[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

[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

[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

[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

[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

[Long-term functional outcome of laparoscopic and reflux surgery]

Medical treatment of gastro esophageal reflux is associated with relapse in 30% of cases. In these patients, the best therapeutic option is surgical treatment, performed laparoscopically. However, there are few data on long-term functional outcome. To determine long-term results of laparoscopic antireflux surgery the mechanisms involved in patients with worse results. We studied patients operated for reflux disease. They had either total or partial laparoscopic fundoplication. These patients were contacted to assess postoperative improvement, satisfaction and asked about the occurrence or not of a persistent postoperative dysphagia. Seventy one patients were included [Nissen in 61% of the cases and Toupet in 39%]. After an average period of 52.4 months,80% of patients were satisfied. 58% were completely improved,while 31% were partially improved after surgery. Persistent reflux symptoms reflux were observed in 8 patients and postoperative dysphagia was reported by 11 patients. Gastroesophageal reflux revealed by chronic cough was the only independent parameter associated with bad functional results in our patients. Laparoscopic anti reflux surgery is associated with a high frequency of satisfaction. However, patients with chronic cough respond less better to surgery. Strict selection of the patients before surgery must be done, to improve the functional results after anti reflux surgery

[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

Frequency and predictive factors of granulomatous hepatitis in patients with peritoneal tuberculosis

The aims of our study were to determine the frequency of granulomatous hepatitis in patients with peritoneal tuberculosis, to identify factors for high risk and whether it is associated with higher frequency of antituberculous treatment side effects. We carried out a prospective study on patients with histologically proven peritoneal tuberculosis between January 1996 and December 2005. We performed a liver biopsy in all the patients before starting the antituberculous treatment. Granulomatous hepatitis was systematically searched in all patients. The study was conducted in 52 patients, 9 men and 43 women of median age of 35,5 years. A granulomatous hepatitis was seen in 24 patients [46%]. In univariate analysis the factors associated with a high risk of liver involvement were a higher level of gamma-G1utamyl transpeptidase [44.5 + 36.8 lU/l vs 23.3 + 9.28 lU/I p=0.005], a higher level of phosphatases alkalines [233.9 + 96.6 lU/l vs 189.4 + 49.9 lU/l p=0.03] and a lower level of cholesterol [1.22 + 0.2 g/l vs 1.56 + 0.3 g/l p<0.0001]. In multivariate analysis, only a cholesterol level lower than 1,31 g/l was significantly associated with a granulomatous hepatitis [p=0.006 OR [IC95%]: 0.10 [0.02-0.52]]. We have found a frequent liver involvement in the case of peritoneal tuberculosis [46%]. Cholesterol level lower than 1,31 gr/l was an independent predictor of granulomatous hepatitis in patients with peritoneal tuberculosis. We suggest, in this case, that percutaneous liver biopsy can be considered as an alternative to laparoscopy