Unusual case of duodenobiliary fistula complicating Crohn's disease successfully treated with Adalimumab

Crohn's disease [CD] is characterized by transmural inflammation of the gastrointestinal tract, which predisposes to the formation of fistula. Duodenal involvement occurs in less than 5% of cases and often leads to clinically relevant strictures. However, fistula formation in the duodenum is exceptional. Herein, we report an unusual case of duodenobiliary fistula due to CD occurring in a 65-year-old patient who was successfully treated by anti-tumor necrosis factor [TNF] agents. This case report highlights the efficacy of anti-TNF alpha agents in the treatment of a bilioenteric fistula because it increases the probability of clinical remission and mucosal healing and therefore reduces the need for surgical treatment which may be associated morbidity

[Prevalence of helicobacter pylori infection and gastroscopic finding in diabetic patients: case control study]

Current data on the prevalence of Helicobacter pylori infection in dyspeptic diabetic patients are contradictory in the literature. The aim was to assess the prevalence of Helicobacter pylori infection, gastroscopic lesions, and gastric histopathological lesions, in dyspeptic diabetic patients. It was a case-control study collecting 394 dyspeptic patients [194 diabetic and 200 nondiabetic patients]. The average age of patients was 47 years. 144 patients [47%] were male and 150 patients [53%] were female. The two patient groups were matched for age and sex. The prevalence of Helicobacter pylori infection was comparable between the two groups of patients [85% in diabetics versus 90% in the controls]. The frequency of gastroscopic lesions was 50% in diabetics and 55% in controls with no significant difference between the two groups. At histology, the prevalence of chronic gastritis, intestinal metaplasia, and gastric atrophy was 85%, 13% and 39% respectively in the group of diabetic patients. These results were comparable to those found in patients without diabetes. Our work shows no difference between diabetics and non-diabetics on the prevalence of Helicobacter pylori infection, gastroscopic, and gastric histopathological lesions

[Hepatic steatosis in chronic hepatitis B: Prevalence, risk factors, and impact on fibrosis and therapeutic response]

Steatosis is a common injury in chronic hepatitis C, but this association has not been sufficiently studied in chronic hepatitis B. To evaluate the prevalence of hepatic steatosis in chronic hepatitis B and determine its association with various histologic, biochemical, virological, and metabolic diseases, and its effect on fibrosis and therapeutic response. Our study was compiled 133 patients with chronic hepatitis B who received no antiviral therapy and who had a liver biopsy. Our patients were divided into 2 groups: 51 patients [38.3%] had steatosis [Group I], while 82 [61.7%] had no steatosis [Group II]. In group l, the average age, BMI, cholesterol, triglycerides, and glucose were significantly higher than the group without steatosis in univariate study [P <0.05]. In multivariate analysis, only high BMI and hypertriglyceridemia were included. No significant difference between the two groups was observed in the rate of transaminases, HBeAg status, viral load [P> 0.05]. Steatosis doesn't influence fibrosis stage and therapeutic response. During chronic hepatitis B, steatosis appears to be the result of metabolic factors of the host rather than the effect of the virus. Hepatic steatosis does not seem to influence the progression of liver fibrosis, or therapeutic response, however, the role of steatosis should be better studied by prospective longitudinal clinical studies on large populations of patients

[ natural history of hepatitis B virus cirrhosis after the first hepatic decompensation in Tunisia]

To define the natural long term course of viral B cirrhosis after the onset of hepatic decompensation and to determine the predictive factors of death. Retrospective longitudinal study including 77 cases of viral B cirrhosis among 192 consecutive patients with cirrhosis, hospitalized between 1997 and 2005 for the first hepatic decompensation. All those patients were followed- up until death or until December 2006. The probability of survival after the first hepatic decompensation was calculated using the Kaplan Meier method. The predictive factors of death were determined through univariate and multivariate analyses with the Cox regression model. Fifty four men and 23 women with an average age of 54 +/- 14.9 years were hospitalized for the first decompensation of the viral B cirrhosis. The 77 patients had been under observation for an average period of 24.2 +/- 21.1 months. During that time 64% among them died. The probability of survival after decompensation was 47% in 2 years and 22% in 5 years. During follow- up, ascites was the most frequent decompensation [85%] followed by hepatic encephalopathy [38%], variceal hemorrhage [34%], jaundice [30%], hepato renal syndrome [27%], hepatocellular carcinoma [21%], and spontaneous bacterial peritonitis [14%]. At univariate analysis four factors were predictive of death: Child Pugh C score [p=0.009], hepatocellular carcinoma [p=0.01], rate of serum gammaglobulin superior to18g / l [p=0.008] and prothrombin time inferior to 50% [p=0.02]. According to the multivariate analysis only the rate of serum gammaglobulin superior to 18g /l was an independent predictive factor of mortality [p=0,001] with IC [95%] [1.623 - 5.88]. In Tunisia, the prognosis of viral B cirrhosis after the first decompensation is bad, because a patient on 5 only was able to survive beyond 5 years. Ascites is the most frequent decompensation. Only the rate of serum gammaglobulin superior to 18g / l is an independent predictive factor of mortality

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

[Autoimmune hepatitis in Tunisia. Retrospective multicentric study about 83 cases]

Autoimmune hepatitis [AIH] is a chronic inflammatory condition of the liver of unknown etiology. Its epidemiological and anatomoclinical characteristics and its outcome were unknown in Tunisia. To analyse epidemiological, anatomoclinical, immunological and histological aspects of AIH and to determine factors predicting relapse after treatment and death of this disease in Tunisia. Patients presenting with AIH between January 1996 and December 2004 were evaluated in retrospective multicentric study. The diagnosis of AIH was established according to the criteria of the revised score of the international autoimmune hepatitis group [1999].Eighty three patients were identified [70 female; mean age = 49 + 17,9 years]. 63% presented probable AIH and 5% of cases were type II HAI. Fifty seven percent of the patients were cirrhotic at presentation. Associated autoimmune diseases was seen in 27 patients, dominated by diabetes, autoimmune thyroiditis and SjOgren's syndrome. An overlap syndrome was diagnosed in 25% of cases; primary biliary Cirrhosis-AIH in 20% of cases and primary sclerosing cholangitis-AIH in 5% of cases. Fifty patients were treated by glucocorticoids as monotherapy or in combination with azathioprine. Complete remission was achieved in 90% of cases. Fourteen percent relapsed within a median time of 12 months. Factors associated with relapse were: treatment with Azathioprine <18 months, absence of lobular necrosis and anti-nuclear antibody [+] profile. Mortality was observed in 17% of cases. Factors associated with death were encephalopathy as an independent factor and treatment with Azathioprine <18 months. In Tunisia, epidemiological and clinical characteristics of AIH were similar to those reported in the literature but with a higher frequency of cirrhosis at presentation. Treatment with Azathioprine <18 months was the main factor associated with relapse and represented with encephalopathy a factor associated with death

particularity of helicobacter pylori chronic gastritis in the west center of Tunisia

The Helicobacter pylori [HP] is strongly associated with chronic gastritis. Our study was to determine prevalence of the HP chronic gastritis in the west center of Tunisia and to clarify the clinical and the histological particularities of this infection. It is a prospective study carried out from September 2002 to July 2005 and had included 352 patients. All the patients had an upper endoscopy in which five gastric biopsies were taken for a histological study. The biopsy specimens were fixed in 10% buffered formol and then included in paraffin. The specimens were cut at 4 pm and stained with Hematoxylin Eosin, modified Giemsa and Alcian bleu SAP. The histological examination revealed HP specimens, the lymphoplasmocytic infiltration, the gastritis activity, the gastric atrophy and the intestinal metaplasia according to Sydney system. They were 162 men and 190 women, with a mean age of 48,3 years. The erythematous antral gastritis was the most frequent at endoscopy [26, 7%] The prevalence of HP chronic gastritis was 89% in patients with endoscopic lesions The activity of the gastritis was 89,7% in the antrum and 52,2% in the fundus. The activity mean score in the antrum was 2, 1,8 and 0,3 respectively in the case of duodenal ulcer and gastric adenocarcinoma vs 0,68, 1,1 and 0,16 in gastric fundus. The prevalence of gastric atrophy was 35%. The atrophy was found in the antrum in 98% of cases. The prevalence of intestinal metaplasic was 11%. The HP chronic gastritis is very frequent in the west center of Tunisia. Its prevalence is found elevated since the adolescence. It predominate the gastric antrum. It is often associated with a duodenal ulcer rather than gastric cancer

[Immunological profile of coeliac disease in a subgroup of patients with symptoms of irritable bowel syndrome]

The purpose of this study was to determine if authentic cases of irritable bowel syndrome could be secondary in a latent or potential coeliac disease. All new patients who consulted for irritable bowel syndrome fulfilling Rome II criteria between 01/04/2003 and 30/03/2004 were included. All patients had upper endoscopy with duodenal biopsy and colonoscopy or enema. Then they were investigated for celiac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies. One hundred patients with irritable bowel syndrome were included. They had an average age of 45.5 +/- 0.98 and they were 61 women. Clinical signs were dominated by abdominal pains associated to constipation [69% of the cases]. Five patients had positive antigliadin antibody [IgG for 2 patients and IgA for 3 patients]. None of them had endomysial antibodies nor abnormal duodenal biopsy. This study didn't provide a relation between celiac disease and irritable bowel syndrome when it is associated to constipation

[Crohn's disease: influence of age at diagnosis on clinical type of disease]

The aim of the study was to examine the influence of age at diagnosis of Crohn's disease on disease site and course in Tunisian patients

Methods: All hospital patients for Crohn's disease between 1993 and 2002 were included. They were segregated by age at diagnosis as follows: younger than 20 years, 20-39 years, and 40 years or older. And all patients were classified at the time of the latest visit into one of three subtypes of disease [non complicating, stricturing, and fistulizing] according Vienna's classification. Crohn's disease was devised also by site [ileum, ileocecal, colon and higher site]

Results: Sixty one patients [50,4%] were 20-39 years old and 43 patients [35,5%] were 40 years and older. Colonic involvement was significantly more common [46,5%] in the 40 years and older group compared with 20-39 years group [24,6%] [p=0,01]. The subtype without complication was significantly more common [58,1%] in the 40 years and older group compared with 20- 39 years group [39,3%] [p=0,05]. The frequency of the need for surgery for any indication for Crohn's disease didn't differ significantly according to age

Conclusion: In this study, Crohn's disease diagnosed in tunisian patients that were 40 years and older had often a colonic site and a less severe phenotype supporting the concept of genetic heterogeneity

Predictive factors of surgery in severe attacks of ulcerative colitis

The purpose of our study was to determine clinical, biological or endoscopic factors that predict surgery after a glucocortico steroid treatment failure in severe attacks of ulcerative colitis. Sixty one patients were analyzed. A therapeutic response for glucocorticosteroid was defined as the absence of resort to surgery within the first 30 days after hospitalization. Predictive factors were assessed using univariate and multivariate analysis. Fifteen patients [24,6%] had a medical response. In univariate analysis, predictive factors of surgery were: male sex, tobacco, number of colitis attacks in case history, temperature over 38°C, ery-throcyte sedimentation rate over 30 mm, systolic blood pressure below 11, deep and wide ulcers. During the course, bowel movements/ day over 7, pulse over 90/mn, temperature over 38°C on day 3 after treatment initiation as well as passage of blood on day 5 were identified as predictors of surgery. In multivariate analysis, bowel movements over II day on day 3 of hospitalization was independently predicted a surgery. Bowel movements/ day over 7 on day 3 of hospitalization was the only independently predictive factor of surgery after glu-cortico steroid treatment failure

Stromal tumors of the digestive tract: three small bowel localisation

Stromal tumors of the digestive tract are undifferenciated connective tissue tumors, identified as stemming of [pace-maker] cells of Cajal related to the immunohistochimical characterization of the phenotype. Report three new cases. We report three observations of the small bowel stromal tumors reveal by anemia in one case and mass formation in two cases. The aim of this study was to discuss the anatomo clinical, prognosis and management of these tumors

[Epidemiologic profile of gastric carcinoma: study of 140 cases]

The authors make a retrospective study of a series of 140 patients aged 59 years in average, followed up from 1995 to 2002 for adenocarcinoma of the stomach. Surgical resection was performed in 79 percent of the patients with total gastrectomy in 15.4%, partial gastrectomy in 50.6%. Resection was considered as curative in 66%. Lymph node metastases were present in 42, 9 percent of the patients. Margins of resection were involved in 24, 5% of the specimens. The mean survival rate was 26.5 months, 13 months and 5 months after curative resection, palliative resection and without resection

[Importance of vaccination chronic hepatitis B]

Weak therapeutic responses and weak immune cytotoxic CD8 and CD4 response in chronic hepatitis B emphasize the necessity to find new therapeutic strategies especially as specific immunotherapy. Vaccination, whose principle was to widen immune repertoire, was used as a curative treatment of chronic hepatitis B. It would be the therapeutic procedure with the lowest cost and the potentially greatest benefit. Our purpose was to enhance the interest of therapeutic vaccination in chronic hepatitis B in order to debate later its usefulness in developing countries

Identification des patients a haut risque de rechute de la maladie de Crohn

The aim of this study is to determine the factors associated with high risk of recurrence of Crohn disease. Patients and methods: During 12 years period from January 1987 till December 1999, 98 patients treated for crohn's disease were included in this study. The risk of recurrence was studied using the Kaplan -Meier method. The possible predictive factors of recurrence were studied using the LOG-RANK test. During the follow-up period, 50 [66%] patients developed a recurrence of Crohn's disease. The factors associated with a high risk of recurrence of the diseases were female [p=0,03], long delay before the diagnosis of the disease [p=0,03] and the presence of extra-intestinal lesions [p=0,05]. Concerning other factors such as the age, smoking, inflammatory syndrome and ano-perineal lesions, the study showed no relationship between these factors and the recurrence of the disease. This study showed that the group of patients treated for crohn's disease and who have predictive factors of recurrence should have prophylactic medical treatment to prevent recurrence of the disease

[Biliary attacks of surgery of the liver hydatid cyst]

The goal of this work was to describe secondary biliary attacks due to liver hydatid cyst surgery and see their different physiopathological mechanisms again. We report three cases of secondary sclerosing cholangitis. There were three women aged 20, 40 and 60 years. respectively. Icterus was the primary sign in the three cases. The three patients were operated on for liver hydatid cyst with a peroperative injection of the scolicide product. The diagnosis of secondary sclerosing cholangitis was based on the thin aspect of the biliary ducts. The generally benign liver hydatid cyst disease may be the cause of a serious and final biliary attack

Utilisation de l'octreotide dans le traitement des hemorragies digestives aigues par rupture de varices oesophagiennes

Aims To asses the value of octreotide in the control of acute bleeding esophageal varices in a retrospective study Methodology: Fourty two patients admitted for esophageal voriceal bleeding confirmed at endoscopy were recruired.An initial 50 micrograms bolus of octreotide followed by a two day continuous infusion of 25 micrograms/h were evaluated for the control of bleeding. Twenty nine patients were endoscopic stigmata of recent bleeding and thirteen were active bleeding at emergency endoscopy. Octreotide was found to be effective regarding hemostasis at 48 hours and on day 7 after the index bleeding episode. 30 day mortality was 1 1,9%. Echec of octreotide was significativement associated with severity of cirrhosis [p<0, 03]. Conclusion These results suggest that octreotide is effective in the treatment of esophageal variceal bleeding and it is a valuable adjuvant treatment in association with endoscopic menagement

steatohepatite non alcoolique: Une pathologie emergeante et potentiellement grave

Nonalcoholic steatohepatitis is an acquired liver disease, usually metabolic coracterised by histologic lesions with steatosis, intralobular necrosis and inflammatory infiltrates. Liver biopsy finding are identical to those seen in alcoholic hepatitis. Nonalcoholic steatohepatitis is increasingly, reported in industrial countries because of an increase of the prevalence of obesity and diabetes wich are the most commonly risk factors of this disease. The diagnosis of nonalcoholic steatohepatilis is based of a confrontation between clinical and anatomic data and an exclusion of an excessive intake of alcohol and other hepatic disease. Liver biopsy has a prognosis and histologic benefit especially when there is risk factors of fibrosis.This disease is potentialy severe with a potential risk for progression to cirrhosis. Progress in pathogenesis is noted but no definite therapy exist.The aim of this review is to indicate current knowledge for the gravity of nonalcoholic steatohepatitis and its consequence and to understand the pathogenesis to prevent cirrhosis