[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

[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

[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

[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

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

[Treatment of crohn's disease by infliximab. about 20 cases]

Infliximab has been an effective chimerical monoclonal antibody in Crohn's disease. Infliximab is available in Tunisia for a few years. Aims: To determine the results of the treatment of Crohn's disease by infliximab. We undertook a retrospective study relating to all the Crohn's disease patients and treated by infliximab. For all the patients, we specified the indication of the treatment, the result of the induction treatment, the recourse or not to a sequential treatment and the adverse effects of the treatment. Our study related to 20 patients. It was in the majority of the cases an anoperineal and fistulizing form [15 case]. Good response to the induction treatment was noted in 15 patients [75%]. A sequential treatment by infliximab was undertaken among seven patients, with good results in the short and medium term. A case of death related to the treatment was noted in our series, as mortal milliary tuberculosis appeared under treatment. Infliximab must be reserved for particular situations of the Crohn's disease. The pre-therapeutic assessment must be complete and the monitoring of the patients must be strict, while insisting on the possibility of reactivation of latent tuberculosis in Tunisia

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

[Proximal gastro-esophageal reflux monitoring in patients with suspected laryngopharyngealreflux disease]

To assess the frequency and associated actors of proximal acid reflux in patients with ENT manifestations of gastroesopliageal reflux disease, and to compare the pHmetric parameters in the distal and the proximal esophagus in these patients. We conducted an open-prospective study, including consecutive patients with chronic pharyngitis or laryngitis. Twenty four hour esophageal pH-monitoring was performed, using a double sensor catheter. Proximal reflux was defined according to the recently published recommendations. We studied 43 patients [17 men and 26 women], mean age 39,5 years [15- 67 years]. Distal reflux was detected in 35 patients [81%]. Proximal reflux was detected in 26 patients [60%]. Ratio of numbers of proximal to distal reflux episodes was 0.34 [0- 0.90]. The proximal reflux episodes were characterized by a small number of episodes exceeding 5 minutes [2.6 + 4.4 vs 10.8 + 9.1: p <0.0001]. a less duration of longest reflux episode [15.6 + 23.5 vs 50.2 + 61 6 minutes p< 0.0001] and better esophageal clearance [1.6 + 1 vs 2.5 + 1 minutes/reflux p = 0.006], associated with a significant correlation between numbers of proximal reflux episodes and distal acid exposure time[r = 0.52 p <0.0001]. Proximal reflux is frequent in patients is with chronic pharyngitis or laryngitis. Proximal reflux episodes are correlated to distal acid exposure and associated with a better esophageal clearance

[Interest of serologic markers in inflammatory bowel disease about 105 cases]

Prerequis: The serum markers ASCA and pANCA can help the clinician in certain difficult situtations of colites in IBD

The aim of this study was to determien the sensitivity and the specificity of each one of these markers and to establish the characteristics of the positive patients for each one

Methods: We included patients having a Crohn's disease [CD] or an ulcerative colitis [UC]. These patients was compared to a control group

Results: 80 CD patients with an average age of 35.62 years, 25 UC cases with an average age of 34.92 years and 79 healthy subjects with an average age of 34.2 years were included. The ASCA were dected in 33.8% of CD cases, 8% of UC cases of RCH and 2.5% of contro group [p<000.1]. The pANCA were detected in 48% of UC cases, 27.5% of CD patients and 1.3% of controls [<000.1]. The sensitivity and the specificity of the ASCA and the pANCA for the diagnosis respectively of CD and UC were 33.8%, 97.5% and of 48%, 97.8%. During the CD, the positivity of the ASCA was significantly associated with ileal location [p=0.001], with the stenosant and/or fistulisant phenotype of the disease [p=0.006], the young age at the time of the diagnosis of the CD [p=0.067] and at a greater frequency of surgical treatment [p=00.7]. The pANCA were more frequently found in colic location of CD [p=0.09]. During UC, the positivity of the pANCA was not associated with the sex, age, location of the disease, medical treatment nor chirurgical treatment

Conclusion: The ASCA and pANCA are useful during some clinical situations such as differentiation between IBD others colitis and to distinguish CD from UC

[Nocturnal gastroesophageal reflux disease in asthmatics patients: a phmetric study about 81 cases]

Aim: To determine the frequency of gastroesophageal reflux disease on 24-hour esophageal pH monitoring in asthmatics patients and to evaluate the clinical and pHmetric characteristics of nocturnal reflux in these patients

Methods: We conducted a retrospective study based on results of 24-hour esophageal pH monitoring during a 10-year period in asthmatics patients with or without digestive symptoms of gastroesophageal reflux disease

Results: We studied 81 patients [37 men, 44 women; mean age: 32 years]. Gastroesophageal reflux was found in 42 patients [52%]. Nocturnal reflux was observed in 35 patients [43%], mostly in association with pathological reflux in the total period [32 cases]. Presence of digestive symptoms was the only associated factor to gastroesophageal reflux during 24-hour, in nocturnal or in diurnal period. Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes [22.69 + 23 vs 70.16 + 56.15; p<0.001], more longer duration of reflux episodes [25.92 + 23.34 minutes vs 15.52 + 16.27 minutes; p=0.02], fewer respiratory symptoms [2.24 + 1.89 vs 6.18 + 4.12; p=0.01] and better symptomatic correlation [13/17: 76% vs 9/24:37%; p=0.02]

Conclusion: Gastroesophageal reflux disease is frequent in asthma. Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by more longer reflux episodes and better symptomatic correlation

[Microscopic colitis. A 20 cases serie]

Microscopic colitis are defined as a chronic inflammation of a normal macroscopic colonic mucosa. We report 20 cases of microscopic colitis. Chronic diarrhea revealed the diagnosis in 95% of cases. Endoscopic examination was normal in 95% of patients. We diagnosed collagenous colitis in 65% of cases and lymphocytic colitis in 35% of cases. The treatment was based on sulphasalazine in 16 patients, on 5 aminosalicylic acid in 1 case, on gluen free diet in 2 cases and a symptomatic treatment was prescripted to one patient. A clinical remission was observed in 41.2% of patients taking sulphasalazine