[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

[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

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

[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

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

Acute peritonitis complicating Crohn's disease: epidemiologic and physiopathological characteristics

An uncommon event in the natural course of Crohn's disease is the spontaneous perforation. It's the most serious intestinal complication. To report the incidence of this complication and to discuss the mechanism of the perforation. We report, retrospectively, 4 cases [3 men and one woman; median age: 30 years] of peritonitis complicating Crohn's disease and study their clinical characteristics intra operatively findings and course evolution. Steroid therapy was administrated to all patients before the perforation. The perforation sites are on the ileum in three cases and on the jejunum in one case. The treatment consists in a resection of the perforated intestine with stoma in all cases. Perforation in Crohn's disease is a rare event. The exact mechanism of the perforation is still unknown and many hypotheses are presented

[Autoimmune pancreatitis: a systematic review]

Autoimmune pancreatitis represents a recently described subset of chronic pancreatitis. To determine etiopathogenic features as well as histologic, morphologic, clinical and therapeutic characteristics of autoimmune pancreatitis. The study was based on a review of all relevant studies published in the literature on autoimmune pancreatitis before august 2008. Autoimmune pancreatitis is now considered as the pancreatic manifestation of a systemic disorder that affects various organs, including the bile duct, retroperitoneum, kidney, and parotid and lachrymal glands. A dense lymphoplasmocytic infiltration with IgG4 positive plasma cells and fibrosis are the histological common feature of this systemic disease. Autoimmune pancreatitis is a rare disease that occurs predominantly in elderly men. Its diagnosis is sometimes difficult and can mimic pancreatic cancer whereas its lesions respond so readily to steroids. Thus, diagnostic criteria where developed so that to provide a secure basis for diagnosis and avoid abusive pancreatic resections. Since its individualisation, interest in autoimmune pancreatitis has grown and many clinical aspects have been clarified

[Faecal calprotectin in inflammatory bowel disease: Review]

The clinical course of inflammatory bowel disease [IBD] is characterized by a succession of relapses and remissions. A regular and a long term monitoring of such patients is required. Faecal markers, especially calprotectin's use, seem to be useful in these patients. Faecal calprotectin is a reliable maker of intestinal inflammation in IBD. Its level is assessed by a simple and a non invasive test. We proposed to review main indications and study results of faecal calprotectin test use in IBD patients. Review of literature. Faecal calprotectin assessment isn't an IBD specific test. Selective use is required to have a good benefit-cost ratio. Prediction of relapses in asymptomatic patients as well as post operative reccurence seems to be the main indications for its use. Mucosal healing assessment after anti-TNF treatment can also be an interesting indication although it isn't well evaluated

[Evaluation of small bowel involvement in Croh'ns disease by small-bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowell radiography]

Small-bowel videocapsule endoscopy [VCE] is a new technique in evaluation of intestinal involvement in several pathologies. Crohn's disease affects principally terminal ileum.Small bowel involvement in Crohn's disease is not well estimated by endoscopic and radiologic conventional techniques. To evaluate the performances of VCE in detection of asymptomatic proximal small bowel lesions in consecutive patients with Crohn's disease with terminal ileal involvement, to compare the results of VCE to small bowel radiography and CT-enteroclysis and to determine the therapeutic impact of VCE in these patients. A prospective study which included Crohn's disease patients with distal ileal involvement, based on radiological or endoscopic findings. We performed in all patients small bowel radiography, CT enteroclysis and VCE. Proximal involvement was characterized by presence of aphtoid, superficial or deep ulcerations in the jejunum or the proximal ileum. We studied 20 patients [12 men, mean age 31.6 years]. VCE confirmed the distal ileal involvement in all patients. Significative proximal lesions was observed in nine patients [jejunum only: one case, jejunum and ileum: six cases and proximal ileum: two cases], in most cases aphtoid or superficial lesions. Deep ulcerations were observed in two patients. Small bowel radiography showed proximal ileal lesions in only two patients, and CT-enteroclysis in only one patient. Treatment by azathioprine was prescribed in two patients with severe and extended small bowel lesions in VCE examination. VCE is more accurate than radiologic techniques in detection of small bowel lesions in Crohn's disease. In cases of severe and extended small bowel involvement, VCE can conduct to changes of therapeutic approach

[Management of failure of infliximab in inflammatory bowel disease]

Infliximab is a chimeric monoclonal anti TNF alpha whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options. Literature review. The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNF alpha, a relay by adalinumab or certolizumab may be proposed. The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed

[Fertility and inflammatory bowel diseases]

Data concerning fertility during inflammatory bowel disease are insufficient and sometimes contradictory. The aims of this review are to precise the impact of inflammatory bowel disease on fertility. Literature review. The risk of infertility seems to be raised at one under group of patients and made to intervene several factors of which, in particular for the Crohn's disease, the activity of the disease and the psychological impact leads by this chronic disorder. The decrease of the fertility, as very feminine as male, during the ulcerative colitis is essentially bound to the surgery. Data concerning the impact of various therapeutic used during inflammatory bowel disease on the fertility are very insufficient and interest especially male fertility

[Mesenteric panniculitis simulating malignancy]

Panniculitis mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown aetiology that affects the mesentery of small bowel and colon. To report a new case of this entity and to highlight its diagnostic difficulties especially when it affects the mesocolon. A 37 years-old women presented with chronic abdominal pain; physical examination found mass of left ilaca fossa. Closcopy and abdominal CT scan showed a thickness of bowel wall with negative biopsies. The patient underwent a colectomy. Histologic examination concluded to the diagnosis of Mesenteric panniculitis without malignant lesion. Mesenteric panniculitis is a rare pathology which diagnosis is difficult to establish. It can simulate malignancy. A better knowledge of its clinical and radiological features could ovoid unecessary digestive resection

Sleep disorders in patients with gastroesophageal reflux disease: an open clinical and pH metric prospective study

Sleep disorders are frequent in patients with GERD. Severity of sleep disorders could be related to occurrence of nighttime symptoms, but the relationship between severity of GERD and the severity of sleep disorders is not well established. To identify the frequency of sleep disorders in patients with suspected GERD and the correlation between the severity of sleep disorders and pH metric parameters in these patients. We studied prospectively 50 patients with esophageal and supra-esophageal symptoms of GERD. 24-hour esophageal pH monitoring examination was performed in all patients. Standard survey was applied to determine the frequency and the severity of sleep disorders in these patients. We included 50 patients [10 men, 40 women], mean age 43.7 years [18-70]. Nighttime symptoms were present in 26 patients [52%]. Pathological acid gastro-esophageal reflux was diagnosed by 24-hour esophageal pH recording in 18 patients [36%], with nocturnal acid reflux in 19 patients [38%]. Sleep disorders were reported by 29 patients [58%]. Mean number of hours of sleep was 6.8 hours by night [4-9 hours]. Clinical factors associated with higher frequency of sleep disorders were occurrence of nighttime symptoms [p<0.0001] and duration of symptoms of GERD [53.2 +/- 41.4 months vs 26.0 +/- 18.1 months; p = 0.007], with no association with BMI, age and sex. pHmetric parameters associated with sleep disorders were pathological acid reflux [p<0.0001; OR [C195%] :28.3 [3.3-240.8]] and nocturnal acid reflux p<0.0001; OR[C195%1 :32.7 [3.8-279.2]]. Patients with sleep disorders had significant changes of pHmetric parameters compared to those without sleep disorders: Acid exposition time, numbers of reflux episodes, number of episodes longest than five minutes, duration of longest reflux episode and DeMeester score [respectively 6.1 +/- 8.8 vs 1.3 +/- 1.5 p = 0.01; 59.2 +/- 52.0 vs 20.7 +/- 21.6 p = 0.001; 3.1 +/- 6.1 vs 0.1 +/- 0.3 p = 0.03; 8.9 +/- 9.3 minutes vs 3.4 +/- 4.0 minutes p = 0.01; 24.0 +/- 33.2 vs 4.8 +/- 4.9 p = 0.01]. Number of hours of sleep was significantly lower in patients with pathological acid reflux [5.3 +/- 1.2 hours vs 7.6 +/- 1.7 hours, p<0.0001] and in patients with nocturnal acid reflux [5.2 +/- 1.1 hours vs 7.8 +/- 1.5 hours, p<0.0001]. Number of hours of sleep was strongly correlated with esophageal pH parameters Sleep disorders are frequent in patients with GERD symptoms. Severity of sleep disorders are strongly correlated with severity of global and nocturnal acid reflux as attested by 24-hour esophageal pH monitoring

[Frequency and predictive factors of colectomyand coloproctectomy in ulcerative colitis]

To determine the frequency and the predictive factors of colectomy and coloproctectomy in patients with ulcerative colitis. We conducted an 11-year retrospective study based on hospitalized ulcerative colitis patients followed up for more than 6 months. From 1995 to 2005, 115 patients were included [50 men, 65 women, mean age: 38.4 years]. Mean duration of follow-up was 39.2 months [6 - 145]. Colectomy was performed in 20 patients [17%], with an actuarial risk of 16% at 5 years and 35% at 10 years. Proctocolectomy with ileoanal anastomosis was performed in 16 cases and total colectomy with ileorectal anastomosis in 4 cases. In univariate analysis, factors associated with an increased risk of colectomy were pancolitic location [p=0.02], acute severe colitis [p < 0.0001], treatment by intravenous corticosteroids [p < 0.0001] and intravenous cyclosporine [p=0.001]. In multivariate analysis, acute severe colitis was the only independent factor associated with colectomy [p = 0.04 OR[CI95%] :6.66[1.04 - 50]]. In patients with distal location, the independent factor associated with colectomy was colonic extension during follow up [p = 0.04 OR[CI95%] :7.69[1.07 - 50]]. In patients with pancolitic location, risk of colectomy was associated with acute severe colitis [p = 0.01 OR[CI95%] :9.09[1.58 - 50]] and years of hospitalization from 1995 to 1999 [p = 0.02 OR[CI95%] :7.14[1.35 - 44]]. Although the diffusion of treatment by intravenous cyclosporin, surgery is frequently performed in our ulcerative colitis patients, specially in case of acute severe colitis. Evaluation of colonic extension during the follow-up is associated with an important prognostic impact

[Oesophageal motility abnormalities in systemic sclerosis: frequency and predictive factors]

Esophageal involvement is frequent during systemic sclerosis. It consists on esophageal motor abnormalities. Esophageal manometry is the gold standard for the diagnosis. To determine the frequency and the type of the esophageal motor abnormalities among patients presenting a systemic sclerosis; and to look for factors associated with a greater risk of theses disorders. A retrospective study relating to all the esophageal manometries carried out among patients presenting a systemic sclerosis was undertaken. During a 12 years period, 128 cases were studied. Esophageal motor abnormalities were found among 97 patients [76%]. Specific esophageal involvement was found among 52 patients [42%], and non specific motor abnormalities among 31 patients [24%]. The only associated factor with a specific esophageal involvement is occurrence of dysphagia. Esophageal motor abnormalities are frequent in patients with systemic sclerosis. They can be specific and nonspecific. Esophageal manometry should be systematically performed among these patients, even in the absence of dysphagia