[Radiation exposure in Crohn's disease patients]

Introudction: Crohn's disease [CD] is a lifelong condition. Multiple imaging investigations are often performed during follow-up. This could cause overexposure to radiation. The aim of our study was to determine mean radiation dose in patients with at least a 5-year course of CD and to determine possible risk factors associated with exposure to high doses of radiation

Methods: We conducted a retrospective study including patients whose CD was diagnosed between 1998 and 2005. Epidemiologic features of patients, characteristics of the disease, types of imaging investigations that were performed during follow-up and cumulative radiation effective dose were determined. Risk factors associated with exposure to high doses of radiation were then determined

Results: One hundred sixty seven patients were included. There were 92 males [55.1%] and 75 females [44.9%] with mean age at dianosis of 31.4 +/- 12.3years. Global radiation dose was 18.8 +/- 18.9 mSv. Twenty seven patients [16,2%] were exposed to more than 35 mSv and 4 patients [2.4%] had an exposure of more than 75 mSv. Use of Infliximab, age at disease onset /= 8 were independent risk factors of radiation exposure more than 35 mSv with adjusted Odds ratios [OR]: 2.5 [2.1- 5.3]; 1.6 [1.2- 4.7] and 3.2 [2.1- 7.8] respectively. Similarly, use of Infliximab and number of flares >/= 8 were independent risk factors of radiation exposure more than 75 mSv with adjusted OR: 4.3 [2.8-9.5] and 7 [3.2-11.2] respectively

Conclusion: Radiation risk seems to be increased with severe course of CD. Both referring physicians and radiologists have the responsibility to minimise radiation exposure. Entero-magnetic resonance imaging [Entero-MRI] may reduce this risk

Stem cell transplantation as rescue therapy for refractory Crohn's disease: a sytematic review

Crohn's disease is a chronic relapsing- remitting affection. It has a strong immunologic component which represent the target of standard therapies including immunosppressants and biological therapies. However, many patients remain refracory or intolerant to these therapies. The aim of this review is to determine the effects of stem cell transplantation in patients with refractory Crohn's disease. Systematic review of observational studies, clinical trials and case reports that focused on the effectiveness and safety of stem cell transplantation in patients with refractory Crohn's disease. Hematopoietic stem cell transplantation seems to be efficient in maintaining clinical and endoscopic remission in patients with Crohn's disease refractory or intolerant to current therapies. However, it has been associated to high morbidity and mortality due to chemotherapy. Mesenchymal stem cell transplantation could induce remission in patients with fistulising refractory Crohns disease with no severe side effects. Its impact on luminal Crohns disease is still controversial. Stem cell transplantation seems to hold promising in patients with refractory Crohn's disease. However, because of the high morbidity and mortality related to chemotherapy, hematopoietic stem cell transplantation should be used as last resort to control this disease. Effectiveness of mesenchymal stem cell transplantation in luminal Crohn's disease has yet to be proven

[Diffuse oesophageal spasms: results of a retrospective manometric study]

Diffuse esophageal spasms is a primary motor disrder of the esophagus of unknown etiology characterized by intermettent peristalsis. This is rare condition which represents 3-5% if primary disorders of the esophagus. Diagnosis and treatment of this entity are difficult. To evaluate the frequency and the clinical and the manometric features of diffuse esophageal spasms. Methods: We conducted a retrospective study related to esophageal manometry performed between January 2000 and December 2011 regardless of the indication. Patients with meeting criteria for diffuse esophageal spasms [> 20% simultaneous waves with greater than 30 mmHg pressure in the esophagus] were included. Out of 1188 patients, 13 [1,09%] met the manometric criteria for diffuse esophageal spasms. It was 8 women and 5 men with a median age of 57 years. Dysphagia was the most relevant symptom and chest pain was only noted in 1 patient. The frequency of simultaneous waves was between 20 and 80%. The pressure of the lower esophageal sphincter was normal in most cases. In this Tunisian manometric study, the diffuse esophageal spasms is rare. Dysphagia was the most relevant symptom and the pressure of the lower esophageal sphincter was normal in most cases

[Dietary intake in Crohn's disease: Results of a prospective comparative study]

Diet is thought to have an important role in the etiopathogenesis of Crohn's disease. In the other hand, Crohn's disease is frequently associated with nutritional deficiencies probably as result of disease activity and poor oral intake. To investigate the dietary intake in patients with Crohn's disease in comparison with matched population controls and to assess the correlation between the results of the dietary enquete, nutritional status and disease activity. We conducted a prospective case control study in patients with Crohn's disease and matched controls. All subjects were evaluated in respect of dietary intake [based on "NUTISTAR" logiciel] and nutritional status. Results: We studied 23 patients and 23 controls. There was no statistical difference between patients and controls according to the proportion of carbohydrates, fat and protein intakes. Energy intakes were significantly lower in patients with Crohn's disease [1991 + 678 kcal/j] compared to controls [2537 + 345 kcal/j] [p=0.007] ; and in active disease [1353 + 308 kcal/j] compared to inactive disease patients [2481 + 415 kcal/j] [p<0.0001]. In Crohn's disease patients, correlation study showed that energy intakes were correlated with CDAI [p<0.0001 ; r = - 0.74] and BMI [p=0.03 ; r = 0.45]. In Crohn's disease, an inadequate dietary intake is correlated with nutritional status and disease activity

[Bone metabolism, biochemical markers of bone resorption and formation processes and interleukine 6 cytokin level during coeliac disease]

Celiac disease [CD] is characterized by a malabsorption syndrom. The bone anomalies are one of the principal complications of this disease. The osteoporosis frequency is high: 3.4% among patients having with CD versus 0.2% in the general population. To study the bone mineral density during the CD, to compare it to a control group and to determine the anomalies of biochemical markers of bone turn over and level of interleukin 6 cytokin [IL6] in these patients. All patients with CD have a measurement of bone mineral density by dual-energy x-ray absorptiometry [DXA], a biological exam with dosing calcemia, vitamin D, parathormone [PTH], the osteoblastic bone formation markers [serum osteocalcin, ALP phosphates alkaline], bone osteoclastic activity [C T‚lopeptide: CTX] and of the IL6. 42 patients were included, with a median age of 33.6 years. 52. 8% of the patients had a low level of D vitamine associated to a high level of PTH. An osteoporosis was noted in 21.5% of patients. No case of osteoporosis was detected in the control group. The mean level of the CTX, ost‚ocalcine and the IL6 was higher among patients having an osteoporosis or ost‚openia compared to patients with normal bone [p = 0,017]. The factors associated with an bone loss [osteopenia or osteoporosis] were: an age > 30 years, a weight < 50 kg, a level of ALP phosphates alkaline > 90 UI/ml, an hypo albuminemia < 40 g/l and a level of CTX higher than 1.2. Our study confirms the impact of the CD on the bone mineral statute. The relative risk to have an osteopenia or an osteoporosis was 5 in our series. The measurement of the osseous mineral density would be indicated among patients having a CD

Prognostic factors in Crohn's disease: a systematic review

The natural history of Crohn's disease is associated with several factors that affect the prognostic of the patients.To determine the most prognostic factors in Crohn's disease, based on a systematic review. methods: Literature review. The most important factors to consider in patients with Crohn's disease are the need for immunosuppressive therapy, the need for intestinal resection and disabling disease. Prognostic factors for these events are ileal involvement, perianal disease and initial treatment by corticosteroid. Other factors such young age, CRP level and smoking status, has not been found in all population-based studies. Protective role of anti-TNF drugs is strongly suggested but need to be confirmed in further studies. In a selected subgroup of patients with Crohn's disease characterized by the presence of these prognostic markers, the "topdown" strategy can be proposed

Unbalanced bone remodeling in Tunisian patients with inflammatory bowel diseases

Bone loss is an ignored complication in inflammatory bowel diseases. Its underling mechanisms are not fully elucidated. To investigate bone turnover in patients with inflammatory bowel diseases.The study included 67 patients with inflammatory bowel diseases and 54 age- and sex-matched healthy subjects. Urinary degradation products of C-terminal telopeptide of type I collagen, serum osteocalcin, parathyroid hormone, 25 hydroxy vitamin D and interleukin-6 were assessed. Bone mineral density was measured by dual energy-X-ray absorptiometry and osteoporosis was defined as T score < -2.5 SD. Patients showed significantly higher levels of C-terminal telopeptide of type I collagen and interleukin-6 and lower levels of 25 hydroxy vitamin D. Serum osteocalcin and parathyroid hormone were in normal range. In multivariate analysis, urinary degradation products of C-terminal telopeptide of type I collagen were associated with disease activity [p=0.04] and osteocalcin was associated with parathyroid hormone [p=0.04]. Urinary degradation products of Cterminal telopeptide of type I collagen and interleukin-6 were significantly increased in inflammatory bowel disease patients with osteoporosis. No association was found between osteoporosis and serum osteocalcin, parathyroid hormone and 25 hydroxy vitamin D. Bone resorption rate is increased and is associated with osteoporosis in inflammatory bowel disease patients. Inflammation, malnutrition, and hypovitaminosis D may contribute to the bone loss

[Is APRI score a suitable tool for prediction of fibrosis in Tunisian patients with genotype 1 chronic viral hepatitis C?]

Therapeutic indications in chronic genotype 1 hepatitis C are based on severity of fibrosis. APRI score is a simple, cheap and reproducible biochemical test. Performances of APRI score in Tunisian population with chronic hepatitis C were not previously prospectively studied. To evaluate the performances of APRI score in prediction of severity of fibrosis in chronic genotype 1 hepatitis C based on a prospective study. We prospectively include patients with chronic genotype 1 hepatitis C and positive viral load. Hepatic biopsy was performed in all included patients and abnormalities were classified according to METAVIR classification. In all patients, APRI score was calculated based on biochemical data collected within the 15 days before hepatic biopsy. We studied 140 patients [46 men, mean age 48.4 years [20 - 65 years]]. Mean APRI score was 0.89 [0.18 - 3.72]. Statistically significant correlation was observed between APRI score and fibrosis severity [r = 0.31 p < 0.0001]. APRI score was higher in patients with severe fibrosis [F2, F3 or F4] compared to patients with moderate fibrosis [F0 or F1] [0.97 + 0.68 vs 0.62 + 0.44; p 0.009]. Threshold value of APRI score of 0.72 was associated with area under the curve of 0.65 + 0.05 [0.57 - 0.73], sensitivity of 56.3% and specificity of 75.8% in prediction of severe fibrosis. APRI score was also higher in patients with cirrhosis [1.24 + 0.79 vs 0.85 + 0.61; p = 0.01]. Threshold value of 0.86 was associated with area under the curve of 0.69 + 0.07 [0.61 - 0.77], sensitivity of 76.4% and specificity of 65.8% in prediction of cirrhosis. APRI score is not a good alternative to hepatic biopsy although a strong correlation with fibrosis severity, because of relatively low area under the curve, sensitivity and specificity in prediction of severe fibrosis and cirrhosis

[24-hour esophageal impedance-pH monitoring: technical aspects, indications and results]

Classical techniques like endoscopy and esophageal pH-metry are the gold standard to study patients with symptoms related to gastroesophageal reflux disease. Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical gastroesophageal reflux disease symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. To precise the technical aspects of the esophageal impedancepH monitoring, indications and results of this technique in clinical practice. Literature revue of the esophageal impedance - pH monitoring. Combined multichannel intraluminal impedance and pH monitoring is a new technique that can be used to evaluate both bolus transport and all types of reflux [acid, weakly acidic and weakly alkaline], without radiation hazards. With this technique, higher rates of sensitivity and specificity than standard techniques are obtained in the diagnosis of pathological gastroesophageal reflux. The technique has also been used in the evaluation of atypical gastroesophageal reflux symptoms, in the assessment of the association of different patterns of reflux with symptoms, and in the evaluation of therapeutic outcome mainly in patients with refractory gastroesophageal reflux disease. The esophageal impedance represents real progress in understanding the different mechanisms involved in the pathophysiology of gastroesophageal reflux. This technique should also allow a better understanding of the responsibility of non-acid reflux in special clinical situations, such as patients resistant to antisecretory or extra-intestinal manifestations of gastroesophageal reflux

[A new clinical entity: Post-infectious irritable bowel syndrome]

Post-infectious irritable bowel syndrome [PI-IBS] is a disorder wherein symptoms of IBS begin after an episode of acute gastroenteritis. To determine epidemiology, clinical features and prognosis of PI-IBS and to precise its physiopathology and treatment. Literature review. Published studies have reported an incidence of PI-IBS ranging from 4 to 32% with a mean of 10%. Bacterial infections are the most responsible agents. Risk factors for PI-IBS include patient's demographics, psychological disorders and the severity of enteric illness. The most common symptoms are those of diarrheapredominant IBS. The mechanisms underlying PI-IBS include especially changes in intestinal permeability and persistent mucosal inflammatory process. In fact, there is increase in lymphocytic, mast and enterochromaffin cells in the gut mucosa. Furthermore, increased inflammatory cytokines have been demonstrated. Treatment of PIIBS is similar to that idiopathic IBS. PI-IBS is a novel clinic entity that suggests a novel approaches to IBS

Dermatologic manifestations in inflammatory bowel disease in Tunisia

Cutaneous manifestations are the most common extra intestinal manifestations associated with inflammatory bowel disease [IBD]. To assess the epidemio-clinical profile of skin manifestations in IBD. A prospective and descriptive study was conducted. We have examined skin, mucosa, hair and nails, of all patients with an IBD during one year. One hundred-ninety-five patients were included. Crohn's disease [CD] was noted in 154 cases [79.8%], ulcerous rectocolitis [UC] in 39 cases [21.2%] and inclassable IBD in 2 cases. Cutaneous manifestations were found in 91% of Crohn's patients and in 92% of UC patients. Granulomatous perianal skin lesions were the main cutaneous manifestations of CD [53%]. The most common affected sites were ano-perineal fistulae, perianal and perineal fissures and oedematous and infiltrated perianal and genital plaques. Reactive lesions [Erythema nodosum, Pyoderma gangrenosum, Aphthous stomatitis] were noted in 14 cases. Skin manifestations due to malabsorption were also frequently observed [101 cases: 51.7%].Other dermatoses implicating various mechanisms such as psoriasis, alopecia areata, vitiligo, rosacea, lichen planus, were also noted. Adverse skin manifestations due to treatment [folliculitis, acne, macula-papular rash and DRESS syndrome] were present in 16 cases. Our series is characterized by a high frequency of cutaneous manifestations associated to IBD. A better recognition of these skin manifestations by the physician may improve their management

[Efficacy and safety of adalimumab in Crohn's disease]

Adalimumab is the first subcutaneously self-administered fully human anti-TNFalpha. To determine efficacy and safety of Adalimumab therapy in Crohn disease. Literature review. Adalimumab has been evaluated for its effect in inducing and maintaining remission and its steroid-sparing effect of refractory Crohn's disease. In addition, it offers a significant treatment option in patients who have lost response to or become intolerant to Infliximab. Results also suggest efficacy of Adalimumab in fistulising Crohn's disease but more studies are needed. Adalimumab was well tolerated and studies show that all anti-TNF inhibitors have similar safety profiles