[Nocturnal gastroesophageal reflux. About a pH metric series]. / Le reflux gastro-oesophagien acide nocturne pathologique. A propos d'une série pHmétrique.

BACKGROUND: Nocturnal gastroesophageal reflux has been shown to be associated with the more severe forms of gastroesophageal reflux disease (GERD), particularly with extraesophageal manifestations as well as complications of mucosal damage. AIM: To determine the frequency of nocturnal gastro esophageal reflux disease on 24-hour esophageal pH monitoring in patients with digestives or extra-digestives symptoms 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 11-year period in patients with or without digestive symptoms of gastroesophageal reflux disease. The nocturnal gastroesophgeal reflux was defined. RESULTS: We studied 696 patients (299 men, 397 women; mean age: 34.05 years). Gastroesophageal reflux was found in 350 patients (50%). Nocturnal reflux was observed in 240 patients (34.3%), mostly in association with pathological reflux in the total period (223 cases). Compared to the diurnal period, the nocturnal period was characterized by fewer number of reflux episodes (21.9±27.4 vs 67.4±5.,1 ; p<0.0001), more longer duration of reflux episodes (24.4±37.9 minutes vs 13.9± 17.5 minutes ; p<0.001), and a lower symptomatic correlation (26% vs 45% ; p=0.0005). CONCLUSION: Nocturnal reflux is associated with overall reflux on the 24 hour examination. Nocturnal period is characterized by longer reflux episodes, less number of reflux episodes and less symptomatic correlation.

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Diagnosis and management of refractory celiac disease: a systematic review.

BACKGROUND: Refractory celiac disease is defined by persisting malabsorptive symptoms in spite of a strict gluten free diet for at least 6 to 12 months. Alternatives to gluten free diet seem to be still controversial. AIM: To describe the clinical and epidemiologic aspects of refractory celiac disease, and to identify therapeutic options in this condition. METHODS: Systematic review and critical analysis of observational studies, clinical trials and case reports that focused on diagnosis and management of refractory celiac disease. RESULTS: Refractory celiac disease can be classified as type 1 or type 2 according to the phenotype of intraepithelial lymphocytes. Great complications such as enteropathy-associated T-cell lymphoma may occur in a subgroup of these patients mainly in refractory celiac disease type 2. Curative therapies are still lacking. CONCLUSION: Refractory celiac disease remains a diagnosis of exclusion. Its prognosis remains still dismal by the absence yet of curative therapies. However, some new treatments seem to hold promise during few cohort-studies.

[24-hour esophageal impedance-ph monitoring: technical aspects, indications and results]. / L'impédancemétrie couplée à la ph-mètrie oesophagienne des 24 heures: technique, indications et résultats.

BACKGROUND: Classical techniques like endoscopy and esophageal pH-metry are the gold standard to study patients with symptoms related to gastroesophageal reflux disease. Although these techniques have been useful over the years both for diagnosis and therapeutic guidance, there are still many patients with typical or atypical gastroesophageal reflux disease symptoms with normal endoscopy and pH-metry that do not respond adequately to antisecretory therapy. Ambulatory esophageal impedance-pH monitoring is a new technique that can be used to evaluate all types of gastroesophageal reflux, achieving higher rates of sensitivity and specificity than standard techniques. AIM: To precise the technical aspects of the esophageal impedancepH monitoring, indications and results of this technique in clinical practice. METHODS: Literature revue of the esophageal impedance - pH monitoring Results: Combined multichannel intraluminal impedance and pH monitoring is a new technique that can be used to evaluate both bolus transport and all types of reflux (acid, weakly acidic and weakly alkaline), without radiation hazards. With this technique, higher rates of sensitivity and specificity than standard techniques are obtained in the diagnosis of pathological gastroesophageal reflux. The technique has also been used in the evaluation of atypical gastroesophageal reflux symptoms, in the assessment of the association of different patterns of reflux with symptoms, and in the evaluation of therapeutic outcome mainly in patients with refractory gastroesophageal reflux disease. CONCLUSION: The esophageal impedance represents real progress in understanding the different mechanisms involved in the pathophysiology of gastroesophageal reflux. This technique should also allow a better understanding of the responsibility of non-acid reflux in special clinical situations, such as patients resistant to antisecretory or extra-intestinal manifestations of gastroesophageal reflux.

[Post-infectious irritable bowel syndrome]. / Une nouvelle entité clinique: le syndrome de l'intestin irritable postinfectieux.

BACKGROUND: Post-infectious irritable bowel syndrome (PI-IBS) is a disorder wherein symptoms of IBS begin after an episode of acute gastroenteritis. AIMS: To determine epidemiology, clinical features and prognosis of PI-IBS and to precise its physiopathology and treatment. METHODS: Literature review. RESULTS: Published studies have reported an incidence of PI-IBS ranging from 4 to 32 % with a mean of 10 %. Bacterial infections are the most responsible agents. Risk factors for PI-IBS include patient's demographics, psychological disorders and the severity of enteric illness. The most common symptoms are those of diarrheapredominant IBS. The mechanisms underlying PI-IBS include especially changes in intestinal permeability and persistent mucosal inflammatory process. In fact, there is increase in lymphocytic, mast and enterochromaffin cells in the gut mucosa. Furthermore, increased inflammatory cytokines have been demonstrated. Treatment of PIIBS is similar to that idiopathic IBS. CONCLUSION: PI-IBS is a novel clinic entity that suggests a novel approaches to IBS.

[Is APRI score a suitable tool for prediction of fibrosis in Tunisian patients with genotype 1 chronic viral hepatitis C?]. / Le score April est il fiable pour la prediction de la fibrose chez les patients Tunisiens atteints d'hepatite chronique virale C de genotype 1?

BACKGROUND: 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. AIM: To evaluate the performances of APRI score in prediction of severity of fibrosis in chronic genotype 1 hepatitis C based on a prospective study. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Long-term functional outcome of laparoscopic anti-reflux surgery]. / Résultats fonctionnels à long terme de la chirurgie anti-reflux sous coelioscopie.

BACKGROUND: 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. AIM: To determine long-term results of laparoscopic antireflux surgery the mechanisms involved in patients with worse results. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Long term evolution of corticodependant and corticoresistant Crohn's disease patients treated by azzathioprine]. / Évolution a long terme des patients atteints de maladie de Crohn corticodépendante et corticorésistante traites par azathioprine.

BACKGROUND: Immunosupressors, particularly azathioprine, represents the therapeutic alternative in patients with corticodependant or corticoresistant Crohn's disease. The prescription of azathioprine in Tunisia is common, but there is not Tunisian studies evaluating the long term results of this drug in Crohn's disease patients. AIMS: To evaluate the long term results of azathioprine treatment with determination of rates of relapses, surgery and need to corticosteroids in patients with corticodependant or corticoresistant Crohn's disease, and to look for predictive factors to theses events. METHODS: A retrospective study on 12 years including all patients treated by azathioprine for corticodependant or corticoresistant Crohn's disease. We excluded the cases of follow up less than 6 months. RESULTS: We studied 56 patients (46 corticodependant and 10 corticoresistant). Induction of remission was obtained in 89% of the cases. Concerning the long term results, the relapse rate was 60% of patients treated with azathioprine, with actuarial rates of 38% at one year, 65% at 5 years and 75% at 10 years. Need for corticosteroid treatment was estimated at 42% and need for surgical treatment was estimated at 24%. The only predictive factor for relapse was duration of treatment by azathioprine more than 36 months, with sensitivity of 93% and specificity of 50%. CONCLUSION: Although an excellent result of azathioprine in induction remission, long term results showed deterioration of results of treatment. Physicians must be followed up Crohn's disease patients in order to rapidly detect and treat the clinical relapses of the disease.

[Management of failure of infliximab in inflammatory bowel disease]. / Que faire devant un échec de l'Infliximab au cours des maladies inflammatoires chroniques de l'intestin ?

BACKGROUND: Infliximab is a chimeric monoclonal anti TNFa whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options. METHODS: Literature review RESULTS: The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNFa, a relay by adalinumab or certolizumab may be proposed. CONCLUSION: The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed.

[Evaluation of small bowel involvement in Crohn's disease by small- bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowel radiography]. / Évaluation de l'atteinte du grêle de la maladie de Crohn par vidéocapsule endoscopique : étude prospective et comparative avec le transit du grêle et l'entéroscanner.

BACKGROUND: 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. AIMS: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.