[Prevention of high digestive hemorrhage on NSAID]. / Prévention des saignements digestifs hauts sur AINS.

Peptic ulcer induced upper gastrointestinal hemorrhage is a frequent digestive emergency and is one of the most common cause of hospitalization. There are several intrinsic risk factors for peptic ulcer bleed such as advanced age, previous gastro-intestinal hemorrhage, male sex and the presence of Helicobacter pylori. In high risk patients for peptic ulcer disease, gastric protection measures should be considered, most often by treatment with proton pump inhibitors. The eradication of Helicobacter pylori should also be discussed for long-term treatments.

L'hémorragie digestive haute sur ulcère peptique est l'une des principales urgences digestives et compte parmi les causes les plus fréquentes d'hospitalisation. Certains facteurs de risque sont intrinsèques, tels que l'âge avancé, le sexe masculin, les antécédents de saignement digestif et la présence d'Helicobacter pylori, alors que d'autres sont extrinsèques comme la prise de médicaments anticoagulants ou d'anti-inflammatoires non stéroïdiens. Dans les situations à risque, des mesures de protection gastrique devraient être envisagées, le plus souvent par un traitement d'inhibiteurs de la pompe à protons. L'éradication d'Helicobacter pylori doit également être discutée pour les traitements au long cours.

[Bariatric surgery : complications and endoscopic treatment]. / Chirurgie bariatrique : complications et traitements endoscopiques.

Obesity is a major public health issue. Surgery is the most effective treatment to obtain weight loss, stabilize weight status and decrease comorbidities. Yet post-operative complications can be serious and their treatment can also be a real challenge. The low invasive nature of endoscopy makes it an alternative to surgery. It can be used to diagnose and treat digestive hemorrhage, ulcers, stenosis, anastomotic leakage or fistula. This article aims to review the different bariatric surgical techniques, complications and their specific endoscopic treatment options.

L'obésité constitue un problème de santé publique majeur. La chirurgie demeure le traitement le plus efficace afin de favoriser la perte de poids, stabiliser le statut pondéral et diminuer les comorbidités chez ces patients. Les complications postopératoires peuvent cependant être graves et leurs traitements représentent un réel défi. Le caractère peu invasif de l'endoscopie en fait une alternative à privilégier face à la chirurgie. Elle permet de diagnostiquer et de traiter les hémorragies digestives, les ulcères, les sténoses, les lâchages anastomotiques ou encore les fistules. Dans cet article, nous passerons en revue les différentes techniques chirurgicales bariatriques, les complications qu'elles peuvent induire et les traitements endoscopiques qu'il est possible de réaliser.

[Benign esophageal strictures : endoscopic treatment options]. / Stenoses benignes de l'oesophage : quelle approche therapeutique ?

Bening strictures of the esophagus are a frequently encountered problem in endoscopy. Dilation by Savary-Gilliard dilators or balloon dilators is the first line treatment and relieves dysphagia in about 75 % of cases. Complex strictures are at higher risk of treatment failure than simple ones and are considered as refractory after repetitive unsuccessful dilations. Adjunction of locally injected corticoids favors outcome in strictures of peptic origin. Further treatment options of refractory strictures are endoscopic incision therapy in short ones and temporary self expandable metallic (SEMS), plastic (SEPS) or biodegradable stent insertion in complex ones. Ultimate rescue treatment consists in self bouginage or esophageal surgery.

Les sténoses œsophagiennes bénignes sont une pathologie fréquemment rencontrée en endoscopie. La distinction entre sténoses simples et complexes est importante en raison de leur réponse différente au traitement de première intention, à savoir la dilatation, qu'elle soit par bougies de Savary-Gilliard ou au ballon. En cas d'échec après trois dilatations, l'injection de corticoïdes peut être associée dans les sténoses à composante inflammatoire. La persistance d'une sténose malgré ce traitement définit une sténose réfractaire ; pour les sténoses courtes, l'incision endoscopique est une option thérapeutique et pour celles plus complexes, la pose d'une prothèse œsophagienne est à envisager. Des prothèses métalliques, plastiques et biodégradables temporaires sont utilisables avec des différences en termes de taux de migration et d'envahissement.

Tocilizumab-Induced Acute Liver Injury in Adult Onset Still's Disease.

Background. Tocilizumab, a monoclonal humanized anti-IL-6 receptor antibody, is used in treatment of refractory adult onset Still's disease (AOSD). Mild to moderate liver enzyme elevation is a well-known side effect, but severe liver injury has only been reported in 3 cases in the literature. Case. A young female suffering from corticoid and methotrexate refractory AOSD was treated by tocilizumab. After 19 months of consecutive treatment, she developed acute severe liver injury. Liver biopsy showed extensive hepatocellular necrosis with ballooned hepatocytes, highly suggestive of drug-induced liver injury. No other relevant drug exposure beside tocilizumab was recorded. She recovered totally after treatment discontinuation and an initial 3-day course of intravenous N-acetylcysteine with normalization of liver function tests after 6 weeks. Conclusion. Acute severe hepatitis can be associated with tocilizumab as documented in this case. Careful monitoring of liver function tests is warranted during tocilizumab treatment.

Clopidogrel and proton pump inhibitors--where do we stand in 2012?

Clopidogrel in association with aspirine is considered state of the art of medical treatment for acute coronary syndrome by reducing the risk of new ischemic events. Concomitant treatment with proton pump inhibitors in order to prevent gastrointestinal side effects is recommended by clinical guidelines. Clopidogrel needs metabolic activation predominantly by the hepatic cytochrome P450 isoenzyme Cytochrome 2C19 (CYP2C19) and proton pump inhibitors (PPIs) are extensively metabolized by the CYP2C19 isoenzyme as well. Several pharmacodynamic studies investigating a potential clopidogrel-PPI interaction found a significant decrease of the clopidogrel platelet antiaggregation effect for omeprazole, but not for pantoprazole. Initial clinical cohort studies in 2009 reported an increased risk for adverse cardiovascular events, when under clopidogrel and PPI treatment at the same time. These observations led the United States Food and Drug Administration and the European Medecines Agency to discourage the combination of clopidogrel and PPI (especially omeprazole) in the same year. In contrast, more recent retrospective cohort studies including propensity score matching and the only existing randomized trial have not shown any difference concerning adverse cardiovascular events when concomitantly on clopidogrel and PPI or only on clopidogrel. Three meta-analyses report an inverse correlation between clopidogrel-PPI interaction and study quality, with high and moderate quality studies not reporting any association, rising concern about unmeasured confounders biasing the low quality studies. Thus, no definite evidence exists for an effect on mortality. Because PPI induced risk reduction clearly overweighs the possible adverse cardiovascular risk in patients with high risk of gastrointestinal bleeding, combination of clopidogrel with the less CYP2C19 inhibiting pantoprazole should be recommended.