Factors predictive of complicated or severe alcohol withdrawal in alcohol dependent inpatients.

OBJECTIVE: In a department of hepatology and gastroenterology, a significant number of patients are hospitalized for alcohol withdrawal. The aim of this retrospective study was to identify factors predictive of severe or complicated alcohol withdrawal in order to improve patient management. METHODS: Between June 2002 and June 2005, 182 patients admitted for alcohol dependence according to the DSM-IV classification were enrolled in this study. A unique management protocol for alcohol withdrawal was applied for all patients. The Cushman score was recorded on day 1, 2 and 3 to assess the severity of alcohol withdrawal. We searched for correlations between epidemiological, clinical and biological data and the Cushman score. RESULT: The study population included 136 (74.7%) men and 46 (25.3%) women, mean age 47.6+/-10.1 years. One hundred and eighteen patients (64.8%) were referred from a specialized outpatient clinic and 64 (35.2%) patients were referred from the emergency unit. The mean and median Cushman scores on day 1, 2 and 3 were: 5.1 and 5; 3.9 and 4; 2.3 and 2, respectively. Twenty patients (11.0%) and five patients (2.7%) had scores greater than or equal to 8 and greater than 12, respectively. The proportion of patients with Cushman score greater than or equal to 8 on day 1 was significantly greater in patients referred from the emergency unit than in those referred from a specialized outpatient clinic (p=0.002). Mean alanine aminotransferase level on day 1 was significantly higher in patients with a score greater than or equal to 8 than in those who had a score less than 8 (112.1+/-44.4 UI/L versus 78.4+/-11.8 UI/L; p=0.046). Referral via an emergency unit as well as an alanine aminotransferase level greater than 1.5fold the upper limit of the normal range were independent predictive factors for a Cushman score greater than or equal to 8. In conclusion, severe alcohol withdrawal (Cushman score>or=8) is significantly associated with initial management in an emergency unit and serum alanine aminotransferase level greater than 1.5 fold the upper limit of the normal range. These predictors should be monitored in order to appropriately adapt the therapeutic schedule.

[Epiploic appendagitis: report of a case]. / Appendagite épiploïque primitive : à propos d'un cas.

Primary epiploic appendagitis are considered to be a rare cause of acute abdomen. They are frequently misdiagnosed as either acute appendicitis or acute diverticulitis and the diagnosis is usually made during surgery. We report a case in which computed tomography (CT) suggested the diagnosis and helped in avoiding unnecessary surgery.

Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome?

BACKGROUND: Obesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship. METHODS: Morbidly obese patients [body mass index (BMI) >40 or >35 kg/m(2) in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a 24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording. RESULTS: Sixty-eight patients [59 women and 9 men, age 39.1 +/- 11.1 years; BMI 46.5 +/- 6.4 kg/m(2) (mean +/- SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at pH <4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES) pressure was lower in patients with GERD (11.6 +/- 3.4 vs 13.4 +/- 3.6 mm Hg, respectively; P = 0.039). There was a relationship between AHI and BMI (r = 0.337; P = 0.005). Patients with OSA were older (40.5 +/- 10.9 vs 33.5 +/- 10.4 years; P = 0.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; P = 0.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (P = 0.031) and with OSA (P = 0.045) but not with gender, age, and BMI. CONCLUSION: In this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly associated with LES hypotonia and OSA independently of BMI.

[A case of acquired angioedema]. / Un cas d'oedème angioneurotique acquis.

We report the case of a 46 year-old woman presenting an acquired angioedema. Angioedema is an C1 inhibitor deficiency. Patients present recurrent non inflammatory swelling of the head and extremities and recurrent attacks of severe abdominal pain. This clinical presentation is non specific : investigation of complement is useful for diagnosis. Laboratory testing show low serum levels of C4 with normal levels of C3. Low C1 esterase inhibitor confirm the diagnosis. If acquired angioedema, a cause must be searched.