Viral B reactivation: risk and prevention

The viral B reactivation is associated to deadly serious forms. There exist populations suffering this risk yet with a possibility of prevention through a pre-emptive treatment. Establishing the diagnosis of a viral B reactivation. Identifying the patients with risk of exposure to viral B reactivation and implementing the means of prevention of viral reactivation. literature review the diagnosis of reactivation is not consensual. It is evoked facing a fast increase of aminotransferases with the ALAT superior to 5-10 times normal or superior to 3 times the basic value, an ascension of the HBV DNA within the serum, a reappearance of anti Hbc of IgM type with, most often, a weak title and /or a reversion Hbs. The reactivation depends on the type of treatment and of the viral B status. It was described under chemotherapy concerning the solid tumors particularly that of the breast, in haematology and increases with the resort to monoclonal antibody [anti-CD20]. Under anti-TNFalpha a reactivation is possible within a variable deadline from the 1st to the 12th perfusion. Besides the type of treatment, the risk is more important with the patients Ag Hbs positive and correlated with the viremia. However, the patients having an occult hepatitis B or even a recovered from hepatitis are equally exposed to the risk of reactivation. viral reactivation is frequent since the larger use of immunosuppressive therapy, anti-TNFalpha and monoclonal antibody. The determination of the initial viral B status by a serology is indispensable. In order to indicate either surveillance or a preemptive treatment

[Molecular characterization of lynch syndrome in Tunisia]

High rates of early colorectal cancers [CRC] are observed in Tunisia suggesting genetic susceptibility. Nevertheless, up to now no molecular studies have been performed in the Tunisian population. To evaluate the clinical and genetic characteristics of Tunisian families suspected of hereditary nonpolyposis colorectal cancer [HNPCC] and to identify new tumoral markers for CRC susceptibility leading to distinguish patients with sporadic CRC from those with familial CRC, like HNPCC. 31 unrelated families suspected of HNPCC were screened for germline mutations in MMR genes. We have also analyzed tumoral phenotype and the genetic characteristics of tumors from 51 patients with CRC meeting the Bethesda criteria. 10 different germ line mutations, 8 of which were novel, were identified in 11 out of the 31 families [35.5%], 5 in MSH2 and 5 in MLH1. Our results showed that MUC5AC expression was more frequent in patients with family history of CRC [p=0.039]. The analysis of MUC5AC expression might be very beneficial in the detection of Tunisian patients with high susceptibility to CRC

[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

Prevalence and risk factor of renal dysfunction induced by bacterial infection other than spontaneous bacterial peritonitis in patients with cirrhosis

Deterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis [SBP] is a predictor for inhospital mortality. However, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. To investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis. Retrospective data from in-patients with bacterial infections other than SBP were analyzed. Eighty-two patients were recruited for the analysis. Infection was located in urinary tract [41.5%], pneumonia [34.1%], biliary tract [3.7%], cellulitis [6.1%], gastrointestinal tract [4.9%] and bacteremia of unknown origin [9.7%]. Renal dysfunction developed in 40 patients [48.8%], of which 13 patients had irreversible renal dysfunction. In the univariate and multivariate analysis, the initial MELD score, neutrophil count, bilirubin, and blood pressure were significant risk factors for renal dysfunction. The prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 48.8%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients

[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 %]

Malignant epithelioid hemangioendothelioma: a case report

Malignant epithelioid hemangioendothelioma [EH] is a rare tumor of vascular origin. We report a case of a woman who was found to have multiple hepatic masses in the right lobe of the liver on radiologic investigations, initially misdiagnosed as a metastatic carcinoma. The diagnosis of EH was made on histopathological study and confirmed by immunohistochemistry, which showed diffuse response for CD34 marker and no response to tissue CEA, HMB-45 or S-100 protein. Partial hepatectomy was made with good results

[Factors predicting mortality in infected hospitalized cirrhotics patients: about 97 cases]

Infections are frequent in cirrhotic patients. They are potentially severe, modifying pejoratively the natural history of the cirrhosis and are suppliers of a heavy mortality. To determine the predictive factors of hospital mortality in cirrhotic infected patients. We conducted a retrospective study including 97 cirrhotic patients hospitalized in the department of gastroenterology of Charles Nicolle's hospital, for a first infectious episode and not having received antibiotics in the previous 15 days. Clinico-biological, bacteriological, therapeutic and evolutionary data were collected. Scores were adopted and calculated such as the score of Child-Pugh, the score MELD [The Model for End-Stage Liver Disease] and the score SOFA [Sequential Organ Failure Assessment]. These data allowed a descriptive study and an uni and multi-varied analysis. The median age of the studied population was of 59 +/- 12 years with a sex ratio of 0.83. The diabetes was the comorbidity most frequently associated with the cirrhosis [26.8% of the cases] Viral aetiology of the cirrhosis was dominant [3/4 of the cases] especially the virus C [62.5% of the cases]. The clinical presentation of the infection was polymorphic with presence of symptoms connected to the infection and the other connected to the progression of the liver disease. The fever was absent in 3/4 of the cases. The identified infections were, in order of frequency, urinary, infection of ascite, bronchopulmonary, cutaneous and gynecological. The responsible germs were especially bacilli gram negative of intestinal origin. The estimated scores of gravity were: a score of Child-Pugh C in 60% of the cases, an average score MELD in 18 +/- 8 points and a score average SOFA in 8 +/- 4 points. Multivariate study found that only encephalopathy, bilirubin level more than 40 micro mol/l and creatinin level more than 120 micro mol/l was independent factors predicting mortality. Infection in cirrhotic patients was a severe and mortal complication. The hepatic encephalopathy, the hyper bilirubinemia and the renal failure are predictive of the hospital mortality. The use of the scores of gravity: Child-Pugh, MELD and SOFA would an important help for the decision to admit in intensive care unit any infected cirrhotic patient

[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

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

[Intestinal intussusceptions in adults: a 20 cases study]

Intestinal intussusception occurs when a portion of the gastrointestinal tract invaginates into the part of the tract that precedes into the peristaltic direction. To determinate clinical presentation, diagnostic methods, and outcome of intestinal intussusception and to compare our results to previous data. A retrospective study of 20 patients with mean age of 40 years admitted between 1982 and 1999 and underwent surgery for intestinal intussusceptions. Our patients were 10 males and 10 females. The clinical findings were essentially abdominal pain[90%].Preoperative diagnosis of intestinal intussusceptions was established in 30% of cases. Intussusceptions were ileo-ileal [n=10], ileo-colic [n=7] and colo-colic [n=3]. 12 patients had tumors. For all intussusceptions involving the colon,all patients underwent resection while intussusceptions located on the small bowel were treated by reduction then resection or simple reduction then fixation. The mortality rate was 5%. Intestinal intussusception in adults is uncommon in comparison with children. Correct diagnosis is often established during surgery. Resection is recommended because of the frequent malignancy

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