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

[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

[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

[Biliary stent occlusion]

Endoscopic stent insertion is as a method of choice for palliative treatment of malignant biliary strictures. Two types of biliary stent were actually used plastic and metallic self-expandable. Occlusion of the stent can be observed in both. To assess the management of biliary stent occlusion. From january 2006 to december 2007, 120 biliary stents were inserted in 97 patients. Indications of biliary stents were malignant stricture in 67%of cases. Biliary stern occlusion was defined by necessity of stent replacement. 118 plastic and 2 metallic self-expandable biliary stents were inserted. Obstruction of the biliary stent was observed in 12 patients, after a mean time of 5,5 months [1-15]. A recurrent biliary desobstruction was necessary in 6 patients. Stent exchange was realised in 33,3%of cases for malignant biliary stenosis and in 66,6%for benign stricture [p=0, 01]. Obstruction of the steot was symptomatic [cholangitis, jaundice] in more of 50%of cases. Management consisted on the stent exchange by a new plastic stent for clogging plastic stent and on insertion of plastic stent inside the metallic one for the occluded metallic stent. Obstruction can occur for the two types of biliary stent. Survival of the patient, cost of the stent guide the choice of the stent will be used

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

[Psoas abscess as the inital manifestation of crohn's disease, report of 30 cases]

Psoas abcess complicating Crohn's disease is a rare condition. Diagnosis remains difficult, especially when it is the first sign of Crohn's disease. We report here 3 patients presenting with psoas abcess as the initial manifestation of the disease, among 118 patients with Crohn's disease seen between 1990 and 2006. Symptoms and signs were fever, lower abdominal quadrant pain or tenderness and psoitis. Diagnosis was confirmed in all cases by computed axial tomography. In 2 cases, psoas abcess secondary to a periappendicular abcess or f colonic neoplasm were suspected, and the etiology was made correctly only after operation. Effective therapy included antibiotics, drainage and bowel resection

[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

[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

[Prospective study of 420 biopsies realised in patients with duodenal ulcer with positive Helcobacter pylori]

It's a prospective study leaded between September 1997 and July 1999 [23 months] in 75 patients with duodenal ulcer and positif for Helicobacter pylori. All patients had a first endoscopy with antral, fundic and duodenal biopsies, followed one months later by a second control fibroscopy with biopsies of the same sites. A total of 420 biopsies was realized. Chronic gastritis was evaluated according to sydney system. Patients was divided by randomization in 4 groups. Every group was received a different therapeutic association. The results was conform to liberation concerning activity 80%, intestinal metaplasia 12%, inflammation 100%. Atrophy was observed in 56% of cases, this percentage is variable in literature; chronic gastritis was predominant in antre relatively to fundus [p< 0.005]. After treatment, a significative fall of Helicobacter pylori and activity and atrophy was established, contrariety to intestinal metaplasia and chronic inflammation witch are persisted. The prevalence of follicular gastritis was 57%. The better rate of ulcer cicatrisation and Helicobacter pylori eradication was respectively of 79% and 66% in group 1 treated by omeprazol, amoxicillin, metronidazol by comparison with the others 3 groups [p< 0.005]

Traitement endoscopique de la lithiase residuelle a propos de 661 cas

Endoscopic sphincterotomy is a well-established procedure for treating choledocolithiasis and particularly residual lithiasis. The aim of this study is to expose our experience with this method and to evaluate its safety and efficacy. It is a retrospectively collected series of 661 patients with residual choledocolithiasis. Endoscopic retrograde cholangio-pancreatographies were performed in 651 patients [98.5%]. Standard sphincterotomy was realized in 633 patients [95%] and a pre-cut technique was done in 15 [2%]. Bile duct clearance was achieved in 583 cases [91%]. Overall, the complication rate of sphincterotomy was about 8.4%. Endoscopic sphincterotomy is a safe and effective procedure for patients with residual choledocolithiasis

[Gastrointestinal angiodysplasia: about 54 cases]

Angiodysplasia is an arteriovenous malformation which can reach the entire gastrointestinal tract and especially the colon. Its management is often difficult. The aim of this study was to assess the clinical, topographic and therapeutic characteristics of angiodysplasia. It is a retrospective study including 54 cases of GI angiodysplasia collected over 13 years. The mean age was 62 years: 66% were males. Angiodysplastic lesions were predominantly located in the colon [85%]. Nine patients required an endoscopic treatment. Electrocoagulation was used in 8 cases and a sclerotherapy in 1 case Surgical resection was necessary in 2 patients which died of the after-effects of surgery.: angiodysplasia is a common etiology of chronic lower 61 bleeding particularly in the elderly

[Gastrointhstinal stromal tumors. a study of 5 cases]

G1 stromal tumors are mesenchymatal tumors arising primarily from the digestive tract or from the omentum. Despite their rarity [less than I% of digestive tumors]. These tumors have become of current interest since the discovery of a treatment for metastatic and locally advanced tumors, the imatinib [Glivecr]. In this study we report 5 cases of stromal tumors. Patients were 42 years old an average. Abdominal mass was the revealing signal in 80% of cases, localisation was obtained by endoscopy and ultrasonography in 60% cases. Total resection of the tumor was performed in all patients. Immuno-histochemical examination confirmed the diagnosis of stromal tumors. Based on these cases and on a review of literature, we insist on the diagnostic difficulties of this rare pathology, while trying to determine the histological prognostic parameters and the latest therapeutic methods

[Cholangitis reveling an intrahepatic Osler's disease]

Osler Weber Rendu Disease is a hereditary haemorrhagic telangectasia habitually revealed by reccurent bleeding [epistaxis]. Hepatic involvement in Osler disease is found in 8 to 31%, manifested by cholestasis. We report an original observation of a cholangitis revealing Osler disease