Gastrojejunocolic fistula: a rare complication of peptic ulcer surgery.

Gastrojejunocolic fistula (GJF) is a very rare complication of peptic ulcer surgery. Patients with this condition often present with diarrhea, fecal vomiting as well as weight loss. Here, we report a case of 62-year-old male with a GJF complicating upper gastrointestinal surgery.

Adenocarcinoma of the small bowel revealing celiac disease in an adult: case report.

Cancer of the small bowel is a rare malignancy. With an incidence of less than one per 100 000 people, it makes up only 5% of all gastrointestinal tract cancers. Celiac disease is a relatively common pathology and is often associated with the development of small bowel lymphoma. However, it is also a known risk factor for small bowel adenocarcinoma. The authors are reporting a case of a patient with recurrent bowel obstruction found to have a small bowel adenocarcinoma and an underlying celiac disease.

Overlap syndrome of primary biliary cholangitis and primary sclerosing cholangitis: two case reports.

BACKGROUND: Overlap syndrome between primary biliary cholangitis and primary sclerosing cholangitis is an extremely rare condition that has been reported in only few published cases so far in the literature. We highlight here the rarity of this condition and indicate the importance of its recognition. CASE PRESENTATION: We report two cases showing the manifestations of both primary biliary cholangitis and primary sclerosing cholangitis in two Tunisian female patients aged 74 and 42 years, respectively. The first case is a woman who was initially diagnosed with decompensated cirrhosis. Magnetic resonance cholangiopancreatography showed multiple strictures of the common bile duct, and histological findings led to the diagnosis of primary biliary cholangitis/primary sclerosing cholangitis. She was successfully treated with ursodeoxycholic acid. The second case is a middle-aged woman, suffering from primary biliary cholangitis and who was treated with ursodeoxycholic acid. At her 12 month follow-up appointment, she presented with a partial clinical and biochemical response. Tests showed normal thyroid function, liver autoimmune tests for autoimmune hepatitis were negative, and celiac disease markers were also negative. The diagnosis of overlap syndrome of primary biliary cholangitis/primary sclerosing cholangitis was finally made on the results of magnetic resonance cholangiopancreatography that showed multiple strictures of the common as well as intrahepatic bile ducts. The patient was put on ursodeoxycholic acid at a higher dose. CONCLUSIONS: Our cases raise awareness for this rare condition and indicate the importance of recognizing a possible overlap syndrome, especially in patients with primary biliary cholangitis, to optimize treatment. We suggest considering the overlap syndrome of primary biliary cholangitis/primary sclerosing cholangitis when a patient presents with the diagnostic criteria of both diseases.

Cannabinoid Hyperemesis Syndrome: A Case Study in a Tunisian Young Man.

The increasing prevalence of cannabis use in the world requires awareness of cannabis-related disorders such as cannabinoid hyperemesis syndrome. This syndrome includes cyclic episodes of nausea, vomiting, and the learned behavior of hot bathing in individuals with chronic cannabis use. We present the case of a suspected cannabinoid hyperemesis syndrome that required a review of the literature to retain the diagnosis. The following case illustrates how cannabinoid hyperemesis syndrome awareness may lead to the diagnosis.

Intrahepatic cholangiocarcinoma mimicking a liver abscess.

Intrahepatic cholangiocarcinoma masquerading as liver abscess, and presenting with fever, is a very rare situation and should be considered in nonresolving liver abscess. Only few cases were reported in the literature. This entity is characterized by late diagnosis and poor prognosis.

Hepatocellular carcinoma arising from hepatic adenoma in a young woman.

Hepatocellular carcinoma (HCC) arising from hepatic adenoma is an infrequent situation. Only a few cases were reported in the literature. We present a rare case of hepatocellular carcinoma arising from HA in a young woman with no medication history of oral contraceptives. Surgical resection is the only available treatment.

Isoniazid-induced pellagra in a patient with Crohn's disease.

Isoniazid preventive therapy in malnourished patients with Crohn's disease has a potential of inducing pellagra but still a very rare situation. No cases of isoniazid-induced pellagra in patients with Crohn's disease were reported in the literature. Pellagra can be easily treated if timely diagnosed.

Dysphagia related to diffuse idiopathic skeletal hyperostosis (DISHphagia).

The important clinical teaching of our case is that dysphagia most likely caused by an extradigestive pathology; hence, imaging studies of the neck is very important in the evaluation process.

Unexpected diagnosis of basal cell carcinoma in a patient presenting with a secondary location of Leishmania parasites in the skin.

We report here a case of simultaneous cutaneous and visceral manifestations due to Leishmania L. infantum diagnosed in an immunocompetent adult. We describe a 74-year-old woman from Tunis, Tunisia, who presented a biologically confirmed visceral leishmaniasis infection concomitant with arm ulceration which appeared 2 years before. Leishmania DNA was detected by ITS PCR in both buffy coat and dermal scrapping of the arm lesion. Sequencing revealed that the 2 isolated strains corresponded to L. infantum and were 100% identical. The symptoms of visceral leishmaniasis responded to amphotericin B with rapid healing. However, the skin lesion did not improve although Leishmania PCR on dermal sample became negative. This location is probably secondarily to lymphatic or blood dissemination during the systemic visceral leishmaniasis infection. It would be favored by the inflammatory environment induced by the basal cell carcinoma subsequently diagnosed.

Rheumatologic manifestations during chronic viral hepatitis C.

INTRODUCTION: Chronic hepatitis C (CHC) is assimilated to a systemic disease because of its multiple extrahepatic manifestations particularly rheumatological. AIM: To determine the prevalence and the characteristics of rheumatological manifestations (RM) associated with CHC. METHODS: a retrospective study including all patients suffering from CHC followed over a period of 11 years (2002 - 2012) at the department of gastroenterology B at La Rabta hospital. Were excluded all patients co-infected by hepatitis B virus or by human immunodefficiency virus and those having decompensated cirrhosis. Different RM were collected and analyzed according to the epidemiological, clinico-biological, immunological, virological and histological data of the CHC. RESULTS: two hundred and four patients affected by CHC were included, meanly aged by 52 years [22- 66 years]. The sex-ratio was 0,46. RM were noted in 76 patients (37,25%) dominated by inflammatory polyarthralgia of big joints (88,15%). Non erosive arthritis was observed in a woman, myalgia was noted in 11 cases (14,47%) among them, 2 appeared under antiviral treatment. Dryness syndrome was observed in 17 cases (22,36%). RM were associated to other extrahepatic manifestations of CHC in 69,7% of cases, notably to mixed cryoglobulinemia (MC) (60%) and to non specific antinuclear antibodies (21,6%). A partial to total amelioration of RM was noted in most patients under antiviral treatment often associated to symptomatic measures. In univariate analysis, only female sex and presence of MC were significantly correlated to the presence of RM. CONCLUSION: RM occur frequently inCHC and are dominated by arthralgia, myalgia and dryness syndrome. Authentic arthritis are uncommon and constitute a diagnostic problem particularly when they inaugurate the disease. MC is the immunological factor the most associated with RM. MR treatment remains mainly antiviral.

Chronic gastric volvulus.

Gastric volvulus is an abnormal rotation of the stomach around his axis. The chronic presenting, as the acute one, is considered as a surgical emergency. We report 4 cases of chronic gastic volvulus. In 2 cases, it was a mesenterico-axial volvulus while in the 2 other cases it was an organo-axial volvulus. The barium enema made the diagnosis in all cases. The volvulus was secondary to a hernia in 3 cases and an agenesis of left diaphragmatic dome with ligament laxity in 1 case. All the patients underwent surgery. The laparoscopic approach was used in two patients.

About an aggressive bone lesion.

We report here a case of hyperparathyroidism with disseminated brown tumors mimicking malignancy. The important clinical teaching of our case is that hyperparathyroidism can take various aspects. Plasma parathyroid hormone concentration should be measured in all patients with multiple bone lesions.

[Unusual cause of sternal swelling]. / A propos d'une tuméfaction sternale.

We here report the case of a 64-year old woman followed up for cirrhosis due to hepatitis C virus who didn't respond favorably to antiviral treatment. During her last follow-up visit, she reported the occurrence of painful anterior chest hump. Physical examination showed hard immobile mass at the level of the manubriosternal joint. The patient underwent sternoclavicular CT scan, which objectified expansive osteolytic lesion centered upon the sternal manubrium invading the soft tissues (A, B). The biopsy revealed malignant papillary epithelial tumor expressing pancytokeratin and CK7. Patient's profile suggested the presence of a metastasis from cholangiocarcinoma or osteophilic tumor. Gynecological examination, associated with mammogram and breast ultrasound, excluded a gynecological origin. The diagnosis of thyroid tumor was excluded on ultrasound. Chest CT scan showed multiple secondary pulmonary nodules. Abdominal angioscanner revealed the presence of a tissutal hepatic mass measuring 6 cm invading the portal bifurcation with portal vein thrombosis, suggesting hepatocellular carcinoma (HCC) (C). Given the discrepancy between anatomopathological data and morphological data, immunohistochemical study of the anti-Hep-Par-1 was performed, showing antibody expression on tumor cells. The diagnosis of manubriosternal metastasis from poorly differentiated hepatocellular carcinoma was retained. The patient was recommended to undergo chemotherapy. Bone metastases revealing HCC are exceptional. However, HCC should be suspected in patients with lytic bone lesion, especially in patients with chronic liver disease. Given its poor prognosis, treatment is based on palliative therapy with the aim of improving mainly the quality of life of patients.

Colonoscopy in elderly: feasibility, tolerance and indications: about 901 cases.

BACKGROUND: Colonoscopy is the standard investigation for colonic disease, but clinicians often are reluctant to refer elderly patients for colonoscopy because of a perception of higher risk and a high rate of incomplete examinations. AIMS: To evaluate feasibility and tolerance of this investigation in elderly and to review the most frequent indications of colonoscopy in these patients. METHODS: A pilot retrospective study including 901 patients from January 2005 to December 2009; divided into two groups. Group (I) included patients 75 years old and more, group (II) included patients 45 years old or less. All those patients underwent colonoscopy at the gastroenterology department of Charles Nicole hospital. RESULTS: The 1st group included 231 patients, and the 2nd group included 670 one. A past history of colorectal cancer was more frequent in the group I (33.3% versus 9.90%; p<0.05) however history of chronic inflammatory bowel disease was more frequent in group II (0 versus 40.6%; p<0.05). The main indication of colonoscopy was constipation in group II (6.1% versus 27%; p<0.05) and chronic diarrhoea in group I (42.9% versus 16.4%; p<0.05). Bowel preparation was poor in 30.4% cases of the group I and 12.9% of group II (p<0.05). The tolerance was similar in the two groups. The incomplete colonoscopy rate was higher in the group I (38.3% versus 23.4%; p<0.05). The most frequent cause of colonoscopy interruption was the poor preparation in group I and the bad tolerance in group II. Diverticular disease, polyps and colorectal cancers prevailed in group I, whereas inflammatory bowel disease was current in group II. CONCLUSION: In elderly patients, colonoscopy is safe, well tolerated and offers a good diagnostic yield. Its non completion was essentially due to the poor preparation. Sedation did not seem essential. The optimisation of results of colonoscopy requires an improvement of quality preparation.