[Prognosis of refractory ascites in cirrhosis]

Background: Ascitic decompensation is a common major complication of cirrhosis and is associated with a poor outcome. In 5-10% of patients, ascites become resistant to treatment [either do not respond to a high dose of diuretics or because these drugs induce complications], which is called refractory ascites [RA]. RA is associated with poor survival: 20-50% at 1 year. The aim of this study was to investigate the outcome of RA

Methods: Retrospective study including consecutive cirrhotic patients admitted for controlling ascites between January 2010 and April 2013. Patients and cirrhosis characteristics were studied. Development of RA during follow-up was investigated. The impact of RA on the outcome [cirrhosis complications and survival] was evaluated

Results: We included 124 cirrhotic patients: 59 females [47.6%]; mean age was 58 years. Ascites was grade 3 in 38.5% and was the first episode in 45.1% of patients. Etiology of cirrhosis was mainly viral [57.3%]. Child-Pugh score was B in 39.5% and C in 28.2%. Mean MELD score was 16 [6-40]. During follow-up, 27 patients developed RA, meaning a prevalence of 21.8%. RA type was diuretic intractable in all cases. Survival without complications was significantly reduced in patients with RA [4 vs 17 monthsp<10-3]. RA was an independent predictive factor of global complications, spontaneous bacterial peritonitis and hepatic encephalopathy. Global survival was reduced in patients with RA [12 vs 16 months, p=0.069]. One year survival was 45% for patients with RA vs 63% for other cirrhotics. In multivariate analysis, only Child-Pugh score, but not RA was an independent prognostic factor

Conclusion: In this Tunisian sample we confirm that RA reduces survival and increases risk of cirrhosis complications, especially hepatic encephalopathy and spontaneous bacterial peritonitis. Therefore, these patients should be promptly listed for liver transplantation, over and above the MELD score

Complete radiological response after sorafenib treatment for advanced hepato-cellular carcinoma

Introduction: Sorafenib, an oral multikinase inhibitor, has recently been shown to improve overall survival in patients with advanced hepatocellular carcinoma [HCC] but only a handful of reports of complete remission on sorafenib have been issued

Case report: We report an intriguing case of advanced HCC complicating HCV infection with cirrhosis, in which the patient achieved complete remission by prolonged administration of sorafenib

Conclusion: Identifying factors that could be associated with good response to this therapy are needed

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

Appropriateness of indications for upper gastrointestinal endoscopy in a Tunisian endoscopy unit

Background: Introduction: Upper gastrointestinal endoscopy [UGE] is an increasing and reliable procedure. Given the high costs and potential risks, appropriate indication of UGE may be facilitated by referring to qualifying criteria such as those devised by the European Panel [EPAGE]. This prospective study evaluates the applicability and efficacy of these criteria in clinical practice

Methods: Cross sectional study. Consecutive patients were referred to our unit endoscopy for diagnostic upper gastrointestinal endoscopy between January 2011 and June 2011. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The appropriateness of UGE was assessed based on EPAGE II criteria before the procedure

Results:EPAGE criteria were applicable in 89.1% of cases. They were 78 men [48.1%] and mean age was 49 years [14 - 91]. Indications for UGE were extremely appropriate, appropriate, inappropriate and uncertain in 21.6%, 47.4%%, 8.8% and 22.2% respectively. Among patients with clinically significant lesions detected by UGE, 70.7% had an appropriate indication. Clinically significant lesions were disclosed in 59% of the appropriate group and 54% of the inappropriate group. All cancers were observed in patients with appropriate indications. Patients with appropriate indication were older than patients belonging to the inappropriate group [53.6 years versus 39.9 years, p =0,0001]

Conclusion: In this present study, EPAGE criteria were applicable in 89.1% and indication was judged appropriate in more than two-third of cases. However, clinical significant lesions were observed in a proportion of patients with inappropriate indication, and in some relevant clinical situations EPAGE criteria were not applicable. Therefore, even if these criteria are helpful for decision-making, final decision must however rely upon practitioner. Qualifying criteria for an appropriate selection of endoscopical procedure adapted to our population are advisable

Ischemic colitis in five points: an update 2013

Ischemic colitis is the most common form of intestinal ischemia. The presence of diarrhea and mild lower gastrointestinal bleeding should guide the diagnosis. Although many laboratory tests and radiographic images may suggest the diagnosis, colonic endoscopic with histological analysis of biopsies is the gold standard for identification of colonic ischemia. The aim of this study was to resume in 5 points: the epidemiology, the clinical features, the diagnostic approach and the management of ischemic colitis in five points. Review of literature. Incidence of ischemic colitis was between 3 and 10%. The clinical presentation is predominated by the non gangrenous form associating abdominal pain, tenderness, diarrhea and lower gastrointestinal bleeding. The most frequent causes are represented by systemic hypoperfusion. Laboratory tests can orientate the diagnosis but are unspecific. Radiographic images based on computed tomography or more recently magnetic resonance imaging may suggest the diagnosis, but the confirmation will be given by endoscopic visualization of colonic mucosa with histological analysis of biopsies. Conservative treatment is the most often sufficient to improve colonic lesions. Surgical treatment is reserved for perforations and strictures. The incidence of colonic ischemia is difficult to ascertain. The diagnosis is usually made by medical history, examination, and endoscopy which have become the diagnostic procedure of choice. A high index of suspicion and prompt management are essential for optimum outcomes in patients with colonic ischemia

[What's new in rectal cancer?]

In recent years, multidisciplinary therapeutic management of rectal cancer has evolved. This progress had interest radio and chemotherapy. Aim: To describe the main spots of the progress in the therapeutic strategies of the disease, surgical techniques and standardization of these techniques, particularly regarding locoregional extension in the mesorectum. Literature review. Treatment of rectal cancer is multidisciplinary. On the surgical field, excision of the mesorectum [total mesorectal excision [TME]] has reduced local recurrence and the genitourinary sequelae. Meanwhile, chemoradiotherapy has become important. The standard now is to indicate to T3 T4 N+ tumors to decrease local recurrence without improving survival, however. Advances in the management of rectal cancer with both imaging progress and therapeutic modalities have improved the prognosis and survival of this cancer

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

Budd-Chiari syndrome

The Budd-Chiari syndrome is a rare disease, often fatal if not treated optimally. It is characterized by a blocked hepatic venous outflow tract. This review attempted to present pathophysiology, aetiologies,diagnosis and therapeutic modalities of the Budd-Chiari syndrome. Review of literature. Budd-Chiari syndrome is a complex disease with a wide spectrum of aetiologies and presentations. Hematologic abnormalities, particularly myeloproliferative disorders, are the most common causes of the Budd-Chiari syndrome. The clinical presentation is governed by the extent and rapidity of the hepatic vein occlusion. Doppler-ultrasound, computed tomography or magnetic resonance imaging of hepatic veins and inferior vena cava are usually successful in demonstrating non-invasively the obstacle or its consequences. A therapeutic strategy has been proposed where anticoagulation, correction of risk factors, diuretics and prophylaxis for portal hypertension are used first; then angioplasty for shortlength venous stenosis; then Transjugular Intrahepatic Portosystemic Shunt [TIPS]; and ultimately liver transplantation. Treatment progression is dictated by the response to previous therapy. This strategy has achieved 5-year survival rates approaching 70%.Medium-term prognosis depends on the severity of liver disease. The diagnosis of the Budd-Chiari syndrome must be considered in any patients with acute or chronic liver disease. Management of this syndrome should follow a step by step strategy

[Bowel preparation: what's new?]

The efficiency of bowel preparation directly affects the quality and the reliability of total colonoscopy. Inadequate bowel cleansing is a common cause of incomplete colonoscopy with a risk of ignoring pre-neoplastic lesions represented primarily as adenomas with a size below centimetre. Due to the numerous factors interfering with preparation, an adapted choice of the type of preparation and the follow-up of diverse methods to optimize bowel preparation allows to improve diagnostic accuracy and to reduce costs while guaranteeing to the patient good tolerabilty and safety. To report the news about the terms of the bowel preparation for colonoscopy quality and to propose practical ways to optimize it. Review of literature and lecture of recommendations. The pre-colonoscopy consultation, prescription of a split dose bowel preparation and a brief time between the last dose of preparation and colonoscopy are the means currently available to optimize bowel preparation. A better understanding of terms of bowel preparation and the factors influencing the degree of preparation improve the diagnostic efficacy of colonoscopy especially in the detection and treatment of colorectal cancer

Colorectal neoplasia in elderly versus young patients in Tunisia: analysis of colonoscopic findings

Colorectal cancer occurs more frequently in older patients. Since the older population is increasing, a better understanding of the characteristics of colorectal neoplasm according to the age would be useful. To determine the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young patients. Colonoscopy database from 2004 to 2008 was retrospectively analyzed. There were 1510 eligible patients who underwent colonoscopy with a mean age of 54 years. Patients were classified into two groups: the older age group [Group 1, aged >/= 60 years, n = 626] and the younger age group [Group 2, aged < 60 years, n = 884]. Data were recorded on age, gender, colonoscopic indications, colonoscopic findings, and their related histological findings and tumor location. The risk of finding polyps and cancer at colonoscopy increases with age [29.4% in the older age group and 11% in the younger age group [p < 0.05]. Left-sided lesions were noted to be more frequent in both age groups [66% and 67% respectively]. The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly. However, both groups had the lesions predominately located in the left side

[Plummer-Vinson syndrome]

Plummer - Vinxon syndrome is one of the names given to the constellation of dysphagia, iron-deficiency anemia, and esophageal webbing. It is a rare affection which affects mainly white women. The purpose of this study is to precise epidemiological, clinical, paraclinical and therapeutic features of the affection. We report a retrospective study enrolled over 6 years [2002 -2008]. Were studied the age, the sex, the main symptoms and the biological parameters [full blood cell, albumin, hepatic, renal and lipidic balance sheet]. Patients were explored by an upper endoscopy. Ten patients with the diagnosis of Plummer-Vinson syndrome were collected. There were 9 women, the average age was 57 years old. Dysphagia was the main symptom, observed in 100% of the cases. Fifty per cent of our patients had iron-deficiency anemia. Iron supplementation was indicated each time there is an iron-deficiency anemia. All the patients were treated with endoscopic dilatation and three of them needed multiple session of endoscopic dilatation. Eighty per cent had a favorable evolution. The malignancy was observed in 2 cases. Dysphagia is the main symptom of the Plummer- Vinson syndrome, which must indicate an upper endoscopy. This syndrome is known to be associated with an increased risk of squamous cell carcinoma of the upper airway tract, so the patients should be followed closely. Endoscopic dilatation is the procedure of choice in the treatment of cervical web of the esophagus