[Diffuse oesophageal spasms: results of a retrospective manometric study]

Diffuse esophageal spasms is a primary motor disrder of the esophagus of unknown etiology characterized by intermettent peristalsis. This is rare condition which represents 3-5% if primary disorders of the esophagus. Diagnosis and treatment of this entity are difficult. To evaluate the frequency and the clinical and the manometric features of diffuse esophageal spasms. Methods: We conducted a retrospective study related to esophageal manometry performed between January 2000 and December 2011 regardless of the indication. Patients with meeting criteria for diffuse esophageal spasms [> 20% simultaneous waves with greater than 30 mmHg pressure in the esophagus] were included. Out of 1188 patients, 13 [1,09%] met the manometric criteria for diffuse esophageal spasms. It was 8 women and 5 men with a median age of 57 years. Dysphagia was the most relevant symptom and chest pain was only noted in 1 patient. The frequency of simultaneous waves was between 20 and 80%. The pressure of the lower esophageal sphincter was normal in most cases. In this Tunisian manometric study, the diffuse esophageal spasms is rare. Dysphagia was the most relevant symptom and the pressure of the lower esophageal sphincter was normal in most cases

Prognostic factors in Crohn's disease: a systematic review

The natural history of Crohn's disease is associated with several factors that affect the prognostic of the patients.To determine the most prognostic factors in Crohn's disease, based on a systematic review. methods: Literature review. The most important factors to consider in patients with Crohn's disease are the need for immunosuppressive therapy, the need for intestinal resection and disabling disease. Prognostic factors for these events are ileal involvement, perianal disease and initial treatment by corticosteroid. Other factors such young age, CRP level and smoking status, has not been found in all population-based studies. Protective role of anti-TNF drugs is strongly suggested but need to be confirmed in further studies. In a selected subgroup of patients with Crohn's disease characterized by the presence of these prognostic markers, the "topdown" strategy can be proposed

[Efficacy and safety of adalimumab in Crohn's disease]

Adalimumab is the first subcutaneously self-administered fully human anti-TNFalpha. To determine efficacy and safety of Adalimumab therapy in Crohn disease. Literature review. Adalimumab has been evaluated for its effect in inducing and maintaining remission and its steroid-sparing effect of refractory Crohn's disease. In addition, it offers a significant treatment option in patients who have lost response to or become intolerant to Infliximab. Results also suggest efficacy of Adalimumab in fistulising Crohn's disease but more studies are needed. Adalimumab was well tolerated and studies show that all anti-TNF inhibitors have similar safety profiles

[Is APRI score a suitable tool for prediction of fibrosis in Tunisian patients with genotype 1 chronic viral hepatitis C?]

Therapeutic indications in chronic genotype 1 hepatitis C are based on severity of fibrosis. APRI score is a simple, cheap and reproducible biochemical test. Performances of APRI score in Tunisian population with chronic hepatitis C were not previously prospectively studied. To evaluate the performances of APRI score in prediction of severity of fibrosis in chronic genotype 1 hepatitis C based on a prospective study. We prospectively include patients with chronic genotype 1 hepatitis C and positive viral load. Hepatic biopsy was performed in all included patients and abnormalities were classified according to METAVIR classification. In all patients, APRI score was calculated based on biochemical data collected within the 15 days before hepatic biopsy. We studied 140 patients [46 men, mean age 48.4 years [20 - 65 years]]. Mean APRI score was 0.89 [0.18 - 3.72]. Statistically significant correlation was observed between APRI score and fibrosis severity [r = 0.31 p < 0.0001]. APRI score was higher in patients with severe fibrosis [F2, F3 or F4] compared to patients with moderate fibrosis [F0 or F1] [0.97 + 0.68 vs 0.62 + 0.44; p 0.009]. Threshold value of APRI score of 0.72 was associated with area under the curve of 0.65 + 0.05 [0.57 - 0.73], sensitivity of 56.3% and specificity of 75.8% in prediction of severe fibrosis. APRI score was also higher in patients with cirrhosis [1.24 + 0.79 vs 0.85 + 0.61; p = 0.01]. Threshold value of 0.86 was associated with area under the curve of 0.69 + 0.07 [0.61 - 0.77], sensitivity of 76.4% and specificity of 65.8% in prediction of cirrhosis. APRI score is not a good alternative to hepatic biopsy although a strong correlation with fibrosis severity, because of relatively low area under the curve, sensitivity and specificity in prediction of severe fibrosis and cirrhosis

[24-hour esophageal impedance-pH monitoring: technical aspects, indications and results]

Classical techniques like endoscopy and esophageal pH-metry are the gold standard to study patients with symptoms related to gastroesophageal reflux disease. Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical gastroesophageal reflux disease symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. To precise the technical aspects of the esophageal impedancepH monitoring, indications and results of this technique in clinical practice. Literature revue of the esophageal impedance - pH monitoring. Combined multichannel intraluminal impedance and pH monitoring is a new technique that can be used to evaluate both bolus transport and all types of reflux [acid, weakly acidic and weakly alkaline], without radiation hazards. With this technique, higher rates of sensitivity and specificity than standard techniques are obtained in the diagnosis of pathological gastroesophageal reflux. The technique has also been used in the evaluation of atypical gastroesophageal reflux symptoms, in the assessment of the association of different patterns of reflux with symptoms, and in the evaluation of therapeutic outcome mainly in patients with refractory gastroesophageal reflux disease. The esophageal impedance represents real progress in understanding the different mechanisms involved in the pathophysiology of gastroesophageal reflux. This technique should also allow a better understanding of the responsibility of non-acid reflux in special clinical situations, such as patients resistant to antisecretory or extra-intestinal manifestations of gastroesophageal reflux

[A new clinical entity: Post-infectious irritable bowel syndrome]

Post-infectious irritable bowel syndrome [PI-IBS] is a disorder wherein symptoms of IBS begin after an episode of acute gastroenteritis. To determine epidemiology, clinical features and prognosis of PI-IBS and to precise its physiopathology and treatment. Literature review. Published studies have reported an incidence of PI-IBS ranging from 4 to 32% with a mean of 10%. Bacterial infections are the most responsible agents. Risk factors for PI-IBS include patient's demographics, psychological disorders and the severity of enteric illness. The most common symptoms are those of diarrheapredominant IBS. The mechanisms underlying PI-IBS include especially changes in intestinal permeability and persistent mucosal inflammatory process. In fact, there is increase in lymphocytic, mast and enterochromaffin cells in the gut mucosa. Furthermore, increased inflammatory cytokines have been demonstrated. Treatment of PIIBS is similar to that idiopathic IBS. PI-IBS is a novel clinic entity that suggests a novel approaches to IBS

[Evaluation of small bowel involvement in Croh'ns disease by small-bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowell radiography]

Small-bowel videocapsule endoscopy [VCE] is a new technique in evaluation of intestinal involvement in several pathologies. Crohn's disease affects principally terminal ileum.Small bowel involvement in Crohn's disease is not well estimated by endoscopic and radiologic conventional techniques. To evaluate the performances of VCE in detection of asymptomatic proximal small bowel lesions in consecutive patients with Crohn's disease with terminal ileal involvement, to compare the results of VCE to small bowel radiography and CT-enteroclysis and to determine the therapeutic impact of VCE in these patients. A prospective study which included Crohn's disease patients with distal ileal involvement, based on radiological or endoscopic findings. We performed in all patients small bowel radiography, CT enteroclysis and VCE. Proximal involvement was characterized by presence of aphtoid, superficial or deep ulcerations in the jejunum or the proximal ileum. We studied 20 patients [12 men, mean age 31.6 years]. VCE confirmed the distal ileal involvement in all patients. Significative proximal lesions was observed in nine patients [jejunum only: one case, jejunum and ileum: six cases and proximal ileum: two cases], in most cases aphtoid or superficial lesions. Deep ulcerations were observed in two patients. Small bowel radiography showed proximal ileal lesions in only two patients, and CT-enteroclysis in only one patient. Treatment by azathioprine was prescribed in two patients with severe and extended small bowel lesions in VCE examination. VCE is more accurate than radiologic techniques in detection of small bowel lesions in Crohn's disease. In cases of severe and extended small bowel involvement, VCE can conduct to changes of therapeutic approach

[Management of failure of infliximab in inflammatory bowel disease]

Infliximab is a chimeric monoclonal anti TNF alpha whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options. Literature review. The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNF alpha, a relay by adalinumab or certolizumab may be proposed. The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed

[Long tem evolution of corticodependant and corticoresistant Crohn's disease patients treated by azzathioprine]

Immunosupressors, particularly azathioprine, represents the therapeutic alternative in patients with corticodependant or corticoresistant Crohn's disease. The prescription of azathioprine in Tunisia is common, but there is not Tunisian studies evaluating the long term results of this drug in Crohn's disease patients. To evaluate the long term results of azathioprine treatment with determination of rates of relapses, surgery and need to corticosteroids in patients with corticodependant or corticoresistant Crohn's disease, and to look for predictive factors to theses events. A retrospective study on 12 years including all patients treated by azathioprine for corticodependant or corticoresistant Crohn's disease. We excluded the cases of follow up less than 6 months. We studied 56 patients [46 corticodependant and 10 corticoresistant]. Induction of remission was obtained in 89% of the cases. Concerning the long term results, the relapse rate was 60% of patients treated with azathioprine, with actuarial rates of 38% at one year, 65% at 5 years and 75% at 10 years. Need for corticosteroid treatment was estimated at 42% and need for surgical treatment was estimated at 24%. The only predictive factor for relapse was duration of treatment by azathioprine more than 36 months, with sensitivity of 93% and specificity of 50%.Although an excellent result of azathioprine in induction remission, long term results showed deterioration of results of treatment. Physicians must be followed up Crohn's disease patients in order to rapidly detect and treat the clinical relapses of the disease

[Long-term functional outcome of laparoscopic and reflux surgery]

Medical treatment of gastro esophageal reflux is associated with relapse in 30% of cases. In these patients, the best therapeutic option is surgical treatment, performed laparoscopically. However, there are few data on long-term functional outcome. To determine long-term results of laparoscopic antireflux surgery the mechanisms involved in patients with worse results. We studied patients operated for reflux disease. They had either total or partial laparoscopic fundoplication. These patients were contacted to assess postoperative improvement, satisfaction and asked about the occurrence or not of a persistent postoperative dysphagia. Seventy one patients were included [Nissen in 61% of the cases and Toupet in 39%]. After an average period of 52.4 months,80% of patients were satisfied. 58% were completely improved,while 31% were partially improved after surgery. Persistent reflux symptoms reflux were observed in 8 patients and postoperative dysphagia was reported by 11 patients. Gastroesophageal reflux revealed by chronic cough was the only independent parameter associated with bad functional results in our patients. Laparoscopic anti reflux surgery is associated with a high frequency of satisfaction. However, patients with chronic cough respond less better to surgery. Strict selection of the patients before surgery must be done, to improve the functional results after anti reflux surgery

[Technical aspects, indications and results of small bowel videocapsule endoscopy]

Videocapsule endoscopy is a new non-invasive endoscopic toll useful for small bowel examination. The aims of this review are to precise the technical aspects of videocapsule endoscopy, indications and results of this technique in clinical practice. Literature review. The main indication of videocapsule endoscopy is obscure gastrointestinal bleeding. Videocapsule endoscopy can precise the aetiology of the bleeding and guide the therapeutic approach. The second indication is Crohn's disease, in establishment of the diagnosis, evaluation of small bowel extension or in differential diagnosis of indeterminate colitis. Videocapsule endoscopy is also useful in patients with small bowel neoplasia, polyposis and some patients with celiac sprue. Videocapsule endoscopy is an important endoscopic technique which is must by quickly part of endoscopic diagnosis tools

[Fertility and inflammatory bowel diseases]

Data concerning fertility during inflammatory bowel disease are insufficient and sometimes contradictory. The aims of this review are to precise the impact of inflammatory bowel disease on fertility. Literature review. The risk of infertility seems to be raised at one under group of patients and made to intervene several factors of which, in particular for the Crohn's disease, the activity of the disease and the psychological impact leads by this chronic disorder. The decrease of the fertility, as very feminine as male, during the ulcerative colitis is essentially bound to the surgery. Data concerning the impact of various therapeutic used during inflammatory bowel disease on the fertility are very insufficient and interest especially male fertility

[Difficulty in diagnosing pseudotumoral autoimmune pancreatitis: two original cases]

In recent years, autoimmune pancreatitis [AIP] has been increasingly recognized. The diagnosis of AIP is based on a series of clinical, biological and radiological criteria. In imaging, it may appear as two different forms: a diffuse form by destroying channels and pseudotumoral lesions that can cause inadequate resections. To report two new cases of pseudotumoral autoimmune pancreatitis. We report two cases of pseudotumoral autoimmune pancreatitis, with different clinical, biological and radiologic features.The diagnosis was established easily in one case and after surgery in a 2nd case. Our two cases underline the difficulties still encountered in the diagnosis of AIP