[Epidemiology of hepatitis C in Tunisia]

Hepatitis C virus [HCV] infection is one of the main causes of chronic liver disease worldwide. To describe epidemiological patterns of hepatitis C in Tunisia. Literature review. In Tunisia, the prevalence of HCV infection is about 0, 7 % in the general population with an increased transmission in the north of the country. Genotype 1b is the most frequent [76 % - 88 %]

Colonoscopy in elderly: feasibility, tolerance and indications: about 901 cases

Colonoscopy is the standard investigation for colonic disease, but clinicians often are reluctant to refer elderly patients for colonoscopy because of a perception of higher risk and a high rate of incomplete examinations. To evaluate feasibility and tolerance of this investigation in elderly and to review the most frequent indications of colonoscopy in these patients. A pilot retrospective study including 901 patients from January 2005 to December 2009; divided into two groups. Group [I] included patients 75 years old and more, group [II] included patients 45 years old or less. All those patients underwent colonoscopy at the gastroenterology department of Charles Nicole hospital. The 1st group included 231 patients, and the 2nd group included 670 one. A past history of colorectal cancer was more frequent in the group I [33.3% versus 9.90%; p<0.05] however history of chronic inflammatory bowel disease was more frequent in group II [0 versus 40.6%; p<0.05]. The main indication of colonoscopy was constipation in group II [6.1% versus 27%; p<0.05] and chronic diarrhoea in group I [42.9% versus 16.4%; p<0.05]. Bowel preparation was poor in 30.4% cases of the group I and 12.9% of group II [p<0.05]. The tolerance was similar in the two groups. The incomplete colonoscopy rate was higher in the group I [38.3% versus 23.4%; p<0.05]. The most frequent cause of colonoscopy interruption was the poor preparation in group I and the bad tolerance in group II. Diverticular disease, polyps and colorectal cancers prevailed in group I, whereas inflammatory bowel disease was current in group II. In elderly patients, colonoscopy is safe, well tolerated and offers a good diagnostic yield. Its non completion was essentially due to the poor preparation. Sedation did not seem essential. The optimisation of results of colonoscopy requires an improvement of quality preparation

[Prevalence and risk factors of thromboembolic complications in inflammatory bowel disease]

Patients with inflammatory bowel disease [IBD] are at increased risk of thromboembolic complications [TEC], which represent an important cause of morbidity and mortality. To assess the prevalence and risk factors of TEC in patients with IBD. We conducted a retrospective study including all the IBD patients in the gastroenterological department of Charles Nicolle hospital between 2000 and 2010. Only thromboembolic events that had been diagnosed by an imaging procedure were counted. A total of 266 patients with IBD were consecutively included. TE events occurred in nine patients [3.4%]; six men and three women. Their mean age was 31years [15-64 years]. Five patients had Crohn's disease and four had ulcerative colitis. The types of TEC were deep venous thrombosis of the leg in five cases with pulmonary embolism in one of them, cerebral venous thrombosis in two cases, portal thrombosis in one case and jugular vein thrombosis in one case. Active disease was present in all cases at the time TEC occurred. In our study, the prevalence of TEC is 3.4% in patients with IBD. Deep venous thromboses of the leg are the most common TEC and all our cases occurs during the active phase of IBD

[Correlation between liver biopsy and fibrotest in the evaluation of hepatic fibrosis in patients with chronic hepatitis C]

To assess the diagnosis value of Fibrotest in comparison with liver biopsy, for the evaluation of hepatic fibrosis in patients with chronic hepatitis C. This prospective study included in 2 years [2006-2007], consecutive patients with chronic hepatitis C native to treatment. Fibrotest and liver biopsy were performed. Receiver operating characteristics [ROC] curves, the sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic value of Fibrotest in comparison with the METAVIR classification. We recruited a total of 65 patients: 28 males and 37 females [mean age: 50 years]; 92% of the patients had genotype 1. The histological fibrosis results were: 3. 1% F0; 24. 6% Fl; 32. 3%F2; 29. 2%F3 and 10.8%F4. The diagnostic value of Fibrotest in the detection of significant fibrosis [F2-F4] was 0.87. A score >0.5 has a sensitivity of 85.1%, a specificity of 72.2%, a positive predictive value of 88. 9%, and a negative predictive value of 65%. The diagnostic value of Fibrotest in the detection of cirrhosis [F4] was0.85. There were 13/65 cases of discordance [20%] for fibrosis, 4 cases were attributed to biopsy and 6 cases to Fibrotest. The discordance was unexplained in 3 cases. The size of biopsy<15mm [OR=2. 82, 95% CI, 1.3-6.07; p=0.008] and the stage of fibrosis F0, F1, F2 [OR= 3.35, 95% CI, 1.1-10.2; p=0.03] were considered as risk factors of discordance in multivariate analysis. This prospective study confirmed the good diagnostic value of Fibrotest as compared with the histological analysis of liver biopsy

[Auto immune hepatitis type 1 triggered by cytomegalovirus infection]

Autoimmune hepatitis is chronic and uncommon disease. The pathogenesis is a complex process. Several triggers for autoimmunity in predisposed individuals. Report a new case. We report a case of 17-year-woman presented with autoimmune triggered by cytomegalovirus infection. Cytomegalovirus induced autoimmune hepatitis has not been reported previously. Evolution was favourable under antiviral treatment, corticosteroid and azathioprine

Hepatocellular carcinoma with sarcomatous change

Hepatocellular carcinoma [HCC] with sarcomatous change is an uncommon neoplasm with a poor prognosis. To report a new case. A 72-year-old man presented with abdominal right upper quadrant pain. The diagnosis of cirrhosis was suspected on clinical and biochemical data. On abdominal computed tomography, the mass was not enhanced in the arterial phase and exhibited peripheral enhancement during portal phase which persisted in the delayed phase. The serum alpha-fetoprotein was 500 ng/ml but since the imaging features were not typical of ordinary HCC, percutaneous liver biopsy was performed and confirmed the diagnosis of HCC with sarcomatous change. Except for liver biopsy, no diagnostic method could distinguish between sarcomatous and ordinary HCC

Evaluation of nutritional status in patients with liver cirrhosis

Malnutrition is a frequently reported complication in patients with liver cirrhosis. It has a high clinical and economic impact reflected by an increased morbidity and prolonged hospital stay. This preliminary prospective study aimed to determine the prevalence of malnutrition in hospitalized cirrhotic patients and to investigate whether biological and anthropometric parameters are a valuable tool for identifying malnutrition in these patients. The nutritional status of 44 consecutive cirrhotic patients [21 men, 23 women] was assessed according to the anthropometric measurements and biochemical analysis. The diagnosis of malnutrition was based on diminished values of Mid arm muscle circumference [MAMC] and/or Triceps skinfold thikness [TST] below the 5th percentile or less than 60%. The aetiology of cirrhosis was viral hepatitis in 29 patients [66%]. Cirrhosis was classified Child Pugh A, B or C in respectively 9, 26 and 9 patients; 37 patients [84%] have mild or tense ascite. In this study, malnutrition was found in 35 patients [79.5%], whereas 9 patients has a good nutritional status. TST and MAMC less than 60%was found in respectively 72%and 25%of patients. No significant statistical difference in epidemiological characteristics was found between malnourished and well-nourished patients. TST and MAMC decreased significantly according to the Child score [p=0.014 and 0.032 respectively; a positive correlation was found between these two paramelers and the severity of cirrhosis. In this study, the high prevalence of denutrition was associated with the severity of cirrhosis. Anthropometric parameters are valuable tools for malnutrition diagnosis

[Association Budd Chiari syndrome, antiphospholipid syndrome and Grave's disease]

Antiphospholipid syndrome is revealed by Budd Chiari syndrome in 5% of the cases. Antiphospholipid syndrome is characterized by venous or arterial thrombosis, foetal loss and positivity of antiphospholipid antibodies, namely lupus anticoagulant, anticardiolipin antibodies and anti-beta2-glycoprotein I. Anticardiolipin antibodies was reported in auto-immune thyroid disorders, particularly in Grave's disease. Antiphospholipid syndrom associated to Grave's disease was reported in only three cases. To describe a case report of association of Grave's disease and antiphospholipid syndrome. We report the first case of Grave's disease associated with antiphospholipid syndrome, revealed by Budd Chiari syndrome. Our observation is particular by the fact that it is about a patient presenting a Grave's disease associated with antiphospholipid syndrome revealed by Budd Chiari syndrome. This triple association has never been reported in literature. Although association between antiphospholipid syndrome and Grave's disease was previously described, further studies evaluating the coexistence of these two affections in the same patient would be useful

[Thrombosis in inflammatory bowel disease: mechanisms and risk factors]

Thromboembolic manifestations are frequent in patients with inflammatory bowel disease. To explaim the mechanisms of thromboembolic manifestations in inflammatory bowel disease. Literature review. Risk factors of thrombosis in inflammatory bowel disease are acquired or genetic. The most important factors are thrombocytosis, increased of activation of platelets and hyperhomocysteinemia. Other factors such factor V leiden, antithrombin III and antiphospholipid antibodies are observed in inflammatory bowel disease patients but not always correlated with thromboembolic manifestations. The mechanisms of thrombosis in inflammatory bowel disease are complex are intricate

[Endoscopic ultrasonography versus helical CT in diagnosis and staging of pancreatic cancer]

Compare the performances of EUS to helical CT in the diagnosis and staging of pancreatic adenocarcinoma. Forty two consecutive patients [mean age 63 years; 25 men, 17 women] who had surgical exploration and histologically proved pancreatic cancer were retrospectively included. All our patients underwent with endoscopic ultrasonography [EUS] and helical computed tomography [helical CT]. Data analysis compared helical CT, EUS with the surgical data with or without histological study in diagnosis, staging and resectability of pancreatic cancer. Surgical findings were used as gold standard. For positive diagnosis EUS was more sensitive 100% [CI:93-100] than helical CT 88% [CI:77-95]. But helical CT was more specific 89% [CI:64-98] than EUS 83% [CI:58-96] for small tumors whose diameter is below 2,5 cm in which EUS was more sensitive in their detection [100% versus 83%]. In evaluating venous involvement EUS was more sensitive than helical CT [96% versus 50%; p<0.05], while CT was more specific [81% versus 75%; p<0.05]. Regarding lymph nodes invasion, the two imaging technique had the same sensibility [56%] with better specificity for helical CT [83% versus 75%; p<0.05]. The accuracy of EUS in identifying the T and N stages were 80% and 67% respectively, while helical CT have an accuracy of 50% and 71% respectively. EUS and helical CT correctly identified all resectable tumors while EUS was more accurate than helical CT in detecting non resectable tumors 94% versus 69%.EUS remains superior to helical CT in positive diagnosis of pancreatic adenocarcinoma especially for small tumors and also for the diagnosis of venous invasion and in identifying non resectable tumors. The two techniques have the same accuracy in the detection of lymph node involvement

[Impact of esophageal manometry before anti-reflux surgery]

Esophageal hypomotility is frequent in patients with gastroesophageal reflux disease [GERD]. To precise the frequency and the patterns of esophageal manometric abnormalities in GERD patients referred before anti-reflux surgery, to determine the frequency of post-operative dysphagia and to look for associated factors with high risk of dysphagia, with special interest on pre-operative esophageal manometric study. We conducted a retrospective study based on patients having anti-reflux surgery and pre-operative esophageal manometry. Post-operative dysphagia was prospectively assessed during the follow-up. We studied 33 patients [mean age: 46 years; sex ratio: 0.4]. Pre-operative esophageal manometry was abnormal in 1/3 of cases, with a high prevalence of non specific motor disorders and hypomotility. Nor epidemiological, clinical or pH metric factor was associated with the risk of motor esophageal abnormalities. Post-operative dysphagia was noted in 21% of the cases, with any correlation with results of pre-operative manometry. Esophageal hypomotility is frequent in patients with GERD; and not associated with a higher risk of post-operative dysphagia after anti-reflux surgery

[Auto-immune serological disorders in chronic viral C hepatitis: Prevalence and clinical significance]

Hepatitis C viral [HCV] infection has been shown to lead to auto-immune phenomena. We review the prevalence of serological auto-immune disorders associated to HCV infection and to clarify their clinical significance. Literature review. The serological immune response to HCV infection may include the development of cryoglobulinemia, rheumatoid factor, anticardiolipin, antinuclear, anti-liver-kidney-microsome 1 and anti-smooth muscle antibodies. Serological auto-immune manifestations were explained by the lymphotropism of HCV and the polyclonal activation of B cells. Interferon-based treatment of HCV infection may precipitate or exacerbate the associated auto-immune disease. In patients with serological auto-immune disorders associated with HCV infection, a very careful analysis of clinical and biological features is needed. Application of classification criteria of systemic auto-immune diseases and testing more specific antibodies can resolve this point