[Immunohistochemical analysis of mismatch repair proteins in colorectal adenomas]

The deficiency of mismatch repair system is one of the main pathways in colorectal cancer. This system consists mainly of four proteins: MLH1, MSH2, MSH6 and PMS2. Colorectal cancer develops in the majority of cases from precancerous lesions called adenomas. Only few studies have reported on the deficiencies of these proteins in adenomas. In this study we used immunohistochemistry staining in colorectal adenomas to assay functional status of MLH1, MSH2, MSH6, and PMS2 proteins. 102 adenomas from 93 patients were collected in our institution during six years [2007-2012]. The immunohistochemical technique was performed with 4 antibodies: MLH1, MSH2, MSH6 and PMS2. The loss of expression was retained if adenomatous cells were not stained with positive internal control. Staining was considered as abnormal if nucleus of adenomatous cells showed low nuclear staining and / or heterogeneous one, while positive internal control had normal staining. Loss of expression of MSH2 and MSH6 in adenomatous cells was found in only 1 case which was a tubular adenoma 3mm high-grade dysplasia. Abnormal staining of the adenomatous cells was noted in 23 cases [22.5%] for MSH2 and in 8 cases [7.8%] for MSH6. No cases showed loss of expression of MLH1 and PMS2. Abnormal expression of MSH2 and MSH6 was not correlated with sex of patients, the location of the adenoma, its grade of dysplasia and its histological type. Loss of Mismatch repair proteins expression is a rare event in adenomas. However, the abnormal expression levels are higher in our study compared to those reported in the literature. This could reflect a higher rate of microsatellite instability in our patients. Multicenter and larger studies with molecular biology techniques are needed

[Efficiency of endoscopic treatment with intra gastric balloon in severe to morbid obesity]

Obesity raises such a healthcare matter throughout the world. Its management is not only complex but also most often multidisciplinary. The medico-dietary treatment is of inconstant efficiency and the surgical treatment, though more efficient, presents a considerable morbidity-death rate. The endoscopic treatment through intra-gastric balloon avails a seducing alternative namely accounting for surgery preparation. To assess the efficiency of the endoscopic treatment through gastric balloon, both in the short and long term, and this is accounting for weight loss as well as tolerance. We have carried out a retrospective study including the patients suffering from severe to morbid obesity and who had a gastric balloon implemented in our Endoscopy Unit between November 2005 and December 2007. Twenty one patients were included. The average age was 32,19 +/- 12,65 years with extremes of 16 and 52 years. Fifteen patients suffered from morbid obesity. The patients' average weight was 134, 52 +/- 26,46 kg [extremes 88 and 194 kg]. Some co-morbidity was found out with 15 patients. Te balloon implementation [Héliosphère[registered sign]] was carried out with no incidents in all patients. Six months after the balloon implementation, the average weight loss was17,5% and the average loss of overweigh was 37%. In biological level, we noted a normalisation of fasting glycaemia in 28,6 % of cases, of the cholesterolemia in 100 %, of the triglyceridemia in 33,33%, of the uraemia in 42,8% and hepatic tests in 50 % of the cases. The metabolic syndrome disappeared in 28,57 % of cases. The assessment after a 5-year-period was marked by the need to surgical treatment in 4 patients and this is due to the loss of efficiency of endoscopic treatment. A bad tolerance of gastric balloon was observed in 34 % of the cases, dominated by sicknesses. Only one patient presented incoercible sicknesses with ionic troubles as well as deshydrating requiring the precocious extraction of the balloon after 48 hours of its implementation. The endoscopic treatment through intra gastric balloon is well tolerated but efficiently limited in time. It might be recommended in preparation for a surgical treatment or in case of contre- indication or surgery refusal

[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 %]

[Epidemiological, clinical and therapeutic features of hepatocellular carcinoma in cirrhotic patients]

Hepatocellular carcinoma [HCC] is the most frequent primitive hepatic tumor, the fifth most common cancer in the world, and the third highest cause of cancer-related mortality. The presence of cirrhosis is the main risk factor. To describe the epidemiological, clinical and therapeutic features of HCC. Retrospective study including all the patients with HCC occurring in cirrhotic liver followed in the gastroenterological department of Charles Nicolle hospital between 1997 and 2009. A hundred and one patient were enrolled; 64 men and 37 women with a median age of 65.4 years [31-88 years]. Cirrhosis was due to viral hepatitis B or C in 25.7% and 62.2% of cases respectively and was classified Child Pugh A, B and C in 30.7%, 50.5% and 18.8% of patients respectively. HCC was inaugural in most cases [68.3%] and it was revealed by a tumoral syndrome in 38.6% of cases, by decompensation in 22.7% and was discovered during systematic screening when cirrhosis was already known in 19.8% of cases. Diagnosis of HCC was non invasive, relying imaging and alphafetoprotein in most cases [95%].84 patients [83.2%] had and advanced HCC, with vascular or extra hepatic spread in 58 [57.5%] of them. Treatment was curative in 14 cases, based on surgical resection in one and percutaneous ablation in 13 cases. Six patients received transarterial chemoembolization as a palliative treatment. In 71 patients, only symptomatic treatment was given. The median survival time was 11 months. In the majority of the cases, HCC was diagnosed at an advanced stage and treatment was only symptomatic

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

[Nephrogenic ascites: an exceptional diagnosis. about one case]

Nephrogenic ascites is a clinical entity that manifests as refractory and exsudative ascites with unknown etiology in patients with end stage renal disease and often undergoing hemodialysis. This entity presents in practice many diagnostic and therapeutic difficulties. The aim of this study is to focus on these difficulties through a new observation. We report one case of nephrogenic ascites in chronic renal failure related to an idiopathic neurologic bladder. It's a 38 years old patient on hemodialysis for three years who consulted for exsudative ascites with a low rate of leucocytes. We conclude that nephrogenic ascites is rare. Its diagnosis is an exclusion diagnosis based on exclusion of other causes of ascites, particularly exsudative forms with low leucocytes rate. Its management is based essentially on renal transplantation and its prognosis is very poor

[Liver disorders specific to pregnancy]

The liver diseases of pregnancy are specific liver disorders during the pregnancy. The principal hepatic anomaly during hyperemesis gravidarum is a reversisble augmentation of liver enzymes under reanimation. lntrahepatic cholestasis of pregnancy occur during the last 2 trimesters of pregnancy, manifested usually by pruritis preceeding a jaundice. The liver enzymes and the serum biliary acids are augmented. The acute fatty liver of pregnancy occur during the last trimester of pregnancy leading to early interruption of pregnancy which would help to diminish the elevated level of maternal and fetal mortality. The HELLP syndrome usually observed during the toxemia of pregnancy, associate an hemolysis elevation of liver enzymes and low platelets