Systematic gastric biopsy in iron deficiency anaemia

Background and study aims: gastric biopsies are recommended in patients with iron deficiency anaemia to identify atrophic gastritis. However, in practice, only duodenal biopsies are routinely performed. The aim of our study was to determine the value of gastric biopsies in iron deficiency anaemia

Patients and methods: a prospective study including all patients referred for gastrointestinal endoscopy for iron deficiency anaemia from May 2008 to September 2014 was performed. All patients having endoscopic lesions which may explain occult bleeding were excluded, as well as patients using non-steroidal anti-inflammatory drugs or anticoagulation treatment. Two fundic biopsies, two antral biopsies, and one biopsy from the lesser curve were taken in all patients. Following entities were particularly looked for: chronic gastritis, Helicobacter pylori infection, intestinal metaplasia, endocrine hyperplasia and villous atrophy. In cases where intestinal metaplasia was present in the fundus and associated with endocrine hyperplasia and glandular atrophy, immunohistochemical study was performed to confirm autoimmune gastritis

Results: one hundred seventy-seven patients [mean age 50 years, range: 15-90] were included. Chronic gastritis was found in 149 cases [84%]. Infection by Helicobacter pylori was found in 107 cases [60%]. Fundic intestinal metaplasia was observed in 25 patients [14%] and was associated with Helicobacter pylori infection in 52% of cases. Atrophic gastritis was observed in 14 cases [8%] and autoimmune gastritis was confirmed in 5 cases by immunohistochemical study. One patient had on gastric biopsy a carcinoma with signet ring cells

Conclusion: intestinal metaplasia was frequently observed and was mostly related to Helicobacter pylori infection. These patients require monitoring, especially if they are young because it represents a pre neoplastic condition. However, in our study autoimmune gastritis often described in the literature in case of iron deficiency anaemia was rarely seen raising the question of relative cost-efficiency of fundic biopsies during iron deficiency anaemia

Chronic pancreatitis; clinical and therapeutic study. six years of experience of a gastroenterology department

The chronic pancreatitis is an inflammatory chronic affection of the pancreatic parenchyma characterized by a mutilating fibrosis with a progressive set up. The endoscopic treatment is actually considered as the first-line treatment and can sometimes be complementary to surgery. To determine the epidemiological, clinical, para-clinical and therapeutic characteristics during chronic pancreatitis. a retrospective study including patients having a chronic pancreatitis hospitalized in the gastroenterology department of Habib Thameur hospital between 2002 and 2008 was performed. Sixteen patients were included in this study [mean age 43 years, sex ratio 7]. All the patients were symptomatic at the time of the diagnosis and the epigastric pain was the main symptom. A complication was noted at the time of diagnosis in 12 patients: endocrine and exocrine pancreatic failure was noted in respectively 5 and 3 patients, while other complications were less frequent: acute pancreatitis [2 patients], cholestatic jaundice [2 patients] and pancreatic pseudo-cyst [2 patients]. The endoscopic treatment was performed in 62% of the patients with success of 63%. The surgical treatment was indicated in 37% of the cases. Mean follow up was 16 months. Survival rate was 93% at one year. One patient died because of hypoglycemia. No pancreatic neoplasia was noted in our study. In chronic pancreatitis, the contribution of endoscopic treatment is considerable but not without a certain risk. Therefore, collaboration between surgeons and endoscopists is needed and the best treatment should be considered individually

[Cutaneous metastasis of a ring cell gastric adenocarcinoma]

Introduction: Cutaneous metastasis of gastric tumors are very rare. Their topography is generally near to the primitive tumor, in the abdominal wall but rarely in cervical region

Aim: the aim of our study was to describe the topography and the clinic-pathological characteristics of cutaneous metastasis of ring cells gastric adenocarcinoma. Observation1: Our first patient is aged of 33 years has epigastralgias and vomiting. Gastric adenocarcinoma with independent cells was diagnosed by gastroscopy and gastric biopsy made for gastric pain and loss of weigh. During hospitalization, he developed 4 cutaneous nodes localized in cervical region. Cutaneous biopsy with histological examination confirmed the metastatic nature of the nodes. Patient was addressed in oncology unit in order to begin palliative systemic chemotherapy. Observation 2: Our second patient is a women aged of 4 3years who had surgical resection for independent cell gastric carcinoma diagnosed by gastroscpy and biopsy for gastric pain and loss of weigh. She had total gastrectomy without any complications and was addressed in oncology unit for adjuvant chemotherapy. After 2 years, she developed peritoneal carcinosis and cutaneous abdominal nodes. Cutaneous metastasis were confirmed by histological examination of cutaneous biopsy and the patient died within one month

Conclusion: Cutaneous metastasis of gastric cancer and especially ring cell adenocarcinoma are rare but do occur. They must be early diagnosed because they modify therapeutic options. Their prognosis remains poor

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

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

[Retained common bile duct stones after endoscopic sphincterotomy temperary and longtern treatment with biliary stenting]

Endoscopic extraction of biliary tract stones is safe and effective. When the procedure is not successful, the use of a biliary stent can be a solution. To prospectively analyse the usefulness of a stenting in management of biliary obstruction due to choledocolithiasis. All patients referred to our endoscopic unit from January 2005 to January 2008, for management of bile duct stone are studied. We included patients subjected to an endoscopic insertion of a biliary stent. Of 414 patients with choledocolithiasis, 51 failed to have their ducts cleared with the first endoscopic retrograde cholangiopancreatography [ERCP]: 25 patients [6%] were referred to surgical stone removal. Twenty six consecutive patients had endoscopic insertion of a 10 Fr biliary stent: There were 12 men and 14 women ranging in age from 35 to 102 years [median age 68 years]. The indications for stent placement in common bile duct stone were mainly the endoscopic portal hypertension, elderly patients or with a short life expectancy. Twenty four patients [88%] are symptom free after stenting. Six patients [23%] had duct clearance after a median of 3 sessions at a mean of 13 months [range 3-48 months]. In 3 patients endoprosthesis was inserted as a permanent therapy of biliary obstruction. Cholangitis occurred in 5 patients, early in two cases and later at a mean of 18 months [range 6-24 months] in 3 patients and was managed endoscopically by stent replacement and fluid antibiotics. These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones until the definitive treatment is carried out. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy

[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

[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

[Biliary stent occlusion]

Endoscopic stent insertion is as a method of choice for palliative treatment of malignant biliary strictures. Two types of biliary stent were actually used plastic and metallic self-expandable. Occlusion of the stent can be observed in both. To assess the management of biliary stent occlusion. From january 2006 to december 2007, 120 biliary stents were inserted in 97 patients. Indications of biliary stents were malignant stricture in 67%of cases. Biliary stern occlusion was defined by necessity of stent replacement. 118 plastic and 2 metallic self-expandable biliary stents were inserted. Obstruction of the biliary stent was observed in 12 patients, after a mean time of 5,5 months [1-15]. A recurrent biliary desobstruction was necessary in 6 patients. Stent exchange was realised in 33,3%of cases for malignant biliary stenosis and in 66,6%for benign stricture [p=0, 01]. Obstruction of the steot was symptomatic [cholangitis, jaundice] in more of 50%of cases. Management consisted on the stent exchange by a new plastic stent for clogging plastic stent and on insertion of plastic stent inside the metallic one for the occluded metallic stent. Obstruction can occur for the two types of biliary stent. Survival of the patient, cost of the stent guide the choice of the stent will be used

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

Management of the hepatocellular carcinoma

The hepatocellular carcinoma, is detected sooner due to the progress of the hepatic ultrasound scan allowing an accessibitity to curative treatment. This cancer treatment still remains difficult in Tunisia. To show the difficulties in the management of the hepatocellular carcinoma in Tunisia Patients hospitalized in the gastrocnterology department of Habib Thameur Hospital, from 2002 until 2007, for a cirrhosis follow-up or for a hepatocellular carcinoma treatment were studied retrospectively. The data was summarized by descriptive statistics and analysed with SPSS version 10. Fifty-seven patients were registered in this study. There were 40 males with an average age of 66 years. The cirrhosis was post-viral C in 28 cases. The discovery of the carcinoma was systematic in 16 cases. Treatment was prescribed in only fifteen patients, in the other patients, treatment was not made because of the multifocal character of the hepatocellular carcinoma. Complications were cirrhosis decompensation [n=3]. Fever [n=3], portal thrombosis [n=1] and pleurisy [n=1]. Regardless of the improvement of diagnostic and therapeutic means, 17.5%of our patients having a hepatocellular carcinoma were subjected to a curative treatment. Au additional effort must be unfolded