant hydatidosis.

The infection caused by the tapeworm Echinococcus granulosus leads to the development of hydatic disease. It is the most frequent mediterranean parasitic infection that commonly affects the liver and rarely involves multiple organs. Herein, we report an exceptional and confusing presentation of hepatopulmonary and splenic hydatidosis due to Echinococcus granulosus that caused diagnostic problems occuring in a 70-year-old man, treated with chemotherapy, with favorable outcome. This was a very unusual case of disseminated hydatid cyst highlighting the interest of keeping a high level of clinical suspicion of this diagnosis every time we have a cystic lesion of the liver.

Appropiateness of colonoscopy in the university hospital center of monastir. Interest and applicability of criteria established by the European panel on the appropriateness of gastrointestinal endoscopy.

AIM: 1) To assess the applicability of EPAGE criteria in there first version (EPAGE I) in clinical practice, 2) to assess colonoscopy appropriateness using EPAGE I criteria, 3) to compare colonoscopy appropriateness and findings. METHODS: Four hundred and eighty-seven consecutive diagnostic colonoscopies were included. The appropriateness of the indication of colonoscopy was appreciated using a scoring system on the basis of the EPAGE criteria in there first version (EPAGE I). RESULTS: Appropriateness were applied in 86,4% of the colonoscopies. Fifty-one percent were appropriate, 14% uncertain and 18% inappropriate. The difference of 17% represented the procedures indicated for hematochezia and for witch an appropriateness score can not be attributed because of lack of clinical information. The probability of finding a clinically significant lesion was significantly higher in patients aged ≥ 50 years, males, inpatients, those referred by gastroenterologists and those who had the colonoscopy for "appropriate" indication according to the EPAGE I criteria. The independent variables correlated with the diagnostic yield of colonoscopy were the age, the appropriateness of indication and the health care setting. CONCLUSION: EPAGE I criteria were applicable in most patients and were correlated with significant findings. They are thereby useful to rationalize colonoscopy demand. However, they could be regularly updated.

[Serodiagnosis of acute hepatitis in adults patients: results of a prospective study in a central region of Tunisia]. / Sérodiagnostic des hepatitis aiguës de l'adulte: résultats d'une etude prospective dans une region du centre tunisien.

UNLABELLED: PRÉREQUIS: Viral hepatitis is a public health problem in many parts of the globe. In Tunisia, the respective responsibility of five viruses (HAV, HDV, HBV, HCV and HEV) in the genesis of acute hepatitis in adults is only roughly indicated in the absence of suitable serological studies, given as important to plan appropriate preventive strategies. OBJECTIVES: To approach the role of viral hepatitis in all adult with acute hepatitis, identify the current share of each virus A, B, C and E in the genesis of hepatitis and to study the epidemiological and evolution of these diseases. METHODS: We conducted a prospective study over two years including patients aged from 15 to 65 years old, with clinical and / or biological acute hepatitis. Data were collected through a standard questionnaire wich covered sociodemographic charactereristics and risk factors. Blood samples were collected and were tested for IgM anti-HAV, IgM anti-HEV, HBsAg, IgM anti-HBc, anti-HCV antibodies .When serological tests were negatives, further explorations including immunological test, search for HCV RNA and a pharmacovigilance survey was conducted. Statistical analysis was performed by SPSS version 10.0 RESULTS: 105 patients were included. Acute viral hepatitis was diagnosis in 70 patients (67%). The proportion of patients with acute viral hepatitis A, B, C and E was 51.5% , 38.5%, 4.3% and 5.7% respectively. The risk factors of viral hepatitis A was drinking of untreated water and poor socioeconomic status. In the HBV group, the notion of sexual contact risk was found in 30% of cases. The small numbers of acute hepatitis E and C does not permit us to draw conclusions. CONCLUSION: Our study confirms the shift in age of onset of hepatitis A to the age of adolescence and young adulthood. The respective responsibilities of the different viruses studied in the genesis of acute hepatitis in adults in our area brings us closer of western populations where HAV infection predominates followed by HBV.

[Epidemiological, clinical features, therapeutic results and evolution of gastrointestinal stromal tumour: about 25 cases]. / Caractéristiques épidémiologiques, cliniques, thérapeutiques et évolutives des tumeurs stromales digestives: à propos de 25 cas.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are mesenchymal tumors occuring in the majority of cases in the stomach and small intestine, rarely in rectum, colon, esophagus or mesentery. They are derived from cells of cajal or their precursor, and are typically CD117/KIT + (95%), CD34 + (70%). AIMS: is to study the epidemiological, clinical, therapeutic and evolution of gastrointestinal stromal tumors. METHODS: retrospective study including all patients with the diagnosis of GIST supported in the department of gastroenterology and surgery in universital hospital of Monastir. RESULTS: 25 patients were included, 12 men and 13 women with an average age of 60.5 years. Digestive symptomatology was dominated by gastrointestinal bleeding (n = 12) and abdominal pain (n = 12). The tumor was discovered incidentally in two patients. The small intestine was the most common site of the tumor (n = 10), followed by the stomach in 9 patients, rectum in two patients, the colon (n = 1), the bulb of water (n = 1), duodenum (n = 1) and liver in a patient. The tumor size ranged from 0.8 to 24 cm. GIST was localized in 16 patients, in whom therapeutic care based mainly on surgery and optimal broad. It was metastatic in 9 patients, in whom treatment using imatinib as first-line in 4 of them with a good response in 3 patients and the possibility of R0 surgery in one patient, initial stabilization and then a secondary exhaust in a patient. The first surgery was necessary in 5 patients in complicated situation or if diagnostic doubt. CONCLUSION: The best characterization of GIST thanks to advances in cancer research has led to improved treatment of these tumors. Surgery is the standard treatment in localized forms. Imatinib is the standard treatment in metastatic GIST first line as well as adjuvant after surgery.