[Large iatrogenic colonic perforation treated by endoscopic suturing]. / Large perforation colique au cours d'une coloscopie traitée par fermeture endoscopique: rapport de deux observations.

Perforation of the colon during colonoscopy is still one of the most severe complications of this technique and occurs with a frequency of between 0.12 % and 0.2 % of cases after diagnostic colonoscopy and in up to 3 % of patients after therapeutic colonoscopy. The site of perforation is usually the sigmoid colon. The gold standard for treatment of this complication is surgery to be performed as rapidly as possible: a simple suture and peritoneal cleaning, with limited resection and anastomosis or colostomy only in case of confirmed fecal peritonitis. However, interventional endoscopy has made progress, in particular endoscopic suturing and Natural Orifice Transluminal Endocopic Surgery (NOTES) has been developed. There are several reports of endoscopically sutured perforated colons, most less than 10mm. We report our experience of two colonic perforations which were at least 10mm treated by endoscopic suturing with hemoclips: a perforated sigmoid diverticulum during simple colonoscopy in the first case and a large polypectomy by endoscopic mucosal resection of the ascending colon in the second.

[Cholangiography by magnetic resonance for detection of cholelithiasis: comparison with endoscopic retrograde cholangiography, operative cholangiography and percutaneous cholangiography]. / Colangiografía por resonancia magnética para la detección de litiasis de la via biliar principal: comparación con la colangiografía retrógrada endoscópica, Colangiografía per operatoria y colangiografía percutánea.

UNLABELLED: To evaluate the diagnostic efficiency of the magnetic resonance cholangiography (MRC) in the detection of main bile duct stones in a set of 102 patients. METHODOLOGY: Criteria of inclusion were: Clinic and biological suspicion of biliary stones obstruction with exams of first intention no contributive. We used the "turbo spin echo" sequences with thick slices in single shot mode and fine slides with reconstruction in 3D by a computer. Exams of reference were the endoscopic retrograde cholangiography (76.47%), an intraoperative cholangiography (20.59%) and a per-cutaneous cholangiography (2.94%). RESULTS: Stones of the main bile duct have been diagnosed at thirty-five patient (35.7%); we had 3 positive forgeries and 6 negative forgeries of the MRC. The sensitivity was 82,9%, the specificity of 95,5%, the positive predictive value and the negative predictive value were, respectively, of 90,6% and 91,4%. The observant variance test was excellent (kappa = 0.83). Mistakes of diagnosis of the MRC were bound to: stones less than 3 mms with a bile duct no dilated, malignant stenosis, structural details as the presence of a duodenal diverticula's or severe duodenitis and a certain difficulty to see the sphincter complex. CONCLUSION: Performances of the CIRM was good, and only in very particular cases, it was the origin of confusions.

Fatigue is associated with high circulating leptin levels in chronic hepatitis C.

BACKGROUND AND AIMS: Fatigue is a frequent and disabling symptom reported by patients with chronic hepatitis C (CHC). Its mechanism is poorly understood. Recent attention has focused on the role of leptin and energy expenditure in CHC. Our aims were to analyse fatigue in CHC and to determine its relationship with disease activity, resting energy expenditure (REE), circulating leptin, and tumour necrosis factor alpha (TNF-alpha). METHODS: Seventy eight CHC patients, 22 healthy controls, and 13 primary biliary cirrhosis (PBC) patients underwent measurements of REE, body composition, leptin, and TNF-alpha. All subjects completed the fatigue impact scale (FIS) questionnaire. A liver biopsy and viral load measurements were performed in all patients. RESULTS: Thirty eight of 78 CHC patients considered fatigue the worst or initial symptom of their disease. The fatigue score of patients was significantly higher than that of controls (53.2 (40.1) v 17.7 (16.9); p<0.0001) and was more pronounced in females (p=0.003). Leptin was increased significantly in CHC patients compared with controls (15.4 (20.7) v 6.4 (4.1) ng/ml; p<0.05). In CHC patients, the fatigue score correlated significantly with leptin corrected for fat mass (r=0.30, p=0.01). This correlation increased when the physical domain of fatigue was included (r=0.39, p=0.0009). Furthermore, a similar positive correlation was found in PBC patients (r=0.56, p=0.04). No correlation was found between fatigue and age, REE, liver function tests, viral load, or the METAVIR score in CHC patients. CONCLUSIONS: Fatigue is present in CHC patients and is more pronounced in females. The FIS questionnaire is clinically relevant and may be useful for future therapeutic trials aimed at reducing fatigue. Fatigue may be partly mediated by leptin.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]. / Maladies alcooliques du foie hospitalisées en Hépato-Gastroentérologie. Enquête multicentrique nationale.

OBJECTIVES: To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis. METHODS: A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis. RESULTS: Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

A new source of drug-induced acute pancreatitis: codeine.

A variety of drugs have been reported to cause acute pancreatitis during the past 40 years. We report the first series of four cases of acute pancreatitis related to codeine ingestion. Four patients (three female, mean age 50.2 yr) presented with clinical, biochemical, and radiological evidence of acute pancreatitis. All four had ingested a therapeutic dose of codeine 1-3 h before the onset of abdominal symptoms. Unintentional rechallenge occurred in three cases and was followed by recurrence of acute pancreatitis in all three. All patients made a full recovery. All four patients had had a previous cholecystectomy. The likely underlying pathophysiological mechanism is codeine-induced spasm of the sphincter of Oddi combined with sphincter of Oddi dysfunction related to a previous cholecystectomy. Codeine ingestion leads to acute pancreatitis in some individuals. Previous cholecystectomy seems to predispose to codeine-induced pancreatitis.

Chondrex (YKL-40), a potential new serum fibrosis marker in patients with alcoholic liver disease.

OBJECTIVES: Chondrex (YKL-40) is a mammalian member of a protein family that includes bacterial chitinases. The pattern of its expression in certain tissues such as human liver or cartilage suggests a function in remodelling or degradation of extracellular matrix. The purpose of this study was to assess whether circulating YKL-40 might be a serum fibrosis marker in alcoholics. METHODS: Plasma YKL-40 was determined in 146 consecutive heavy drinkers (106 men, 40 women; mean age, 49.2 +/- 9.0 years). Liver biochemical parameters and serum fibrosis markers such as hyaluronate were also measured. Fibrosis and inflammation in liver biopsy were evaluated using a semi-quantitative scoring system. RESULTS: Plasma YKL-40 increased in parallel with the severity of fibrosis (P<0.00001). YKL-40 also increased in the presence of hepatic inflammation (P<0.01). Receiver operating characteristic curves of Chondrex revealed that a threshold of 330 microg/l gave a specificity of 88.5%; however, the sensitivity was only 50.8%. Only 11.5% of patients without severe fibrosis displayed a Chondrex plasma level above this threshold. A positive correlation was found between Chondrex and hyaluronate (r=0.40, P<0.0001), and a negative correlation was shown between Chondrex and the prothrombin index (r=-0.37, P<0.0001). CONCLUSIONS: The severity of liver fibrosis is associated with elevated circulating Chondrex levels. The overlap in YKL-40 values prevents use of Chondrex in a screening programme. High levels of Chondrex (above 330 microg/l) are predictive of severe liver fibrosis. Increased plasma YKL-40 may reflect the remodelling of liver fibrosis in alcoholics.

Non invasive prediction of severe fibrosis in patients with alcoholic liver disease.

OBJECTIVES: The aim of this study was to assess the diagnostic accuracy of noninvasive markers of liver fibrosis in alcoholic liver disease. PATIENTS AND METHODS: Fifty-four clinical and biochemical parameters including serum fibrosis markers (hyaluronate and transforming growth factor beta1) were analyzed in 146 consecutive heavy drinkers (106 men, 40 women; mean age 49.2 years). Following liver biopsy, fibrosis was evaluated using a semi-quantitative scoring system (no fibrosis (0) to severe fibrosis (3 + )). Multivariate analysis was performed to determine the markers that were best correlated with the fibrosis score. RESULTS: Fifty-nine patients (40.4 %) had severe fibrosis (3 +) while 87 (59.6 %) had no fibrosis or moderate fibrosis (0 to 2 +). In multivariate analysis, serum hyaluronate and the prothrombin index were the best markers for the prediction of severe fibrosis. Hyaluronate and the prothrombin index had a diagnostic accuracy of 91.1 % and 89.7 %, respectively in the whole population. Finally, a significant negative correlation was found between hyaluronate and the prothrombin index (r =- 0.86, P <0.0001). CONCLUSIONS: Using only hyaluronate and the prothrombin index, 9 out of 10 alcoholic patients can be correctly classified according to the severity of liver fibrosis.

Endoscopic bilateral metal stent placement for malignant hilar stenoses: identification of optimal technique.

BACKGROUND: The aim of this study was to identify factors that facilitate bilateral insertion of metal stents in malignant hilar stenoses, for which plastic stents often result in incomplete drainage and subsequent cholangitis. METHODS: Between January 1994 and April 1998, we collected 45 cases of advanced (Bismuth stage II or higher) hilar malignant stenoses. The insertion technique was progressively modified and the success rate in the early period (1994 to 1995) was compared with that of a later period (1996) and the most recent period (1997 to 1998). RESULTS: Overall success rate was 73.3% (33 of 45). The success rates for the three periods were 50%, 67%, and 88% (p = 0.008), respectively. Cholangitis occurred in 3 of the patients with unilateral stents compared with 1 with bilateral stents. CONCLUSION: We have described a technique for endoscopic insertion of bilateral metallic stents for malignant hilar stenoses that results in high (>88%) and reproducible success rates.

[Prevalence of hepatitis C in patients with chronic inflammatory bowel disease in the region of Nice and evaluation of risk factors]. / Prévalence de l'hépatite C chez les malades atteints d'une maladie inflammatoire chronique de l'intestin dans la région Niçoise et évaluation des facteurs de risque.

OBJECTIVES: To estimate the prevalence of viral hepatitis C markers and to determine independent risk factors in a population of patients with inflammatory bowel disease. METHODS: We studied 117 consecutive out-patients (male/female, 53/64; mean age 41 +/- 16 yrs) with ulcerative colitis (43 patients) or Crohn's disease (74 patients). Anti-hepatitis C virus antibodies were tested with a third generation Elisa test. The following risk factors were tested for each patient: duration of inflammatory bowel disease, number of colonoscopies, history of surgical procedures, blood transfusions, intravenous drug abuse and immunosuppressive treatments. RESULTS: The seroprevalence of hepatitis C virus was 5.98% (7/117). The only risk factor independently associated with serological markers for hepatitis C virus was blood transfusion (odds ratio: 7.77; confidence interval: 95% (1.63-49.09); P=0.012). CONCLUSIONS: The prevalence of hepatitis C virus infection was high in patients with inflammatory bowel disease, mainly due to blood transfusions. Colonoscopies and surgical procedures were not found to be additional risk factors for infection with hepatitis C virus.

Extensive aetiological investigations in acute pancreatitis: results of a 1-year prospective study.

BACKGROUND: Epidemiological data on acute pancreatitis are poorly defined. AIMS: To prospectively evaluate the aetiology of acute pancreatitis and to assess the benefits of intensive investigations. METHODS: In a prospective, 1-year study all cases of acute pancreatitis in the Nice catchment area were enrolled. Subjects underwent routine (serum calcium, phosphate and triglycerides; abdominal ultrasonography and CT scan) and additional, delayed intensive investigations (ERCP with bile sampling and/or endoscopy ultrasonography). RESULTS: One hundred and twenty-one cases were included. After routine investigations, a biliary, alcoholic, miscellaneous or unknown origin was diagnosed in 43%, 31.4%, 9.9% and 15.7%, respectively. In subjects with biliary pancreatitis, 43% had no previous history of biliary disease. In the alcohol-related subgroup, pancreatitis recurred in 18.5% during 114.5 days mean follow-up. In subjects with a first episode of alcoholic pancreatitis, delayed supplemental investigations revealed underlying chronic pancreatitis in 92.8%. After routine investigations, a diagnosis of pancreatitis of unknown origin was made in 15.7% (n = 19) of subjects. Additional investigations revealed an underlying cause in 57.8% of these patients (n = 11), including malignancy (n = 3) and biliary disease (n = 4), reducing the overall rate of pancreatitis with no apparent cause to 6.6%. CONCLUSIONS: Investigative techniques, particularly ERCP, will reveal the underlying aetiology of pancreatitis in the majority of patients presenting with 'idiopathic' pancreatitis and should be considered when routine tests are negative.

Prevalence of cholelithiasis: results of an epidemiologic investigation in Vidauban, southeast France. General Practitioner's Group of Vidauban.

Cholelithiasis leads to 80,000 cholecystectomies being performed every year in France, but its prevalence is still unknown. The aim of this study was to assess the prevalence and risk factors of cholelithiasis in a random population of 1027 women and 727 men over the age of 30 in a small town in the southeast of France. Detailed clinical history, dietary investigation, and gallbladder ultrasound were collected for each subject and assessed by univariate analysis. A regression model was used in the multivariate analysis to detect the relative risk of cholelithiasis. Cholelithiasis was found in 130 individuals (global prevalence 13.9%). The relative risk for lithiasis was higher in women compared to men (1.89). Age (P<0.0001) and body mass index (BMI) >25 (P = 0.013) were also significant risk factors. Neither pregnancy nor oral contraceptive use proved to be risk factors. Typical biliary colic pain was the only symptom significantly associated with cholelithiasis (P<0.0001). These results show that the prevalence of gallstones in France is similar to that in Denmark and Italy.

Chronic pancreatitis and inflammatory bowel disease: true or coincidental association?

OBJECTIVE: Several cases of pancreatitis have been described during the course of Crohn's disease (CD) or ulcerative colitis (UC), but many of them were related to either biliary lithiasis or drug intake. We tried to evaluate the clinical and morphological features of so-called idiopathic pancreatitis associated with inflammatory bowel disease and to define their pathological characteristics. METHODS: Chronic idiopathic pancreatitis was diagnosed on the basis of abnormal pancreatograms suggestive of chronic pancreatitis associated with or without impaired exocrine pancreatic function, or pathological examination in patients undergoing pancreatic resection. We found 6 patients presenting with features of chronic idiopathic pancreatitis and UC and 2 patients with CD seen between 1981 and 1996 in three hospital centers of the south of France. A review of the literature has identified 6 cases of pancreatitis associated with UC and 14 cases of pancreatitis associated with CD based on the above criteria. RESULTS: Hyperamylasemia was not a sensitive test since it was present in 44% and 64% of patients with UC or CD. In UC, pancreatitis was a prior manifestation in 58% of patients. In contrast, the pancreatitis appeared after the onset of CD in 56% of the cases. In patients with UC, pancreatitis were associated with severe disease revealed by pancolitis (42%) and subsequent surgery. Bile duct involvement was more frequent in patients with UC than with CD (58% vs 12%) mostly in the absence of sclerosing cholangitis (16% vs 6%). Weight loss and pancreatic duct stenosis were also more frequent in UC than in CD (41% vs 12% and 50% vs 23%, respectively). Pathological specimens were analyzed in 5 patients and demonstrated the presence of inter- and intralobular fibrosis with marked acinar regression in 3 and the presence of granulomas in 2 patients, both with CD. CONCLUSIONS: Pancreatitis is a rare extraintestinal manifestation of inflammatory bowel disease. Chronic pancreatitis associated with UC differs from that observed in CD by the presence of more frequent bile duct involvement, weight loss, and pancreatic duct stenosis, possibly giving a pseudotumor pattern.

[Inflammatory pseudotumor of the intrahepatic biliary tract]. / Pseudo-tumeur inflammatoire des voies biliaires intra-hépatiques.

Hepatic inflammatory pseudotumors are rare, presenting with a severe clinical pattern mimicking neoplasm. The diagnosis is almost always based on pathological examination showing inflammatory lesions with a polymorphous infiltrate and variable amounts of fibrous tissue. Development in the biliary tract is rare. We report the case of a 53-year-old patient who was referred for poor general condition and jaundice; the initial diagnosis was cholangiocarcinoma. Pathological examination of the surgical specimen showed a right intrahepatic biliary duct inflammatory pseudotumor. The patient developed recurrent jaundice three months after surgery due to a lesion of the left biliary ducts. Treatment with cortisone resulted in rapid improvement of jaundice.

Gallbladder volume in adults and its relationship to age, sex, body mass index, body surface area and gallstones. An epidemiologic study in a nonselected population in France.

BACKGROUND/AIMS: The role of a large gallbladder volume with regard to a predisposition for gallstones is unknown. It is possible that an increase in gallbladder volume could result in impaired gallbladder motility and bile stasis. We looked for factors affecting gallbladder volume in a random population in the southeast of France. METHODS: To assess the relationship between gallbladder volume and gallstones, 528 subjects over the age of 30 were studied (72 with lithiasis). Age, sex, body mass index, body surface area and gallbladder volume were collected for each subject. A linear regression analysis was performed to look for significant variables. RESULTS: The overall adjusted prevalence of cholelithiasis was 13.9% in our population. On linear regression analysis, two variables (age and surface area) were found to be independently correlated with gallbladder volume. Gallbladder volume was significantly increased in subjects over 50 years (p < 0.001). There was a positive correlation between gallbladder volume and body surface area (r = 0. 33, p < 0.001). In this study, the presence or absence of gallstones did not significantly affect the gallbladder volume. CONCLUSIONS: We report that there is dilatation of the gallbladder with age and with an increase in body surface area. Whether this could represent risk factors for the occurrence of gallstone remains uncertain.

Long term treatment of biliary stricture due to chronic pancreatitis with a metallic stent.

The exact role of endoprostheses in the management of chronic pancreatitis-associated biliary strictures has not yet been clearly established. We report an unusual case of a patient with this condition who was treated for an unexpectedly long term with a self-expanding metallic endoprosthesis. There has only been one previous report of the use of metallic stents in this situation. It appears that metallic endoprostheses may have a role to play in the management of selected patients who have chronic pancreatitis-associated bile duct stricture.

A prospective study of pancreatic disease in patients with alcoholic cirrhosis: comparative diagnostic value of ERCP and EUS and long-term significance of isolated parenchymal abnormalities.

BACKGROUND: The prevalence of pancreatic disease in patients with alcohol-related liver cirrhosis is uncertain. We assessed the prevalence of pancreatic abnormalities in patients with alcoholic cirrhosis, and we compared endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for the detection of chronic pancreatitis and other pancreatic lesions. In addition, we assessed the long-term significance of isolated pancreatic parenchymal abnormalities detected at EUS. METHODS: EUS and ERCP were performed in each patient. Subjects with minimal parenchymal changes at initial EUS underwent clinical follow-up and subsequent EUS and/or ERCP to document the occurrence, absence, or progression of these changes. RESULTS: Seventy-two patients with alcoholic cirrhosis were recruited. Chronic pancreatitis was diagnosed in 14 patients (19%) by both methods independently. Isolated parenchymal lesions were observed in 18 patients by EUS alone. After a mean follow-up of 22 months the EUS appearance was unchanged. Ten of the 18 patients underwent follow-up ERCP and this was normal in all cases. CONCLUSIONS: This study demonstrated that (1) 19% of patients with alcoholic cirrhosis have chronic pancreatitis, (2) an additional 25% have isolated pancreatic parenchymal changes at EUS, and (3) these parenchymal abnormalities do not progress during follow-up.

The role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease.

BACKGROUND AND STUDY AIMS: Hydatid disease of the liver, and its complications, causes serious morbidity and mortality. We evaluated the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatic hydatid disease. PATIENTS AND METHODS: This retrospective analysis includes 28 patients with hepatic hydatid disease who underwent ERCP. ERCP was performed preoperatively in 11 patients, for acute cholangitis (n =7), acute pancreatitis (n = 1) and right upper quadrant pain (n = 3), and in eight asymptomatic cases to search for fistulae between the cyst and the biliary tree. In a further nine patients ERCP was performed for early (< 30 days; n = 7) and late (n = 2) postoperative biliopancreatic problems. RESULTS: In all seven patients with cholangitis preoperative ERCP with EST and ductal clearance of daughter cysts and debris led to substantial clinical improvement, including four acutely ill elderly patients who stabilized and were later able to undergo surgery. EST in two of the three patients with pain who had papillary stenosis led to resolution of the abdominal pain. Six of the seven postoperative fistulae could be successfully treated endoscopically using EST. CONCLUSIONS: This study demonstrates the usefulness of ERCP in symptomatic patients with hepatic hydatid cysts; EST enables clearance of the common bile duct and allows healing of postoperative fistulae in the majority of patients. We do not, however, recommend performing routine preoperative ERCP in asymptomatic patients with the disease.