Microbiological study and antimicrobial susceptibility of bile in biliary therapeutic endoscopy

Background: Biliary obstruction together with bacterial colonization of the bile duct may lead to development of acute cholangitis. The reported incidence of infectious complications may reach up to 10%. Nevertheless, no antibiotic prophylaxis is administered routinely, prior to endoscopic therapeutic procedures

Aim: To investigate the presence and degree of biliary bacterial colonization during endoscopic retrograde cholangiopancreatography [ERCP] in patients with biliary obstruction. Furthermore, we evaluated antibiotic therapy regimens, which would cover the bacterial species obtained by ERCP and subsequent culture in each patient.

Methods:Forty-four patients with biliary obstruction who underwent an ERCP with biliary drainage were prospectively included. The primary indication of ERCP was choledocholithiasis [48%], followed by benign biliary strictures [32%] and malignant bile duct obstruction [18%]. Bile cultures were obtained by means of bile aspiration via the cannulation catheter. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for different antibiotics was performed

Results: The overall positive rate of bile culture was 93%. The organisms cultured were Escherichia coli [26.8%], Enterococcus [17%], Klebsiella [14.6%], Enterobacter [14.6%] and Pseudomonas [9.7%] in decreasing order. In-vitro testing of different antibiotics was carried out in these 41 isolates. Imipenem showed the best antimicrobial activity [sensitivity, 100%], followed by colistin [94%], tobramycin [93%], amikacin [89.6%], gentamycin [85.2%] and ceftazidin [82%]. Amoxicillin/clavulanic acid and ofloxacin were less sensitive [66% and 60% respectively]. Ceftazidin was the most effective antibiotic on Escherichia coli [sensitivity 83%]. Multi-resistant organisms were noted in 22% of the cases

Conclusions: Escherichia coli was found to be the pathogen most frequently detected in bile following endoscopic interventions in the biliary tract. Enterococci and Klebsiella were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, amoxicillin/clavulanic acid or quinolons are not suitable antibiotics for the prophylaxis of biliary infections. Moreover, Gram-positive bacteria such as Enterococcus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials

Hypogammaglobulinemia associated with nodular lymphoid hyperplasia of the intestine and pernicious anaemia

Background: Nodular lymphoid hyperplasia of the gastrointestinal tract, recurrent acute pulmonary infections and autoimmune disease are well-recognized complications of common variable immunodeficiency

Aim: We aimed to focus on clinical presentation and differential diagnosis of diffuse nodular lymphoid and hyperplasia of the gastrointestinal tract coexisting with hypogammaglobulinemia

Case-report: We report the case of nodular lymphoid hyperplasia associated with pernicious anaemia in a young man with hypogammaglobulinemia and a long history of pulmonary infections

Conclusion: The considerable point was a mismatch primary clinical diagnosis of familial adenomatous polyposis, due to prominent polyplike endoscopic appearance of the lesions throughout the digestive tract

Epidemiological evolution of epidemiology of the inflammatory bowel diseases in a hospital of Tunis

The epidemiological studies showed that the incidence of the inflammatory bowel diseases describes a gradient North- South. Besides, concerning the evolution according to the time, recent studies noted an increase of the incidence of the Crohn's disease at the expense of the one of the ulcerative colitis. To determine the evolution of the epidemiology of the inflammatory bowel diseases across the time. The study included inpatients followed for Crohn's disease, ulcerative colitis and indeterminate colitis, in the department of gastroenterology of Habib Thameur hospital. For every patient were collected the sex, the age and the year of the diagnosis, the type of inflammatory bowel disease and the initial location. We compared the evolution of the frequency of the inflammatory bowel diseases, them type and their initial location according to 5 periods of 3 years. During this period, 202 cases of inflammatory bowel disease were diagnosed [55,5% of Crohn's disease, 41,5% of ulcerative colitis, 6% of indeterminate colitis]. For the first period, we noted 21 cases of inflammatory bowel disease, for the 5th period, we noted 43 cases. The frequency of the Crohn's disease passed from 8 cases in the 1[st] period to 23 cases in the 5th one. The frequency of the ulcerative colitis passed from 12 cases in the 1[st] period to 17 cases in the 5th one. The number of indeterminate colitis was 1 in the 1[st] period and 3 in the 5th one. These differences did not been significant. The distribution of initial locations of the Crohn's disease and the ulcerative colitis increased in a proportional manner for each period. The average age to the diagnosis was 32 years in the 1[st] period and 35 years in the 5th period and comparable whatever the inflammatory bowel disease type. Although we cannot amount the exact incidence, we noted an increase of the frequency of the inflammatory bowel diseases, with a more marked elevation for the Crohn's disease

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

Colorectal neoplasia in elderly versus young patients in Tunisia: analysis of colonoscopic findings

Colorectal cancer occurs more frequently in older patients. Since the older population is increasing, a better understanding of the characteristics of colorectal neoplasm according to the age would be useful. To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. Colonoscopy database from 2004 to 2008 was retrospectively analyzed. There were 1510 eligible patients who underwent colonoscopy with a mean age of 54 years. Patients were classified into two groups: the older age group [Group 1, aged >/= 60 years, n = 626] and the younger age group [Group 2, aged < 60 years, n = 884]. Data were recorded on age, gender, colonoscopic indications, colonoscopic findings, and their related histological findings and tumor location. The risk of finding polyps and cancer at colonoscopy increases with age [29.4% in the older age group and 11% in the younger age group [p < 0.05]. Left-sided lesions were noted to be more frequent in both age groups [66% and 67% respectively]. The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly. However, both groups had the lesions predominately located in the left side

[Clincopathologic characteristics of low grade primary gastric non-Hodgkin's lymphomas: experience from a single center]

To report the clinicopathological data and the treatment outcomes in patients with primary gastric low grade non-Hodgkin's lymphoma. We carried out a retrospective analysis of 16 consecutive patients [median age 46 and range 28-75 years] who presented to our department with histopathological diagnosis of primary gastric low grade non-Hodgkin's lymphoma. We analyzed clinical manifestations, endoscopic features, pathological features,Helicobacter pylori infection and treatment. Common symptoms included abdominal pain [87.5%],vomiting [62.5%], and gastrointestinal bleeding [25%]. Endoscopic appearances were mainly ulcers and ulcerations [93.75%].Endoscopic biopsy confirmation rate reached 87.5% when biopsies were repeated. Helicobacter pylori detection rate was 75%. A total of 9 patients received surgeries. Three patients had chemotherapy and 8 patients had Helicobacter pylori eradication therapy. The range of follow-up was 2-74 months with a median of 27 months. A complete remission was obtained in 12 cases, whereas 1 patient died and 3 were lost of view. Eradication therapy may be offered as an initial treatment option in patients with low-grade gastric lymphoma

[Survival in patients with gastric lymphoma]

Mucosa-associated lymphoid tissue lymphoma is a histological type of marginal zone non-Hodgkin's lymphoma. Its clinical features and prognosis have seldom been reported because of its indolent clinical course. To establish prognostic factors that should be considered for the staging and management of this disease. Clinical data of 40 pathologically confirmed gastric lymphoma patients, treated during a period of 13 years, were analyzed. Of the 40 patients, 65% had stage IE - II1E disease and 35% had stage II2E - IV disease. A total of 18 patients received surgeries. Eighteen patients had chemotherapy and 10 patients had Helicobacter Pylori eradication therapy. The complete remission rate after treatment was 50%. The patients were followed up for a median of 26.75 months. The 5-year overall survival rate was 70%. Early stage at presentation, surgery, normal lactic dehydrogenase [LDH] levels and Helicobacter Pylori infection were associated with longer survival in univariate analysis. This study suggested that surgery might be an important factor predicting the long-term survival of patients with primary gastric lymphoma. Patients with poor prognostic factors should be treated more aggressively

[Steatosis in chronic hepatitis C: prevalence and predictive factors]

Patients with hepatitis C virus seem to often have hepatic steatosis. To assess the prevalence and the predictive factors of steatosis during chronic hepatitis C. We studied 50 HCV RNA positive subjects, who had liver biopsy performed. Steatosis was searched and patients were divided into to groups according to the presence or not of steatosis. On liver biopsy, 28 patients [56%] had steatosis. Multivariante analysis showed that steatosis was associated with age 58 years > 1,1 micro mol/l, odds ratio 2 [95% CI 1.48 - 2.6; p= 0.02] and triglycerides level, odds ration 4,22 [95% CI 1.05 - 16.98; p = 0,03. In this study, steatosis was significantly associated with metabolic factors

[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

[Plummer-Vinson syndrome]

Plummer - Vinxon syndrome is one of the names given to the constellation of dysphagia, iron-deficiency anemia, and esophageal webbing. It is a rare affection which affects mainly white women. The purpose of this study is to precise epidemiological, clinical, paraclinical and therapeutic features of the affection. We report a retrospective study enrolled over 6 years [2002 -2008]. Were studied the age, the sex, the main symptoms and the biological parameters [full blood cell, albumin, hepatic, renal and lipidic balance sheet]. Patients were explored by an upper endoscopy. Ten patients with the diagnosis of Plummer-Vinson syndrome were collected. There were 9 women, the average age was 57 years old. Dysphagia was the main symptom, observed in 100% of the cases. Fifty per cent of our patients had iron-deficiency anemia. Iron supplementation was indicated each time there is an iron-deficiency anemia. All the patients were treated with endoscopic dilatation and three of them needed multiple session of endoscopic dilatation. Eighty per cent had a favorable evolution. The malignancy was observed in 2 cases. Dysphagia is the main symptom of the Plummer- Vinson syndrome, which must indicate an upper endoscopy. This syndrome is known to be associated with an increased risk of squamous cell carcinoma of the upper airway tract, so the patients should be followed closely. Endoscopic dilatation is the procedure of choice in the treatment of cervical web of the esophagus

Helicobacter pylori and gastric cancer

Patients infected with Helicobacter pylon, a stomach colonizing bacteria, have an increased risk of developing gastric malignancies, in particular gastric carcinomas. This review was aimed to analyze the relationship between gastric carcinoma and Helicobacter pylon infection and to rule out the possibility of preventive measures. To identify articles for this review, a PubMed search was conducted using the following key words gastric cancer, Helicobacter pylon. The risk for developing cancer includes environmental, host-genetic and bacterial factors, which induce physiologic and histologic changes in the stomach. There are two major pathways for the development of gastric cancer by helicobacter pylon: the indirect action on gastric epithelial cells through inflammation leading to gastric atrophy and intestinal metaplasia and the direct action through the induction of protein modulation and gene mutation

Ciclosporin for severe refractory colitis

Intravenous Ciclosporin is a promising alternative, rapidly effective, for patients with severe steroid-refractory colitis previously facing only surgical options, however its use is controversial because of the frequency of adverse effects and the doubt about the long-term response. This review will provide information on clinical pharmacology, clinical indications for use, methods of dose adjustment, monitoring of metabolites for efficacy and for potential side effects and the adverse event profile of ciclosporin in severe refractory colitis. Literature review. Toxicity is dominated by opportunistic infections. Renal and neurotoxicity are also recognized. Risks of toxicity can be reduced by using lower doses, by oral microemulsion or by monotherapy without corticosteroids. The drug should not be continued for more than 3 to 6 months. As a bridge to other maintenance therapy such as azathioprine or 6-mercaptopurine ciclosporin can be an effective treatment. CSA is a viable alternative to emergency colectomy in severe UC in the short term. Although these benefits are not maintained in all patients, more than a half will also avoid colectomy in the longer term. Careful selection and monitoring of patients, use of lower doses, and oral therapy will help to reduce side effects

[Psoas abscess as the inital manifestation of crohn's disease, report of 30 cases]

Psoas abcess complicating Crohn's disease is a rare condition. Diagnosis remains difficult, especially when it is the first sign of Crohn's disease. We report here 3 patients presenting with psoas abcess as the initial manifestation of the disease, among 118 patients with Crohn's disease seen between 1990 and 2006. Symptoms and signs were fever, lower abdominal quadrant pain or tenderness and psoitis. Diagnosis was confirmed in all cases by computed axial tomography. In 2 cases, psoas abcess secondary to a periappendicular abcess or f colonic neoplasm were suspected, and the etiology was made correctly only after operation. Effective therapy included antibiotics, drainage and bowel resection