[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

[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

[Autoimmune hepatitis in Tunisia. Retrospective multicentric study about 83 cases]

Autoimmune hepatitis [AIH] is a chronic inflammatory condition of the liver of unknown etiology. Its epidemiological and anatomoclinical characteristics and its outcome were unknown in Tunisia. To analyse epidemiological, anatomoclinical, immunological and histological aspects of AIH and to determine factors predicting relapse after treatment and death of this disease in Tunisia. Patients presenting with AIH between January 1996 and December 2004 were evaluated in retrospective multicentric study. The diagnosis of AIH was established according to the criteria of the revised score of the international autoimmune hepatitis group [1999].Eighty three patients were identified [70 female; mean age = 49 + 17,9 years]. 63% presented probable AIH and 5% of cases were type II HAI. Fifty seven percent of the patients were cirrhotic at presentation. Associated autoimmune diseases was seen in 27 patients, dominated by diabetes, autoimmune thyroiditis and SjOgren's syndrome. An overlap syndrome was diagnosed in 25% of cases; primary biliary Cirrhosis-AIH in 20% of cases and primary sclerosing cholangitis-AIH in 5% of cases. Fifty patients were treated by glucocorticoids as monotherapy or in combination with azathioprine. Complete remission was achieved in 90% of cases. Fourteen percent relapsed within a median time of 12 months. Factors associated with relapse were: treatment with Azathioprine <18 months, absence of lobular necrosis and anti-nuclear antibody [+] profile. Mortality was observed in 17% of cases. Factors associated with death were encephalopathy as an independent factor and treatment with Azathioprine <18 months. In Tunisia, epidemiological and clinical characteristics of AIH were similar to those reported in the literature but with a higher frequency of cirrhosis at presentation. Treatment with Azathioprine <18 months was the main factor associated with relapse and represented with encephalopathy a factor associated with death

Inhibiteurus selectifs de la cyclo-oxygenase-2 et tube digestif

The use of non steroidal anti-inflammatory drugs [NSAIDS] is tempered by the development of side effects primarily in the gastro-intestinal tract. These effects result mainly from inhibition of the enzyme cyclo-oxygenase [COX]-1. Two NSAIDS [celecoxib and rofecoxib] COX-2 specific inhibitors had considerably lower ulcerogenic rates and lower serious gastro intestinal side effects when compared with other NSAIDs used in rhumatoid arthritis and osteoarthritis. However, the exact place of COX-2 specific inhibitors remain to be determined as compared with the association of other NSAIDs and proton pump inhibitors in the elderly. The efficacy of COX-2 specific inhibitors in digestive tumors is still unclear