Predictive factors of recurrence in spontaneous bacterial peritonitis in Tunisian patients with cirrhosis.

Introduction: Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. Aim: To assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Materials & methods: We conducted a retrospective study including patients with cirrhosis having a first episode of SBP. Results: A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. The mean time to onset of the first SBP recurrence from the first episode was 32 days. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score. Conclusion: There was no impact on survival of recurrent SBP compared with the first SBP episode.

Recurrent spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is associated with poor prognosis. The aims of this study were to assess the prevalence and the risk factors for recurrence and to evaluate its impact on the prognosis. Thus, we conducted a retrospective study including patients with cirrhosis having a first episode of SBP. A recurrence of SBP was identified in 43.4% of the patients who survived after a first episode of SBP. Recurrence factors were endoscopic hypertensive signs, a positive ascites culture, diarrhea and the MELD score.

Predictors of postoperative recurrence in a cohort of Tunisian patients with Crohn's disease.

Background: The aim of our study was to evaluate the frequency and risk factors of clinical postoperative recurrence in Tunisian patients with Crohn's disease (CD). Methods: Clinical data of 86 patients with CD who underwent ileocolonic resection at University Hospital of Sahloul in Tunisia were retrospectively reviewed. Continuous data are expressed as median (interquartile range), and categorical data as frequencies and percentages. Multivariate Cox proportional hazard regression analysis was conducted to identify the risk factors of postoperative clinical recurrence. Results: A total of 86 patients with CD were included in this study. During follow-up, 21 patients (24.4%) had clinical recurrence. The cumulative clinical recurrence rate was 9.3% at 1 year and 20.9% at 5 years. In univariate analysis, predictive factors of postoperative clinical recurrence were active preoperative smoking (p = 0.008), ileal location of the disease (p = 0.01), active CD [Crohn's Disease Activity Index (CDAI) > 150] (p = 0.04), duration of disease before first surgery <9.5 months (p = 0.027), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.005). In multivariate analysis, only smoking (p = 0.012), duration of disease before first surgery <9.5 months (p = 0.048), and limited resection margins (<2 cm) from macroscopically diseased bowel (p = 0.046) were confirmed to be independent factors of clinical relapse. Conclusion: Smoking, duration of disease before first surgery <9.5 months, and limited resection margins (<2 cm) from macroscopically diseased bowel were independent risk factors for clinical recurrence. Based on these factors, patients could be stratified in order to guide postoperative therapeutic options.

Spectrum of acute hepatitis and its clinical outcome in a central region in Tunisia.

INTRODUCTION: given the lack of studies on acute hepatitis (AH) in Tunisia, we carried out this study to find the etiological spectrum and clinical profile of AH and to investigate the impact of viral etiology on the outcomes of AH. METHODS: retrospective descriptive study collecting all patients with AH from 2010 to 2017. The data were compared between two groups (viral AH and non-viral AH). RESULTS: one hundred and three patient´s files were included. The average age of our patients was 30.15 years. An etiology was found in 92 patients (89.3%). The viral etiology was found in 70 patients (76.1%). Hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV) and cytomegalovirus (CMV) were in the cause in 52, 16, 1 and 1 patient respectively. Elsewhere, it was toxic hepatitis in 10 patients (10.9%) including 7 of drug-related AH. Budd-Chiari syndrome and autoimmune hepatitis with acute onset were reported in 3 (3.3%) and 7 (7.6%) patients, respectively. Patients with viral AH were younger than those with non-viral AH (p = 10-3). There was more recourse to hospitalization for non-viral AH. Patients with viral AH had a higher mean aminotransferase (ALT) level than those with non-viral AH. The liver damage was more severe in the non-viral AH group with lower PT. There was more severe form, more transition to chronicity and more deaths in the non-viral AH group. Conclusion: the results found in our study concerning the distribution of the etiologies of AH as well as their evolutionary aspects are consistent with the data in the literature.

Synchronous Hepatocellular Carcinoma in a Patient with Primary Gastric Cancer: An Exceptional Association.

Hepatocellular carcinoma (HCC) is the most frequent type of liver cancer. Liver cirrhosis of any etiology is considered the main risk factor for the development of HCC. However, HCC in noncirrhotic livers remains an uncommon finding. The association of HCC with a primary gastric adenocarcinoma was described in the literature as part of a hepatoid adenocarcinoma which is a special type of primary gastric carcinoma characterized by histologic similarities to HCC with excessive production of α-fetoprotein. Herein, we report the case of a 50-year-old male patient, with no history of pre-existing liver disease, who was admitted due to epigastric pain and vomiting. He was diagnosed with HCC in noncirrhotic liver associated with primary gastric adenocarcinoma. To our knowledge, this is the first case report of synchronous HCC and gastric cancer with no hepatoid adenocarcinoma features in Tunisia.

Cirrhotic cardiomyopathy.

The presence of cardiocirculatory dysfunction in liver cirrhosis has been described since 1960 and it was exclusively attributed to alcoholic cardiomyopathie. Only in the last two decades, the term of cirrhotic cardiomyopathy (CCM) was introduced to describe cardiac dysfunction in patients with cirrhosis. This entity is currently underdiagnosed because the disease is usually latent and manifests when the patient is under stress. However, overt cardiac failure has been described after transjugular intrahepatic portosystemic shun and liver transplantation. The diagnosis of CCM is still difficult to determine because of the lack of specific diagnosis tools. CCM is characterized by systolic dysfunction, diastolic dysfunction and electrophysiological abnormalities. At present, there is no specific treatment outside liver transplantation in the light of increased mortality and postoperative complications.Our review provides an overview of CCM, its definition, prevalence, pathogenic mechanisms, clinical presentation, various explorations and management in light of the most recent published literature.

Vogt-Koyanagi-Harada syndrome and Crohn's disease: an exceptional association.

Vogt-Koyanagi-Harada disease (VKH) is a rare, multisystem disease of melanocyte-containing organs. It is characterized by diffuse, granulomatous inflammation involving various organs. It has been reported to occur in association with other autoimmune disorders. We report the case of a female patient who was diagnosed with VKH at the age of 4 years and who was treated with corticosteroids until the age of 16. Twenty years later, Crohn's disease was diagnosed, with a severe flare-up. Three cases of VKH associated with ulcerative colitis have previously been reported anecdotally but, to our knowledge, this is the first case occurring in association to Crohn's disease.

Quality of life in inflammatory bowel disease in Tunisian patients.

BACKGROUND: The management of the health-related quality of life (HRQL) is increasingly considered as an important treatment goal in chronic diseases including inflammatory bowel diseases (IBD). AIM: The aim of our study was to determine the impact of IBD on HRQLand identify the factors involved in the deterioration of HRQL in these patients. METHODS: We conducted a case-control study including 108 patients; 66 had Crohn's disease (CD) and 42 had ulcerative colitis (UC). In the measurement of HRQL, we used a general questionnaire "Short Form 36: SF36" and a specific questionnaire "Tunisian Inflammatory Bowel Disease Questionnaire: T-IBDQ". RESULTS: HRQL of patients was worse than controls with a statistically significant difference for six of the eight dimensions of the SF 36 "Physical Functionning PF", "Role Physical RP", "General health GH","SocialFunctionning SF "," Mental Health MH "and" Role Emotional RE "as well as the Mental summary score (MCS) and the Physical summary score (PCS ) (p <0.05). The factors involved in the alteration of HRQL were: age <30 years, poor socioeconomic conditions, disease activity, use of corticosteroids, a number of surgeries ≥2 and anterior hospitalization history. CONCLUSION: In this study, IBD cause impaired HRQL affecting almost all areas of the SF 36 questionnaire. Incriminated factors may be related to the patient, disease and even treatment.

Unusual case of duodenobiliary fistula complicating Crohn's disease successfully treated with Adalimumab.

Crohn's disease (CD) is characterized by transmural inflammation of the gastrointestinal tract, which predisposes to the formation of fistula. Duodenal involvement occurs in less than 5% of cases and often leads to clinically relevant strictures. However, fistula formation in the duodenum is exceptional. Herein, we report an unusual case of duodenobiliary fistula due to CD occurring in a 65-year-old patient who was successfully treated by anti-tumor necrosis factor (TNF) agents. This case report highlights the efficacy of anti-TNF alpha agents in the treatment of a bilioenteric fistula because it increases the probability of clinical remission and mucosal healing and therefore reduces the need for surgical treatment which may be associated morbidity.

Antiphospholipid Antibodies and Procoagulant Profile in Tunisians With Inflammatory Bowel Diseases.

The hypercoagulable state accompanying inflammatory bowel diseases (IBDs) is still poorly understood. The aim of this study was to assess antiphospholipid antibodies (APAs) and a large panel of inherited and acquired thrombotic markers simultaneously in a sample of Tunisian patients with IBD. In total, 89 consecutive patients with IBD (mean age 38 ± 15 years; 48 with Crohn disease and 41 with ulcerative colitis) and 129 controls were prospectively evaluated for immunoglobulin (Ig) G, IgM, and IgA antibodies against cardiolipin (aCL), ß2glycoprotein I (aß2GPI), and prothrombin (aPT); IgG and IgM antibodies against phosphatidic acid (aPA), phosphatidylinositol (aPI), and annexin V (aAnnV); lupus anticoagulant (LA); coagulation factors; natural inhibitors; and thrombotic genetic polymorphisms. Levels of fibrinogen, factors II, V, and VIII and von Willebrand factor, antithrombin, and protein C were significantly higher in patients with IBD than in controls (P < .05 for all comparisons). At least 1 APA subset was detected in 54 patients. The frequencies of antibodies against anionic phospholipids-aCL, aPI, and aPA-in patients with IBD were 15.9%, 21.3%, and 14.6%, respectively. The frequencies of antiphospholipid cofactor antibodies were 39.8% for aß2GPI and 15.7% for both aAnnV and aPT. Isolated aß2GPI IgA was detected in 22 patients, and 12 (13.5%) patients had LA. The IgA aß2GPI antibodies were frequently detected in Tunisian patients with IBD. These results are of potential diagnostic, prognostic, and therapeutic interest.

Suspected azathioprine induced liver cirrhosis: an unusual side effect.

In recent years, the hepatotoxic potential of thiopurines, in particular 6-thioguanine (6-TG) has been discussed in literature. However, cirrhosis was exceptionally reported. We report the case of a 56-year-old woman with ileocaecal Crohn's disease treated with azathioprine. After taking azathioprine (2 mg/kg daily) for four years, she underwent surgical treatment for acute intestinal obstruction. In peroperative, we noticed a cirrhotic liver. A surgical biopsy was performed and the diagnosis of cirrhosis was confirmed. Autoimmune and viral liver diseases were ruled out by laboratory parameters. Therefore, Azathioprine is believed to be the causative actor for inducing liver cirrhosis. Thus, treating inflammatory bowel disease effectively while trying to limit iatrogenic disease is a continuous struggle.

[Primary biliary cirrhosis: a retrospective study of 36 cases]. / La cirrhose biliaire primitive: étude rétrospective d'une série de 36 cas au centre Tunisien.

BACKGROUND: Primary biliary cirrhosis is a rare cholestasis liver disease affecting the women of mature age,it association with Autoimmune hepatitis defined the overlap syndrome. AIM: It was to determine epidemiological, clinic-biological, immunological, histological, therapeutic and evolutive characteristics of PBC and to compare them to those in subjects having an overlap syndrome. METHODS: It is a retrospective study grouping all the cases of PBC hospitalized over a period of 15 years (1995-2009) in the hepatogastro-enterology department at Sahloul hospital in Sousse. RESULTS: Thirty six cases were grouped over the period of the study. They were all women. The mean age was 54.5 years (28-79). The disease was symptomatic at the moment of diagnosis in 75% of the cases. The functional signs revealing the disease were principally asthenia, present in 69.4% of the cases, followed by jaundice and prurit. Cholestasis was constant in all the patients, stage III of scheuer was the most frequent in the patients (25%) followed by stage IV (22%). OS was present in 1/3 of the patients; the treatment is based on the prescription of urso-desoxycholic Acid associated with corticoids and with immunosuppressors in the case of OS. The average survival of the patient having PBC and OS was comparable. It was respectively of 61.8 and 55.9 months. CONCLUSION: Our results as well as the literature reveal the rarety of this disease and its predominance in women. PBC has to be diagnosed at an early stage to guarantee a better response and a better survival of the patients.

[Prévalence de l'infection à Helicobacter pylori et des lésions endoscopiques hautes chez les diabétiques: Etude cas/témoins]. / Prevalence of helicobacter pylori infection and gastroscopic finding in diabetic patients: a case-control study.

BACKGROUND: Current data on the prevalence of Helicobacter pylori infection in dyspeptic diabetic patients are contradictory in the literature. AIM: the aim was to assess the prevalence of Helicobacter pylori infection, gastroscopic lesions, and gastric histopathological lesions, in dyspeptic diabetic patients. METHODS: It was a case-control study collecting 394 dyspeptic patients (194 diabetic and 200 nondiabetic patients). RESULTS: The average age of patients was 47 years. 144 patients (47%) were male and 150 patients (53%) were female. The two patient groups were matched for age and sex. The prevalence of Helicobacter pylori infection was comparable between the two groups of patients (85% in diabetics versus 90% in the controls). The frequency of gastroscopic lesions was 50% in diabetics and 55% in controls with no significant difference between the two groups. At histology, the prevalence of chronic gastritis, intestinal metaplasia, and gastric atrophy was 85%, 13% and 39% respectively in the group of diabetic patients. These results were comparable to those found in patients without diabetes. CONCLUSION: Our work shows no difference between diabetics and non-diabetics on the prevalence of Helicobacter pylori infection, gastroscopic, and gastric histopathological lesions.

Sclerosing Cholangitis in Behçet's Disease.

Introduction. Sclerosing cholangitis is characterized by an inflammatory and fibrotic lesion of intra- and/or extrahepatic bile ducts. When a causal mechanism of a bile duct lesion is identified, the sclerosing cholangitis is considered secondary. The vasculitis, including the Behçet disease, is cited as a probable cause of the ischemia and the sclerosing cholangitis. No cases of extrahepatic secondary sclerosing cholangitis have been reported to date. Case Report. We report the first case of secondary sclerosing cholangitis of the extrahepatic bile ducts associated with Behçet disease in a male who is aged 43, with a previous history of the angio-Behçet followed by complications of thrombophlebitis and a cerebral thrombophlebitis, and who has a cholestatic jaundice. The diagnosis has been carried out by the MR cholangiopancreatography which has objectified a moderate distension of the intrahepatic bile ducts upstream of regular stacked parietal thickening of the main bile duct. The patient has been treated successfully with the ursodeoxycholic acid and the placement of a plastic stent. Conclusion. This diagnosis should be mentioned to any patient with vasculitis and who has a cholestatic jaundice.

[Hepatic steatosis in chronic hepatitis B: prevalence, risk factors, and impact on fibrosis and therapeutic response]. / La stéatose hépatique au cours de l'hépatite chronique B: prévalence, facteurs de risque, et effet sur la fibrose et la réponse thérapeutique.

BACKGROUND: steatosis is a common injury in chronic hepatitis C, but this association has not been sufficiently studied in chronic hepatitis B. aim: To evaluate the prevalence of hepatic steatosis in chronic hepatitis B and determine its association with various histologic, biochemical, virological, and metabolic diseases, and its effect on fibrosis and therapeutic response. METHODS: Our study was compiled 133 patients with chronic hepatitis B who received no antiviral therapy and who had a liver biopsy. Our patients were divided into 2 groups: 51 patients (38.3%) had steatosis (Group I), while 82 (61.7%) had no steatosis (Group II). RESULTS: In groupeI, the average age, BMI, cholesterol, triglycerides, and glucose were significantly higher than the group without steatosis in univariate study (P <0.05). In multivariate analysis, only high BMI and hypertriglyceridemia were included.No significant difference between the two groups was observed in the rate of transaminases, HBeAg status, viral load (P> 0.05). Steatosis doesn't influence fibrosis stage and therapeutic response. CONCLUSION: During chronic hepatitis B, steatosis appears to be the result of metabolic factors of the host rather than the effect of the virus. Hepatic steatosis does not seem to influence the progression of liver fibrosis, or therapeutic response, however, the role of steatosis should be better studied by prospective longitudinal clinical studies on large populations of patients.

The natural history of hepatitis B virus cirrhosis after the first hepatic decompensation in Tunisia.

AIM: To define the natural long term course of viral B cirrhosis after the onset of hepatic decompensation and to determine the predictive factors of death. METHODS: Retrospective longitudinal study including 77 cases of viral B cirrhosis among 192 consecutive patients with cirrhosis, hospitalized between 1997 and 2005 for the first hepatic decompensation. All those patients were followed- up until death or until December 2006. The probability of survival after the first hepatic decompensation was calculated using the Kaplan Meier method. The predictive factors of death were determined through univariate and multivariate analyses with the Cox regression model. RESULTS: Fifty four men and 23 women with an average age of 54±14.9 years were hospitalized for the first decompensation of the viral B cirrhosis. The 77 patients had been under observation for an average period of 24.2 ±21.1 months. During that time 64% among them died. The probability of survival after decompensation was 47% in 2 years and 22 % in 5 years. During follow- up, ascites was the most frequent decompensation (85%) followed by hepatic encephalopathy (38 %), variceal hemorrhage (34 %), jaundice (30%), hepato renal syndrome (27%), hepatocellular carcinoma (21%), and spontaneous bacterial peritonitis (14%). At univariate analysis four factors were predictive of death: Child Pugh C score (p=0.009), hepatocellular carcinoma (p=0.01), rate of serum gammaglobulin superior to18g / l (p=0.008) and prothrombin time inferior to 50 % (p=0.02). According to the multivariate analysis only the rate of serum gammaglobulin superior to 18g /l was an independent predictive factor of mortality (p=0,001) with IC (95 %) [1.623 - 5.88]. CONCLUSION: In Tunisia, the prognosis of viral B cirrhosis after the first decompensation is bad, because a patient on 5 only was able to survive beyond 5 years. Ascites is the most frequent decompensation. Only the rate of serum gammaglobulin superior to 18g / l is an independent predictive factor of mortality.

Variceal band ligation in the prevention of variceal bleeding: a multicenter trial.

BACKGROUND/AIM: Variceal bleeding is a life-threatening complication of portal hypertension with a high probability of recurrence. Treatment to prevent first bleeding or rebleeding is mandatory. The study has been aimed at investigating the effectiveness of endoscopic band ligation in preventing upper gastrointestinal bleeding in patients with portal hypertension and to establish the clinical outcome of patients. PATIENTS AND METHODS: We analyzed in a multicenter trial, the efficacy and side effects of endoscopic band ligation for the primary and secondary prophylaxis of esophageal variceal bleeding. We assigned 603 patients with portal hypertension who were hospitalized to receive treatment with endoscopic ligation. Sessions of ligation were repeated every two to three weeks until the varices were eradicated. The primary end point was recurrent bleeding. RESULTS: The median follow-up period was 32 months. A total of 126 patients had recurrent bleeding. All episodes were related to portal hypertension and 79 to recurrent variceal bleeding. There were major complications in 51 patients (30 had bleeding esophageal ulcers). Seventy-eight patients died, 26 deaths were related to variceal bleeding and 1 to bleeding esophageal ulcers. CONCLUSIONS: A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

[Autoimmune hepatitis in Tunisia. Retrospective multicenter study of 83 cases]. / L'hépatite auto-immune en Tunisie. Étude multicentrique rétrospective de 83 cas.

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory condition of the liver of unknown etiology. Its epidemiological and anatomoclinical characteristics and its outcome were unknown in Tunisia. AIM: To analyse epidemiological, anatomoclinical, immunological and histological aspects of AIH and to determine factors predicting relapse after treatment and death of this disease in Tunisia. METHODS: Patients presenting with AIH between January 1996 and December 2004 were evaluated in retrospective multicentric study. The diagnosis of AIH was established according to the criteria of the revised score of the international autoimmune hepatitis group (1999) RESULTS: Eighty three patients were identified (70 female; mean age=49+17.9 years). 63% presented probable AIH and 37% presented definite AIH. Thirty two percent presented with the acute pattern. Eighty three per cent of cases were type I AIH and 5 % of cases were type II HAI. Fifty seven percent of the patients were cirrhotic at presentation. Associated autoimmune diseases was seen in 27 patients, dominated by diabetes, autoimmune thyroiditis and Sjögren's syndrome. An overlap syndrome was diagnosed in 25% of cases; primary biliary Cirrhosis-AIH in 20% of cases and primary sclerosing cholangitis-AIH in 5% of cases. Fifty patients were treated by glucocorticoids as monotherapy or in combination with azathioprine. Complete remission was achieved in 90% of cases. Fourteen percent relapsed within a median time of 12 months. Factors associated with relapse were: treatment with Azathioprine<18 months, absence of lobular necrosis and anti-nuclear antibody (+) profile. Mortality was observed in 17 % of cases. Factors associated with death were encephalopathy as an independent factor and treatment with Azathioprine<18 months. CONCLUSION: In Tunisia, epidemiological and clinical characteristics of AIH were similar to those reported in the literature but with a higher frequency of cirrhosis at presentation. Treatment with Azathioprine < 18 months was the main factor associated with relapse and represented with encephalopathy a factor associated with death.

[The particularity of Helicobacter pylori chronic gastritis in the west center of Tunisia]. / Les particularités de la gastrite chronique a Hélicobacter pylori au centre ouest de la Tunisie.

BACKGROUND: The Helicobacter pylori (HP) is strongly associated with chronic gastritis. The aim of our study was to determine prevalence of the HP chronic gastritis in the west center of Tunisia and to clarify the clinical and the histological particularities of this infection. METHODS: it is a prospectif study carried out from September 2002 to July 2005 and had included 352 patients. All the patients had an upper endoscopy in which five gastric biopsies were taken for a histological study. The biopsy specimens were fixed in 10% buffered formol and then included in paraffin. The specimens were cut at 4 microm and stained with Hematoxyline Eosine, modified Giemsa and Alcian bleu SAP. The histological examination revealed HP specimens, the lymphoplasmocytic infiltration, the gastritis activity, the gastric atrophy and the intestinal metaplasia according to Sydney system. RESULTS: They were 162 men and 190 women,with a mean age of 48.3 years. The erythematous antral gastritis was the most frequent at endoscopy (26.7%). The prevalence of HP chronic gastritis was 89% in patients with endoscopic lesions. The activity of the gastritis was 89.7% in the antrum and 52.2% in the fundus. The activity mean score in the antrum was 2, 1.8 and 0.3 respectively in the case of duodenal ulcer and gastric adenocarcinoma vs 0.68, 1.1 and 0.16 in gastric fundus. The prevalence of gastric atrophy was 35%. The atrophy was found in the antrum in 98% of cases. The prevalence of intestinal metaplasic was 11%. CONCLUSION: the HP chronic gastritis is very frequent in the west center of Tunisia. Its prevalence is found elevated since the adolescence. It predominate the gastric antrum. It is often associated with a duodenal ulcer rather than gastric cancer.