Eradication of Helicobacter pylori: a prospective comparative randomized trial of standard versus optimized quadruple therapy.

The treatment of Helicobacter pylori infection remains a challenge. None of the proposed treatment regimens has resulted in a 100% eradication rate. The aim of our study was to compare the rate of H. pylori eradication after standard or dose-optimized amoxicillin quadruple therapy. We conducted a prospective comparative study collating patients naive to any anti-H. pylori treatment and with chronic H. pylori infection documented by histological examination. Patients were randomly assigned to either standard quadruple therapy or optimized quadruple therapy. Eradication control was performed by urea breath test. Eighty-eight eligible patients were included with 44 in each group.There was no significant difference between the eradication rates of Qo-14 and Qs-14 neither in ITT (84 vs 70.4%; p = 0.127) nor in PP (82.1 vs 77.7%; p = 0.473). Compliance and tolerance appeared similar in each group.

H. pylori is a common bacterium that can cause several digestive infections, including gastric ulcers and gastric cancer. The aim of this study was to compare the rate of H. pylori eradication after a standard dose compared with a double dose of a specific therapy known as amoxicillin quadruple therapy. The results showed no significant difference between the eradication rates of standard or optimized quadruple therapy.

Arteriovenous gastric malformation: A challenging diagnosis. A case report.

INTRODUCTION: Gastro-intestinal bleeding etiological diagnosis could be challenging especially for rare etiologies as it was the case of our patient having an arteriovenous gastric malformation. CASE PRESENTATION: A 50-years old man consulted for hematemesis. Esophagogastroduodenoscopy didn't show bleeding signs. Angio-scan revealed an arteriovenous gastric malformation. Median laparotomy revealed multiple radiologically unsuspected great omentum arteriovenous malformations and confirmed the existence of this arteriovenous malformation in the posterior part of the lesser curvature guided by per-operative esophagogastroduodenoscopy. Atypical gastrectomy was performed. DISCUSSION: Our case illustrated a rare life-threatening condition with a challenging diagnosis. Arteriovenous gastric malformation accounted for 1 to 2 % of nonvariceal upper gastrointestinal bleeding. Great omentum localization corresponded to an exceptional condition that had been reported in only one adult patient and one childhood case. Its pathogenesis is still unknown. CONCLUSIONS: Arteriovenous gastric malformation had to be considered in case of normal endoscopic esophagogastroduodenoscopy. Computed tomography had to be done for both diagnosis and therapeutic purposes.

[Endoscopic removal of intrauterine device perforating the sigmoid colon: case report]. / Retrait endoscopique d'un dispositif intra-utérin perforant le côlon sigmoïde: à propos d'un cas.

Intrauterine device (IUD) is the mainstay of family planning methods in developing countries. However, it is associated with severe complications such as bleeding, perforation and migration to adjacent organs. Although perforation of the uterus is not rare, migration to the sigmoid colon is exceptional. We here report a case of IUD migration into sigmoid colon; this was removed via low endoscopy. The study involved a 45-year-old woman using an IUD who presented with pelvic pain associated with a feeling of pelvic heaviness 6 years later of insertion. Clinical examination was without abnormalities, and computed tomography (CT) scan showed the IUD embedded in the sigmoid colon wall. Diagnostic and therapeutic laparoscopy was performed, which objectified IUD-related intestinal perforation. IUD was partially embedded in the sigmoid colon wall and couldn't be removed. The device was removed during colonoscopy by diathermy loop excision (15 mm in diameter).

Correlation between the intensity of Helicobacter pylori colonization and severity of gastritis: Results of a prospective study.

Helicobacter pylori infection is strongly associated with chronic gastritis and is probably the main course of chronic inflammation in the gastric mucosa. Gradually, H. pylori gastritis will result in gastric atrophy and intestinal metaplasia. Identifying the relationship between intensity of colonization and activity of gastritis helps the clinician in more effective treatment and post-treatment follow-ups. The aim of our work was to analyze the relationship between the density of H. pylori colonization of the gastric mucosa and the severity of histological parameters of gastritis (inflammation activity, gastric atrophy, and intestinal metaplasia). This was a prospective monocentric study conducted from January 2020 to December 2020, collecting patients naive to any anti-H. pylori treatment and having a chronic H. pylori infection documented by histological examination. Epidemiological, endoscopic, and anathomopathological data were collected. Ninety-seven patients with a mean age of 42.6 years [18-65 years] and a sex ratio of M/F = 0.64 were included. The density of H. pylori colonization was mild (+) in 43.3% of patients, moderate (++) in 47.4% of patients, and significant (+++) in 9.3% of patients. Nearly, ten per cent of patients had no gastritis, 33% had mild gastritis, 50.5% had moderate gastritis, and 6.2% had severe gastritis. Gastric atrophy and intestinal metaplasia were found in 44.3% and 10.3% of our population, respectively. Patients with mild H. pylori colonization rates had the highest level of mild activity (59.5%). There was a statistically significant association between the severity of H. pylori infection and gastritis activity (p < .001). Gastric atrophy was significantly associated with the intensity of H. pylori colonization (p = .049). No significant relationship was found between the intensity of colonization and metaplasia (p = .08). Our study shows that there is a statistically significant association between the density of H. pylori and histopathological findings including gastritis activity and intestinal atrophy.

[Intraperitoneal cystic lymphangioma and Crohn's disease: an exceptional association]. / Kystique intra-péritonéal et maladie de Crohn: à propos d'une association exceptionnelle.

Cystic lymphangioma is a rare benign malformative tumor of the lymphatic vessels which may occur in various locations. Intra-abdominal cystic lymphangioma is less frequent than cervicoaxillary cystic lymphangioma. Clinical presentation is polymorphic. Diagnosis is based on imaging data but it requires histological confirmation. Surgery is the gold standard treatment. We here report a rare case of acquired intraperitoneal cystic lymphangioma secondary to subtotal colectomy in a female patient with severe evolutive Crohn's disease treated with anti-TNF alpha. The patient presented with irreducible right painful paramedian mass with no impulse on coughing, suggesting the diagnosis of strangulated eventration within a surgical scar from midline laparotomy. She underwent emergency surgery. Surgical exploration showed multi-cystic intraperitoneal mass protrunding through the right paramedian eventration. Anatomo-pathological examination helped to confirm the diagnosis of cystic lymphangioma. Postoperatively, the mass was punctured twice to evacuate the fluid, because of incomplete surgical resection. This is the first reported case of cystic lymphangioma in a patient under anti-TNF alpha. It could be caused by disruption of the immune system and more specifically of the lymphocyte population. This association has not hitherto been established and experimental studies are necessary to accept or refuse this hypothesis.

[Epithelial cell in intestinal homeostasis and inflammatory bowel diseases]. / Rôle de la cellule épithéliale dans l'homéostasie intestinale et les maladies inflammatoires chroniques de l'intestin.

Crohn's disease (CD) and ulcerative colitis (UC) are the principal inflammatory bowel diseases (IBD) which physiopathology is currently poorly elucidated. During these diseases, the participation of the epithelial cell in the installation and the perpetuation of the intestinal inflammation is now clearly implicated. In fact, the intestinal epithelium located at the interface between the internal environment and the intestinal luminal, is key to the homeostatic regulation of the intestinal barrier. This barrier can schematically be regarded as being three barriers in one: a physical, chemical and immune barrier. The barrier function of epithelial cell can be altered by various mechanisms as occurs in IBD. The goal of this article is to review the literature on the role of the epithelial cell in intestinal homeostasis and its implication in the IBD.

[Bone metabolism, biochemical markers of bone resorption and formation processes and interleukine 6 cytokin level during coeliac disease]. / Anomalies du métabolisme osseux et résultats des marqueurs biochimiques du remodelage osseux et de l'interleukine 6 au cours de la maladie coeliaque.

BACKGROUND: Celiac disease (CD) is characterized by a malabsorption syndrom. The bone anomalies are one of the principal complications of this disease. The osteoporosis frequency is high: 3.4% among patients having with CD versus 0.2% in the general population. AIM: To study the bone mineral density during the CD, to compare it to a control group and to determine the anomalies of biochemical markers of bone turn over and level of interleukin 6 cytokin (IL6) in these patients. METHODS: All patients with CD have a measurement of bone mineral density by dual-energy x-ray absorptiometry (DXA), a biological exam with dosing calcemia, vitamin D, parathormone (PTH), the osteoblastic bone formation markers (serum osteocalcin, ALP phosphates alkaline), bone osteoclastic activity (C Télopeptide: CTX) and of the IL6. RESULTS: 42 patients were included, with a median age of 33.6 years. 52. 8% of the patients had a low level of D vitamine associated to a high level of PTH. An osteoporosis was noted in 21.5% of patients. No case of osteoporosis was detected in the control group. The mean level of the CTX, ostéocalcine and the IL6 was higher among patients having an osteoporosis or ostéopenia compared to patients with normal bone (p = 0,017). The factors associated with an bone loss (osteopenia or osteoporosis) were: an age > 30 years, a weight <50 kg, a level of ALP phosphates alkaline > 90 UI/ml, an hypo albuminemia < 40 g/l and a level of CTX higher than 1.2. CONCLUSION: Our study confirms the impact of the CD on the bone mineral statute. The relative risk to have an osteopenia or an osteoporosis was 5 in our series. The measurement of the osseous mineral density would be indicated among patients having a CD.

Dermatologic manifestations in inflammatory bowel disease in Tunisia.

BACKGROUND: Cutaneous manifestations are the most common extra intestinal manifestations associated with inflammatory bowel disease (IBD). AIM: To assess the epidemio-clinical profile of skin manifestations in IBD. METHODS: A prospective and descriptive study was conducted. We have examined skin, mucosa, hair and nails, of all patients with an IBD during one year. RESULTS: One hundred-ninety-five patients were included. Crohn's disease (CD) was noted in 154 cases (79.8%), ulcerous rectocolitis (UC) in 39 cases (21.2%) and inclassable IBD in 2 cases. Cutaneous manifestations were found in 91% of Crohn's patients and in 92% of UC patients. Granulomatous perianal skin lesions were the main cutaneous manifestations of CD (53%). The most common affected sites were ano-perineal fistulae, perianal and perineal fissures and oedematous and infiltrated perianal and genital plaques. Reactive lesions (Erythema nodosum, Pyoderma gangrenosum, Aphthous stomatitis) were noted in 14 cases. Skin manifestations due to malabsorption were also frequently observed (101 cases: 51.7%).Other dermatoses implicating various mechanisms such as psoriasis, alopecia areata, vitiligo, rosacea, lichen planus, were also noted. Adverse skin manifestations due to treatment (folliculitis, acne, macula-papular rash and DRESS syndrome) were present in 16 cases. CONCLUSION: Our series is characterized by a high frequency of cutaneous manifestations associated to IBD. A better recognition of these skin manifestations by the physician may improve their management.

[Management of failure of infliximab in inflammatory bowel disease]. / Que faire devant un échec de l'Infliximab au cours des maladies inflammatoires chroniques de l'intestin ?

BACKGROUND: Infliximab is a chimeric monoclonal anti TNFa whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options. METHODS: Literature review RESULTS: The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNFa, a relay by adalinumab or certolizumab may be proposed. CONCLUSION: The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed.

[Faecal calprotectin in inflammatory bowel diseases: review]. / Place de la calprotectine fécale au cours des maladies inflammatoires chroniques de l'intestin : mise au point.

BACKGROUND: The clinical course of inflammatory bowel disease (IBD) is characterised by a succession of relapses and remissions. A regular and a long term monitoring of such patients is required. Faecal markers, especially calprotectin's use, seem to be useful in these patients. Faecal calprotectin is a reliable maker of intestinal inflammation in IBD. Its level is assessed by a simple and a non invasive test. AIM: We proposed to review main indications and study results of faecal calprotectin test use in IBD patients. METHODS: Review of literature. RESULTS: Faecal calprotectin assessment isn't an IBD specific test. Selective use is required to have a good benefit-cost ratio. Prediction of relapses in asymptomatic patients as well as post operative reccurence seems to be the main indications for its use. CONCLUSION: Mucosal healing assessment after anti-TNF treatment can also be an interesting indication although it isn't well evaluated.

[Evaluation of small bowel involvement in Crohn's disease by small- bowel videocapsule endoscopy: a prospective comparative study with computed-tomography enteroclysis and small bowel radiography]. / Évaluation de l'atteinte du grêle de la maladie de Crohn par vidéocapsule endoscopique : étude prospective et comparative avec le transit du grêle et l'entéroscanner.

BACKGROUND: Small-bowel videocapsule endoscopy (VCE) is a new technique in evaluation of intestinal involvement in several pathologies. Crohn's disease affects principally terminal ileum. Small bowel involvement in Crohn's disease is not well estimated by endoscopic and radiologic conventional techniques. AIMS: To evaluate the performances of VCE in detection of asymptomatic proximal small bowel lesions in consecutive patients with Crohn's disease with terminal ileal involvement, to compare the results of VCE to small bowel radiography and CT-enteroclysis and to determine the therapeutic impact of VCE in these patients. METHODS: A prospective study which included Crohn's disease patients with distal ileal involvement, based on radiological or endoscopic findings. We performed in all patients small bowel radiography, CT enteroclysis and VCE. Proximal involvement was characterized by presence of aphtoid, superficial or deep ulcerations in the jejunum or the proximal ileum. RESULTS: We studied 20 patients (12 men, mean age 31.6 years). VCE confirmed the distal ileal involvement in all patients. Significative proximal lesions was observed in nine patients (jejunum only: one case, jejunum and ileum: six cases and proximal ileum: two cases), in most cases aphtoid or superficial lesions. Deep ulcerations were observed in two patients. Small bowel radiography showed proximal ileal lesions in only two patients, and CT-enteroclysis in only one patient. Treatment by azathioprine was prescribed in two patients with severe and extended small bowel lesions in VCE examination. CONCLUSION: VCE is more accurate than radiologic techniques in detection of small bowel lesions in Crohn's disease. In cases of severe and extended small bowel involvement, VCE can conduct to changes of therapeutic approach.

Prevalence and risk factors of hyperhomocysteinemia in Tunisian patients with Crohn's disease.

BACKGROUND AND AIMS: The role of hyperhomocysteinemia (HHC) and its determinants in Crohn's disease (CD) remain uncertain. This study was aimed to determine the prevalence of HHC and its main risk factors in Tunisian patients with CD. METHODS: This study included 89 patients with CD and 103 age- and sex-matched healthy subjects. Fasting venous blood was collected in all subjects allowing the assessment of homocysteine, folate, vitamin B(12), C-reactive protein and creatinine levels. Logistic regression models were applied to identify factors associated with HHC in CD patients. RESULTS: Plasma homocysteine was higher (13.69 ± 4.84µmol/l vs. 10.77 ± 2.80µmol/l; p<0.01) and HHC was more frequent (31.5% vs. 7.8%; p<0.001) in patients compared with controls. The association between HHC and CD persisted after adjustment for smoking, body mass index and serum folate, vitamin B(12), creatinine and C-reactive protein. In patients with CD, multivariate analysis showed that HHC was positively associated with age [multi-adjusted odds-ratio (95% confidence interval): 1.14 (1.06-1.24); p<0.001], active disease [7.54 (1.15-49.3); p=0.03], disease duration >2 years [8.69 (1.53-49.3); p=0.02] and inversely related to plasma folate [0.64 (0.48-0.84); p=0.002] and vitamin B(12) (0.993 (0.987-0.999); p=0.02]. CONCLUSION: HHC is common in Tunisian patients with CD and is related to B vitamins deficit, as well as disease activity and duration. Further studies should test the effect of correction of HHC by vitamin B supplementation on progression and complications of CD.