Value of water enema computed tomography in elderly symptomatic patients

Background and study aims: colonoscopy remains the gold standard for the examination of the colon. However, its use in the elderly is not well tolerated, and there is often a need for general anaesthesia, thus increasing the risk, especially if there are co-morbidities. Water enema computed tomography has been suggested to be a satisfactory alternative as a non-invasive, fast and effective means for the diagnosis of colorectal supra-centimetric lesions

Background and study aims: the aim of our study was to assess the performance of water enema computed tomography as first-line examination by calculating its negative predictive value [NPV] for the diagnosis of supra-centimetric lesions in symptomatic elderly referred to colonoscopy

Patients and methods: this was a prospective study including 57 symptomatic patients older than 65 years. All patients were explored by water enema computed tomography at first, followed by colonoscopy, and responded to a questionnaire on the tolerance to the preparation and both procedures

Results: the mean age of patients was 73 years. The M:F sex ratio was 1.59. The most frequent indication for colonoscopy was bowel disorders associated with abdominal pain [30%]. Water enema computed tomography allowed the diagnosis of tumours [n = 2], polyps [n = 6], diverticulosis [n = 7], inflammatory wall thickening [n = 1] and extra-colic lesions [n = 28]. NPV of water enema computed tomography for supra-centimetric lesions was 96.5%. Sensitivity and specificity were 87.3% and 98%, respectively. However, for sub-centimetric lesions, water enema computed tomography had a low sensitivity estimated at 6%, specificity at 89.9%, positive predictive value at 91.9% and NPV at 27.7%

Conclusion: water enema computed tomography has proven to be a valuable and non-invasive method indicated as a first-line examination in case of colonic symptoms in the elderly to diagnose supracentimetric lesions

Surgical treatment of Crohn's disease: indications, results and predictive factors of recurrence and morbidity

Background: Crohn's disease management represents a major problem in gastroenterology and general surgery because it affects young subjects and has a major impact on their quality of life. The aims of our study were to identify the indications for surgery in Crohn's disease, the results and the complications of surgery in our series, and to identify possible predictive factors of recurrence and postoperative morbidity

Methods: A retrospective descriptive study including 38 cases of patients with Crohn's disease who underwent surgical treatment in the department of surgery in Mongi Slim Hospital, during the period between January 1992 and December 2011 was performed

Results: The occurrence of stenosis was the most common indication for surgical treatment in Crohn's disease in our series, and ileocecal resection was the most performed surgery. Twenty six patients [58%] received maintenance therapy after surgery. Twenty two patients relapsed and 13 had surgical management for recurrence. In univariate analysis, predictive factors of post operative morbidity in our study were leukocytosis, penetrating phenotype and intraabdominal sepsis. Ileocecal location was the only factor that significantly improved the incidence of recurrence. In multivariate analysis, only penetrating phenotype was a predictive factor or post operative morbidity

Conclusion: Despite the development of medical treatment, surgical treatment keeps large indications for the management of complications of Crohn's disease. The surgery should be an alternative to immunosuppressive therapy. Currently, prevention postoperative recurrence is well codified, reducing the risk of complications

Percutaneous treatment versus hepatic resection for the treatment of small hepatocellular carcinoma

Hepatocellular carcinoma is the first liver tumor worldwide. Therefore, it is a matter of debate whether surgical treatment or percutaneous treatment should be preferred for the treatment of patients with small hepatocellular carcinoma. The aim of our study was to compare the long-term outcome and the survival between surgically and percutaneously treated small hepatocellular carcinomas. A retrospective study was performed in the department of hepatology during a period of 2009-2012. The study included all patients carrying small hepatocellular carcinoma which were divided in: group 1 including patients who underwent surgical treatment, and group 2 including patients who underwent percutaneous treatment. Among the 63 patients who were diagnosed for hepatocellular carcinoma, 28 carried a small hepatocellular carcinoma with a mean age of 63 years and sex-ratio of 0.64. Etiology of cirrhosis was viral in 96% cases. Surgical treatment [hepatic resection] was performed in 53.5% cases while percutaneous treatment was proposed for 46.5%: radiofrequency ablation in 69% and alcoholic injection in 31%. No major complications for both surgical and percutaneous treatment occurred in our study. Overall survival was significantly lower in the surgical resection group. The corresponding 6 months and 1-year overall survival rates for the surgical resection group and the percutaneous treatment group were 100%, 100%, 20%, and 52%, respectively [p=0,04]. The disease free survival were not significantly different. Our results showed the efficacy and safety of percutaneous ablation treatments which were better than those of surgical treatment in patients with small hepatocellular carcinoma

Risk factors of psychological disorders in inflammatory bowel disease in a Tunisian survey. Results of a cross-sectional study

Little is known in inflammatory bowel disease [IBD] regarding risk factors for psychological distress. The aims of our work were to evaluate the frequency of anxiety and depression among patients with IBD and to determine the factors associated with these psychological disorders in Tunisian patients. From June 2012 to April 2013, 60 consecutive patients with IBD answered a questionnaire about psychological and socioeconomic factors and adherence to treatment. In this study we focused the analysis on the characteristics of IBD [type, localization, severity, treatment] and socioeconomic factors [professional, educational, and marital status]. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale [HADS]. According to the HADS, 25 patients [41.6%] were anxious while 4 [6.6%] were depressed. Three had anxiety and depression at the same time. Twelve patients had a probable anxiety, 2 patients had a probable depression and 3 patients had a probable depression and anxiety at the same time. By univariate analysis, factors associated with anxiety and depression were: female gender [p<0.03], rent [p<0.03], high school graduation [p<0.009], IBD type ulcerative colitis [p<0.05]. By multivariate analysis, independent factors associated with these emotional disorders were: female gender [p=0.005, OR 11.3], the high school graduation [p=0.004, OR 12.1]. In our cohort, risk factors for anxiety and depression were the high school graduation and IBD type ulcerative colitis. Consequently, psychological interventions would be useful when these factors are identified

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

[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 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

[Virological response of Tunisians patients treated by peginterferon plus ribavirin for chronic hepatitis C: a preliminary study]

Peginterferon plus ribavirin is actually the most effective therapy for chronic hepatitis C. This study was designed to evaluate the efficacy and safety of peginterferon and ribavirin combination therapy in Tunisian patients with chronic hepatitis C and to identify predictors of response to treatment. Fifty patients with chronic HCV infection recruited from the gastroenterology department of Habib Thameur hospital between January 2003 and March 2006 were prospectively included. All patients received peginterferon a 2a or alpha 2b subcutaneously respectively at a dose of 180 micro g or 1, 5 micro g/Kg once weekly plus oral ribavirin given in two divided doses per day at a dose of 1000 mg/day for patients weighing 75 Kg or less and 1200 mg/day for those weighing more than 75 Kg. The clinical endpoints were the end of treatment response [EOT] and the sustained virological response [SVR] defined as an undetected serum HCV RNA 6 months after the end of treatment [< 600 IU/ml]. Items associated with the main dependant variable [virological response [EOT and SVR] such us sex, age, body mass index, pretreatment viral load, pretreatment ALT quotient, pretreatment histologic degree of fibrosis, activity, steatosis, and HCV genotype [1 vs. non-1] were studied in an unvaried analysis. A total of 50 patients were included in the study. The mean age of patients was 47.64 +/- 8.54 years. Thirty three patients were infected by HCV genotype 1 [66%] and 15 patients by HCV genotype 2 [30%]. Forty five patients [90%] had normal ALT values at the end of treatment. At the end-of-treatment 82% of patient had virologic responses. Seventy three percent of patients with HCV genotype 1 had an end-of-treatment [EOT] virologic response and 52% had sustained virologic response [SVR]. In patients with HCV genotypes 2 or 3, EOT and SVR were obtained respectively in 100% and 81% of patients. Only one patient infected by HCV genotype 4 was included in this study, she achieved an EOT virologic response whereas the SVR wasn't assessed. Among the 41 patients with EOT virologic response, 3 patients [7.31%] relapses during the 6 months after the end of therapy. Nine patients didn't achieve virologic response. Treatment was well-tolerated for 80% of patients. Laboratory abnormalities were observed in 12 of the 50 included patients [24%] and 7 patients experienced severe adverse events during the treatment period. Combination therapy with peginterferon plus ribavirin for HCV infection was effective and safe. Careful monitoring of treatment-associated adverse events is necessary to avoid withdrew of therapy and to maintain a reasonable quality of life

[Prognostic factors for survival in cirrhosis]

Background: Assessment of prognosis in patients with cirrhosis is important so as to plan their management as well as the choice of major procedures

The aim of the present study was to determine the survival rates and to identify indicators associated with shorter life expectancy in Tunisians patients with cirrhosis

Methods: This is a retrospective study of patients with cirrhosis admitted during 14-years period. We studied clinical and biochemical characteristics of all patients and the occurrence of decompensation or complication [gastro-intestinal bleeding, hepatic encephalopathy, spontaneous bacterial peritonitis, hepato-renal syndrome, hepatocellular carcinoma]. The overall survival, mortality rate and causes of death were reviewed. Univariate and multivariate analysis was performed on all variables to identify parameters with a lower life expectancy

Results: We studied 85 patients [50 females/35 males] with a mean age of 57 years. Mean follow up was 31 months. The overall survival was 47% at 5 years. With univariate analysis, 13 variables were associated with a poor prognosis: male sex, jaundice, ascites, and decompensation at admission, increased serum gammaglobulin, gammaGT, bilirubine and ASAT levels, Child-Pugh C, occurrence of spontaneous bacterial peritonitis, hepatic encephalopathy, hepato-renal syndrome and hepatocellular carcinoma. With multivariate analysis, 2 variables were independently correlated with survival: male sex and elevated gammaGT

Conclusion: In our study, male sex, increased serum gammGT and gammaglobulin are uncommon parameters that may predict survival in cirrhotic patient. The Child-Pugh score was a good index for assessing the prognosis