Hepatic myelopathy neurological complication of chronic liver disease: two case reports.

BACKGROUND: Hepatic myelopathy is a very rare neurological complication of chronic liver disease. Patients habitually present with progressive pure motor spastic paraparesis. This neurological dysfunction is almost always due to cirrhosis and portocaval shunt, either surgical or spontaneous. CASES REPORT: We report two cases of a 57-year-old man and a 37-year-old woman with progressive spastic paraparesis linked to cirrhosis and portal hypertension. The two patients are of Tunisian origin (north Africa). Magnetic resonance imaging of the spinal cord of two patients was normal, while brain magnetic resonance imaging showed a T2 hypersignals of the pallidums. These signs, in favor of hepatic encephalopathy in the two patients with cirrhosis with isolated progressive spastic paraparesis without bladder or sensory disorders, help to retain the diagnosis of hepatic myelopathy. CONCLUSION: Hepatic myelopathy is a severe and debilitating neurological complication of chronic liver disease. The pathogenesis is misunderstood and seems to be multifactorial, including the selective neurotoxic role both of ammonia and other pathogenic neurotoxins. Usually a pathological brain magnetic resonance imaging showing a hepatic encephalopathy was documented, contrasting with a normal spinal cord magnetic resonance imaging that contributed to diagnosis of hepatic myelopathy. Conservative therapies such as ammonia-lowering measures, diet supplementation, antispastic drugs, and endovascular shunt occlusion show little benefit in improving disease symptoms. Liver transplantation performed at early stage can prevent disease progression and could probably allow for recovery.

Treatment of Helicobacter pylori infection 14-day concomitant quadruple therapy versus triple therapy: A parallel double-blind randomized controlled trial.

Background and Aims: Successful Helicobacter pylori (Hp) eradication with the traditional 7-day course of proton pump inhibitor triple therapy is declining. Prolonging therapy to 14 days is associated with better eradication rates. Most learned societies recommend concomitant quadruple therapy (QC) as a first-line alternative therapy for this bacterial infection. The aim of this study is to compare the efficacy and safety of triple therapy (TT) and QC for the eradication of Hp infection. Methods: A parallel double-blind randomized controlled trial was conducted. The diagnosis of Hp infection was made by pathological examination of gastric biopsies. Patients were randomly assigned to two treatment groups: either QC (esomeprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily) or triple therapy (esomeprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses) for 14 days. The efficacy of the treatment is defined by Hp eradication attested by a negative breath test performed 6 weeks after the completion of treatment. Treatment outcomes were compared using the chi-square test, while binary logistic regression identified predictors of treatment failure. Results: Ninety-two patients were included. Forty-two patients belonged to the QC group and 50 to the TT group. No significant difference was noted between the two groups concerning the rate of Hp eradication either by intention to treat (81% vs. 72% respectively, p = 0.31) or per protocol (81.6% vs. 76.1% respectively, p = 0.54). Likewise, there was no difference between the two groups in terms of tolerance to treatment (59.5% for QC vs. 58% for TT, p = 0.88). No factor has been associated with treatment failure. Conclusion: There was no significant difference in the rate of HP eradication between the QC and the 14-day triple therapy. Neither regimen should be used topically because of their low eradication rates.

Developing learning objectives in postgraduate medical education for family medicine (Tunisia).

Introduction-Aim: The third cycle of medical studies (TCMS) lasts 3 years for the specialty of family medicine (FM) in Tunisia. The members of the FM committee of the Faculty of Medicine of Monastir (FMM) aimed to detail the learning objectives (LO) of residents in FM. METHOD: We used the Delphi method in 2 rounds including a group of experts called FM Learning Objectives Writing Group (FMLOWG) at the FMM. The FMLOWG included 74 university hospital physicians and FM internship supervisors. These members actively participated in the 10 meetings held during the month of March 2022. Three points were discussed: the identification of LOs; the development of training titles and the proposal of the teaching methods to be adopted. The writing was subdivided into 5 domains of LO: transversal, public health, typical population and by system. RESULTS: We identified 1359 LOs for FM residency, for which 552 were LOs per system (40.5%). The learning included 618 training session titles. Residents will have an academic training day every 3 weeks during 9 months for each TCMS year. CONCLUSION: A detailed, MF-specific consensus has been developed by majority of medical specialties. It will be a learning base for learners, a reference for supervisors and TCMS teachers.

Black esophagus: a case report.

INTRODUCTION: Acute esophageal necrosis, also known as black esophagus, is a rare digestive complication, frequently manifested by an upper gastrointestinal hemorrhage and occurs in patients with comorbidities. AIM: To report the case of a patient with a black esophagus revealed by an upper gastrointestinal hemorrhage. OBSERVATION: A 72-year-old patient with a history of diabetes mellitus, hypertension and ischemic heart disease was hospitalized in surgical intensive care unit for hemorrhagic shock induced by cholecystectomy. On the 7th postoperative day, the patient developed acute hematemesis. Gastroscopy showed circumferential necrosis, localized in the middle and lower third of the esophagus and stopped abruptly at the gastroesophageal junction. Gastric mucosa was strictly normal. The bulb and the first part of duodenum showed multiple superficial ulcers without signs of recent hemorrhage. The patient was placed on absolute diet and total parenteral nutrition associated with high-dose intravenous proton pump inhibitor. Second-look gastroscopy, performed six days later, showed a significant improvement in esophageal lesions. The evolution was marked by the occurrence of pneumonia complicated by septic shock which caused patient's death. CONCLUSION: Black esophagus is a rare pathology of multifactorial etiology. Treatment is based on proton pump inhibitors in combination with resuscitation measures to control comorbidities. Mortality remains high due to the seriousness of comorbid disease states often associated with this condition.

Primary biliary cholangitis : therapeutic and evolving aspects about 46 cases.

BACKGROUND: Primary biliary cholangitis (PBC) is a rare autoimmune chronic liver disease whose prevalence is increasing. Medical treatment is based on ursodeoxycholic acid. It association with autoimmune hepatitis defined the overlap syndrome (OS). AIM: It was to determine therapeutic and evolving characteristics of PBC and to compare them to those in subjects having an overlap syndrome. METHODS: This was a retrospective study of all the patients' files with PBC from hepato-gastroenterology department at Monastir hospital from April 1999 to November 2013. RESULTS: Forty six patients were included in our study: 43 women and 3 men with an average age of 55 years. OS was retained in 13 patients. Cirrhosis was retained in 21 patients. Thirty-eight patients were treated with ursodeoxycholic acid (UDCA) associated with corticosteroids and immunosuppressors in the case of OS. After an average follow-up of 50 months [13-169 months] the overall response rate to UDCA was 55%. This rate was comparable between the 2 groups isolated PBC and OS. It was lower in the cirrhosis group compared with non-cirrhotic patients (40% vs 65%, p=0,06). One patient underwent a liver transplantation. Three patients were died as a result of decompensated cirrhosis. CONCLUSION: Our study highlights the frequency of cirrhosis at the time of PBC diagnosis, which may explain the low rate of response to UDCA. There is no difference in the therapeutic and evolving aspects between patients with isolated PBC and those with SC.