Viral B reactivation: risk and prevention

The viral B reactivation is associated to deadly serious forms. There exist populations suffering this risk yet with a possibility of prevention through a pre-emptive treatment. Establishing the diagnosis of a viral B reactivation. Identifying the patients with risk of exposure to viral B reactivation and implementing the means of prevention of viral reactivation. literature review the diagnosis of reactivation is not consensual. It is evoked facing a fast increase of aminotransferases with the ALAT superior to 5-10 times normal or superior to 3 times the basic value, an ascension of the HBV DNA within the serum, a reappearance of anti Hbc of IgM type with, most often, a weak title and /or a reversion Hbs. The reactivation depends on the type of treatment and of the viral B status. It was described under chemotherapy concerning the solid tumors particularly that of the breast, in haematology and increases with the resort to monoclonal antibody [anti-CD20]. Under anti-TNFalpha a reactivation is possible within a variable deadline from the 1st to the 12th perfusion. Besides the type of treatment, the risk is more important with the patients Ag Hbs positive and correlated with the viremia. However, the patients having an occult hepatitis B or even a recovered from hepatitis are equally exposed to the risk of reactivation. viral reactivation is frequent since the larger use of immunosuppressive therapy, anti-TNFalpha and monoclonal antibody. The determination of the initial viral B status by a serology is indispensable. In order to indicate either surveillance or a preemptive treatment

[Efficiency of endoscopic treatment with intra gastric balloon in severe to morbid obesity]

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. 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. 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. 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[registered sign]] was carried out with no incidents in all patients. Six months after the balloon implementation, the average weight loss was17,5% and the average loss of overweigh 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. 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

Malignant epithelioid hemangioendothelioma: a case report

Malignant epithelioid hemangioendothelioma [EH] is a rare tumor of vascular origin. We report a case of a woman who was found to have multiple hepatic masses in the right lobe of the liver on radiologic investigations, initially misdiagnosed as a metastatic carcinoma. The diagnosis of EH was made on histopathological study and confirmed by immunohistochemistry, which showed diffuse response for CD34 marker and no response to tissue CEA, HMB-45 or S-100 protein. Partial hepatectomy was made with good results

Prevalence and risk factor of renal dysfunction induced by bacterial infection other than spontaneous bacterial peritonitis in patients with cirrhosis

Deterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis [SBP] is a predictor for inhospital mortality. However, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. To investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis. Retrospective data from in-patients with bacterial infections other than SBP were analyzed. Eighty-two patients were recruited for the analysis. Infection was located in urinary tract [41.5%], pneumonia [34.1%], biliary tract [3.7%], cellulitis [6.1%], gastrointestinal tract [4.9%] and bacteremia of unknown origin [9.7%]. Renal dysfunction developed in 40 patients [48.8%], of which 13 patients had irreversible renal dysfunction. In the univariate and multivariate analysis, the initial MELD score, neutrophil count, bilirubin, and blood pressure were significant risk factors for renal dysfunction. The prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 48.8%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients

[Factors predicting mortality in infected hospitalized cirrhotics patients: about 97 cases]

Infections are frequent in cirrhotic patients. They are potentially severe, modifying pejoratively the natural history of the cirrhosis and are suppliers of a heavy mortality. To determine the predictive factors of hospital mortality in cirrhotic infected patients. We conducted a retrospective study including 97 cirrhotic patients hospitalized in the department of gastroenterology of Charles Nicolle's hospital, for a first infectious episode and not having received antibiotics in the previous 15 days. Clinico-biological, bacteriological, therapeutic and evolutionary data were collected. Scores were adopted and calculated such as the score of Child-Pugh, the score MELD [The Model for End-Stage Liver Disease] and the score SOFA [Sequential Organ Failure Assessment]. These data allowed a descriptive study and an uni and multi-varied analysis. The median age of the studied population was of 59 +/- 12 years with a sex ratio of 0.83. The diabetes was the comorbidity most frequently associated with the cirrhosis [26.8% of the cases] Viral aetiology of the cirrhosis was dominant [3/4 of the cases] especially the virus C [62.5% of the cases]. The clinical presentation of the infection was polymorphic with presence of symptoms connected to the infection and the other connected to the progression of the liver disease. The fever was absent in 3/4 of the cases. The identified infections were, in order of frequency, urinary, infection of ascite, bronchopulmonary, cutaneous and gynecological. The responsible germs were especially bacilli gram negative of intestinal origin. The estimated scores of gravity were: a score of Child-Pugh C in 60% of the cases, an average score MELD in 18 +/- 8 points and a score average SOFA in 8 +/- 4 points. Multivariate study found that only encephalopathy, bilirubin level more than 40 micro mol/l and creatinin level more than 120 micro mol/l was independent factors predicting mortality. Infection in cirrhotic patients was a severe and mortal complication. The hepatic encephalopathy, the hyper bilirubinemia and the renal failure are predictive of the hospital mortality. The use of the scores of gravity: Child-Pugh, MELD and SOFA would an important help for the decision to admit in intensive care unit any infected cirrhotic patient

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

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. To evaluate feasibility and tolerance of this investigation in elderly and to review the most frequent indications of colonoscopy in these patients. 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. 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. 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

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

To assess the diagnosis value of Fibrotest in comparison with liver biopsy, for the evaluation of hepatic fibrosis in patients with chronic hepatitis C. This prospective study included in 2 years [2006-2007], consecutive patients with chronic hepatitis C native 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. 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% Fl; 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] was0.85. There were 13/65 cases of discordance [20%] for fibrosis, 4 cases were attributed to biopsy and 6 cases to Fibrotest. The discordance was unexplained in 3 cases. The size of biopsy<15mm [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. This prospective study confirmed the good diagnostic value of Fibrotest as compared with the histological analysis of liver biopsy

[Auto immune hepatitis type 1 triggered by cytomegalovirus infection]

Autoimmune hepatitis is chronic and uncommon disease. The pathogenesis is a complex process. Several triggers for autoimmunity in predisposed individuals. Report a new case. We report a case of 17-year-woman presented with autoimmune triggered by cytomegalovirus infection. Cytomegalovirus induced autoimmune hepatitis has not been reported previously. Evolution was favourable under antiviral treatment, corticosteroid and azathioprine

Evaluation of nutritional status in patients with liver cirrhosis

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. 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. 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%. 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 paramelers and the severity of cirrhosis. In this study, the high prevalence of denutrition was associated with the severity of cirrhosis. Anthropometric parameters are valuable tools for malnutrition diagnosis

Transverse myelitis associated with chronic viral hepatitis C

HCV infection could cause several extra hepatic diseases including mixed cryoglobulinemia, Peripheral neuropathy is the most common complication of mixed cryoglobulinemia. In addition to cryoglobulinemia's neuropathy, transverse myelitis had been related to had infection. But causality of this association is not clearly established. A 55-year-old man presented with motor deficiency in lower extremities and urinary retention Neurological exams showed a spastic paraparesis and proprioceptive ataxia. Spinal MRI revealed a contrast enhancing signal abnormality within the spinal cord extending from Levels C3 to CS. Serology hepatitis C and viremia were positive. Clinical diagnosis of acute demyelinating sensorimotor polyneuropathy associated to chronic hepatitis C was etablished. Screening of HCV infection must be done in patients with transverse myelitis and no clear aetiology

[Nephrogenic ascites: an exceptional diagnosis. about one case]

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. The aim of this study is to focus on these difficulties through a new observation. 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. 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

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

Peginterferon plus ribavirin is actually the most effective therapy for chronic hepatitis C. 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. 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 a 2a or alpha 2b subcutaneously respectively at a dose of 180 micro g or 1, 5 micro g/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. 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. 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 maintain a reasonable quality of life

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

Compare the performances of EUS to helical CT in the diagnosis and staging of pancreatic adenocarcinoma. 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. 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 which 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%.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

[Prevalence of malnutrition in gastroenterology hospitalized patients: a 70 patients prospective study]

Malnutrition is a common problem in gastroenterology hospitalized patients. Its frequency varies considerably with the studied population and nutritional screening tools. The purpose of this study was to assess the prevalence of malnutrition in gastroenterology hospitalized patients. A prospective study was carried between January 2005 and March 2005 including 70 patients. The nutritional state of the patients was assessed according to the subjective global assessment scale [SGA]. anthropometric measurements and serum albumin level. Moderately and severely malnutrition was found for 54 patients [77 percent]. Statistical analysis found positive correlation between body mass index [BMI] and SGA C [p=0 .002] and between albumin level and SCA [p<0.005]. The median nutritional risk index [NRI] was 89.5 +/- 13 with significantly positive correlation with the other parameters [BMI, Albumin and SGA] respectively p=0.03, p=0.003 and p=0.004. Malnutrition is common in gastroenterology patients. The assessment of patient's nutritional state according to the subjective global assessment had a positive correlation with the others nutritional screening tools