[Clinicobiological and morphological profiles of primary sclerosing cholangitis in Tunisia]

Primary sclerosing cholangitis [PSC] is a chronic cholestatic disease strongly associated, in the western series, to inflammatory bowel disease [IBD] and particularly to chronic ulcerative colitis. North African data are rare. To study the epidemiological, clinicobiological and morphological profile of PSC in Tunisia. A retrospective multicenter study extended over a period of 14 years [1995-2009], including all patients suffering from PSC, hospitalized in the four participants departments. We collected epidemiological, clinico-biological, histopathologic and morphological data for each patient. We brought together 33 patients [22 men and 11 women], middle aged 44 years. The disease was symptomatic in 73% of cases. Laboratory tests showed cholestasis [100%] associated with hyperbilirubinemia [72%] and a moderate cytolysis [78%]. Morphological analysis of bile ducts by cholangioMRI or endoscopic retrograde cholangio-pancreatography objectified diffuse damage of the biliary tract in 61% of cases. Association with IBD was found in 33% of cases [Crohn's Disease: 27%, chronic ulcerative colitis: 6%]. An association with autoimmune hepatitis was found in 6% of cases and primary biliary cirrhosis in 3% of cases. PSC is rare in Tunisia and affects men more often than women. The association with IBD is less frequent than in literature. It concerns essentially Crohn's disease. These data require confirmation by prospective multicenter studies

Variceal band ligation in the prevention of variceal bleeding: a multicenter trial

Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients [30 had bleeding esophageal ulcers]. Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed

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

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. To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. 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 >/= 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. 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]. 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

[Retained common bile duct stones after endoscopic sphincterotomy temperary and longtern treatment with biliary stenting]

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. To prospectively analyse the usefulness of a stenting in management of biliary obstruction due to choledocolithiasis. 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. 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. 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

[Clincopathologic characteristics of low grade primary gastric non-Hodgkin's lymphomas: experience from a single center]

To report the clinicopathological data and the treatment outcomes in patients with primary gastric low grade non-Hodgkin's lymphoma. We carried out a retrospective analysis of 16 consecutive patients [median age 46 and range 28-75 years] who presented to our department with histopathological diagnosis of primary gastric low grade non-Hodgkin's lymphoma. We analyzed clinical manifestations, endoscopic features, pathological features,Helicobacter pylori infection and treatment. Common symptoms included abdominal pain [87.5%],vomiting [62.5%], and gastrointestinal bleeding [25%]. Endoscopic appearances were mainly ulcers and ulcerations [93.75%].Endoscopic biopsy confirmation rate reached 87.5% when biopsies were repeated. Helicobacter pylori detection rate was 75%. A total of 9 patients received surgeries. Three patients had chemotherapy and 8 patients had Helicobacter pylori eradication therapy. The range of follow-up was 2-74 months with a median of 27 months. A complete remission was obtained in 12 cases, whereas 1 patient died and 3 were lost of view. Eradication therapy may be offered as an initial treatment option in patients with low-grade gastric lymphoma

[Survival in patients with gastric lymphoma]

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. To establish prognostic factors that should be considered for the staging and management of this disease. Clinical data of 40 pathologically confirmed gastric lymphoma patients, treated during a period of 13 years, were analyzed. 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. 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

[Steatosis in chronic hepatitis C: prevalence and predictive factors]

Patients with hepatitis C virus seem to often have hepatic steatosis. To assess the prevalence and the predictive factors of steatosis during chronic hepatitis C. 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. On liver biopsy, 28 patients [56%] had steatosis. Multivariante analysis showed that steatosis was associated with age 58 years > 1,1 micro mol/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. In this study, steatosis was significantly associated with metabolic factors

[Survival in cirrhosis]

Assessment of prognosis in patients with cirrhosis is important so as to plan their management. To determine the survival rates and to identify indicators associated with shorter life expectancy in Tunisians patients with cirrhosis. This is a retrospective study of in-patients with cirrhosis during a 5-years period. We studied clinical and biochemical characteristics of all patients and the occurrence of decompensation or complication. 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. We studied 222 patients [60% females] with a mean age of 60 years. Mean follow up was 22 months. The overall survival was 52,5% at 5 years. With univariate analysis, 10 variables were associated with a poor prognosis: male gender, decompensation at admission, Child-Pugh C, esophageal varices, hypertensive gastropathy, occurrence of spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome, hepatocellular carcinoma and portal thrombosis. With multivariate analysis, only male gender was independently correlated with survival. In our study, male gender was an uncommon parameter that predicts survival in cirrhotic patient. The Child-Pugh score was a good index for assessing the prognosis

[Plummer-Vinson syndrome]

Plummer - Vinxon 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. The purpose of this study is to precise epidemiological, clinical, paraclinical and therapeutic features of the affection. 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. 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. 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

Ciclosporin for severe refractory colitis

Intravenous Ciclosporin is a promising alternative, rapidly effective, for patients with severe steroid-refractory colitis previously facing only surgical options, however its use is controversial because of the frequency of adverse effects and the doubt about the long-term response. This review will provide information on clinical pharmacology, clinical indications for use, methods of dose adjustment, monitoring of metabolites for efficacy and for potential side effects and the adverse event profile of ciclosporin in severe refractory colitis. Literature review. Toxicity is dominated by opportunistic infections. Renal and neurotoxicity are also recognized. Risks of toxicity can be reduced by using lower doses, by oral microemulsion or by monotherapy without corticosteroids. The drug should not be continued for more than 3 to 6 months. As a bridge to other maintenance therapy such as azathioprine or 6-mercaptopurine ciclosporin can be an effective treatment. CSA is a viable alternative to emergency colectomy in severe UC in the short term. Although these benefits are not maintained in all patients, more than a half will also avoid colectomy in the longer term. Careful selection and monitoring of patients, use of lower doses, and oral therapy will help to reduce side effects

Management of the hepatocellular carcinoma

The hepatocellular carcinoma, is detected sooner due to the progress of the hepatic ultrasound scan allowing an accessibitity to curative treatment. This cancer treatment still remains difficult in Tunisia. To show the difficulties in the management of the hepatocellular carcinoma in Tunisia Patients hospitalized in the gastrocnterology 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. 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]. Regardless of the improvement of diagnostic and therapeutic means, 17.5%of our patients having a hepatocellular carcinoma were subjected to a curative treatment. Au additional effort must be unfolded

[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

[Digestive epilepsy: think about, before surgery]

Digestive epilepsy is a vegetative comitial at the origin of abdominal pain that can dress a variety of clinical pictures returning its diagnosis difficult. Gastroenterologists and abdominal surgeons poorly recognize this entity to determine clinical characteristics of digestive epilepsy and its therapeutic modalities. Patient and method: We report the particular case of an epileptic 36-year-old patient who came in emergency twice in a pseudo-surgical abdominal picture having brought to a laparotomy. The diagnosis of digestive epilepsy was carried in front of a beam of clinical arguments and the negativity of explorations. An anti-convulsive treatment allowed the decline of the symptomatology digestive epilepsy can be presented as a pseudo-surgical abdominal picture, so it is important to think about before surgery when there is a stereotyped symptomatology and whether the diagnosis of epilepsy is known or not

[Hepatic steatosis in chronic hepatitis B: contributing factors and effect on fibrosis]

To determine factors that contribute to the steatosis's formation in chronic hepatitis B, to evaluate its influence on the development of hepatic fibrosis and to research aim eventual relation to virologic factors in a Tunisian cohort of patients. All patients with chronic hepatitis B confirmed by data of liver biopsy were included in this study, which was enrolled from 1990 to 2006. The studied parameters were: age, gender, body mass index, transaminases, cholesterol, triglycerides. glycaemia and DNA rate, status HBe antigen and the degree of activity and histological fibrosis was estimated according to the score of METAVIR. Fifteen patients [34.1%] among the 44 patients includes in this study had hepatic steatosis; that was mild in 10 patients [66.6%], moderate in 3 cases [20%] and severe in 2 patients [13.4]. The antigen HBe was negative in 27 patients [62.22%.] The mean age of the patients having a steatosis was of 32.33 years versus 27.75 years for those who had no it [p=0.185]. The transaminases rate was superior in patients with steatosis than those without, the difference was not significant. Univariate correlation between predictor variables was studied. Significant predictors to steatosis included body mass index [p=0.011] and cholesterol [p=0.037]. HBe Ag status was not associated with steatosis. Neither activity nor fibrosis was correlated with steatosis. In Tunisian patients, factors contributing to the formation of steatosis during the chronic hepatitis B were the body mass index and the rate of cholesterol. The steatosis did not seem to have an influence on the development of the hepatic fibrosis and seems to be independent on the viral effect

[Surveillance for hepatocellular carcinoma: does it work?]

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 aggressive 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]

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 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 gammGT and gammaglobulin are uncommon parameters that may predict survival in cirrhotic patient. The Child-Pugh score was a good index for assessing the prognosis