Microbiological study and antimicrobial susceptibility of bile in biliary therapeutic endoscopy

Background: Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The reported incidence of infectious complications may reach up to 10%. Nevertheless, no antibiotic prophylaxis is administered routinely, prior to endoscopic therapeutic procedures

Aim: To investigate the presence and degree of biliary bacterial colonization during endoscopic retrograde cholangiopancreatography [ERCP] in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient.

Methods:Forty-four patients with biliary obstruction who underwent an ERCP with biliary drainage were prospectively included. The primary indication of ERCP was choledocholithiasis [48%], followed by benign biliary strictures [32%] and malignant bile duct obstruction [18%]. Bile cultures were obtained by means of bile aspiration via the cannulation catheter. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for different antibiotics was performed

Results: The overall positive rate of bile culture was 93%. The organisms cultured were Escherichia coli [26.8%], Enterococcus [17%], Klebsiella [14.6%], Enterobacter [14.6%] and Pseudomonas [9.7%] in decreasing order. In-vitro testing of different antibiotics was carried out in these 41 isolates. Imipenem showed the best antimicrobial activity [sensitivity, 100%], followed by colistin [94%], tobramycin [93%], amikacin [89.6%], gentamycin [85.2%] and ceftazidin [82%]. Amoxicillin/clavulanic acid and ofloxacin were less sensitive [66% and 60% respectively]. Ceftazidin was the most effective antibiotic on Escherichia coli [sensitivity 83%]. Multi-resistant organisms were noted in 22% of the cases

Conclusions: Escherichia coli was found to be the pathogen most frequently detected in bile following endoscopic interventions in the biliary tract. Enterococci and Klebsiella were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, amoxicillin/clavulanic acid or quinolons are not suitable antibiotics for the prophylaxis of biliary infections. Moreover, Gram-positive bacteria such as Enterococcus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials

Hypogammaglobulinemia associated with nodular lymphoid hyperplasia of the intestine and pernicious anaemia

Background: Nodular lymphoid hyperplasia of the gastrointestinal tract, recurrent acute pulmonary infections and autoimmune disease are well-recognized complications of common variable immunodeficiency

Aim: We aimed to focus on clinical presentation and differential diagnosis of diffuse nodular lymphoid and hyperplasia of the gastrointestinal tract coexisting with hypogammaglobulinemia

Case-report: We report the case of nodular lymphoid hyperplasia associated with pernicious anaemia in a young man with hypogammaglobulinemia and a long history of pulmonary infections

Conclusion: The considerable point was a mismatch primary clinical diagnosis of familial adenomatous polyposis, due to prominent polyplike endoscopic appearance of the lesions throughout the digestive tract

Epidemiological evolution of epidemiology of the inflammatory bowel diseases in a hospital of Tunis

The epidemiological studies showed that the incidence of the inflammatory bowel diseases describes a gradient North- South. Besides, concerning the evolution according to the time, recent studies noted an increase of the incidence of the Crohn's disease at the expense of the one of the ulcerative colitis. To determine the evolution of the epidemiology of the inflammatory bowel diseases across the time. The study included inpatients followed for Crohn's disease, ulcerative colitis and indeterminate colitis, in the department of gastroenterology of Habib Thameur hospital. For every patient were collected the sex, the age and the year of the diagnosis, the type of inflammatory bowel disease and the initial location. We compared the evolution of the frequency of the inflammatory bowel diseases, them type and their initial location according to 5 periods of 3 years. During this period, 202 cases of inflammatory bowel disease were diagnosed [55,5% of Crohn's disease, 41,5% of ulcerative colitis, 6% of indeterminate colitis]. For the first period, we noted 21 cases of inflammatory bowel disease, for the 5th period, we noted 43 cases. The frequency of the Crohn's disease passed from 8 cases in the 1[st] period to 23 cases in the 5th one. The frequency of the ulcerative colitis passed from 12 cases in the 1[st] period to 17 cases in the 5th one. The number of indeterminate colitis was 1 in the 1[st] period and 3 in the 5th one. These differences did not been significant. The distribution of initial locations of the Crohn's disease and the ulcerative colitis increased in a proportional manner for each period. The average age to the diagnosis was 32 years in the 1[st] period and 35 years in the 5th period and comparable whatever the inflammatory bowel disease type. Although we cannot amount the exact incidence, we noted an increase of the frequency of the inflammatory bowel diseases, with a more marked elevation for the Crohn's disease

[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

[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

[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