Triple whammy in a patient with portal vein thrombosis.

Infection with SARS-CoV-2 has been shown to predispose to thromboembolic events. The risk of such thromboses further increases in those with underlying inherited or acquired prothrombotic states. The authors present a 30-year-old lady who developed acute abdominal pain, three days after recovery from a mild COVID-19 infection. She was also using oral contraceptive pills. Laboratory investigations revealed elevated inflammatory markers, and a contrast-enhanced abdominal CT scan demonstrated portal vein thrombosis (PVT). Due to the unusual site of thrombosis, a thrombophilia screen was performed, which detected a heterozygous Factor V Leiden mutation (FVL). Thus, her PVT was attributed three simultaneous risk factors, namely COVID-19 infection, OCP use and FVL mutation. She was initiated on anti-coagulation, with which she improved significantly. In patients presenting with thromboses at uncommon sites, investigation for evidence of recent Covid-19 infection and screening for inherited and acquired thrombophilia should be considered, while discontinuing any offending medications.

[Serodiagnosis of acute hepatitis in adults patients: results of a prospective study in a central region of Tunisia]. / Sérodiagnostic des hepatitis aiguës de l'adulte: résultats d'une etude prospective dans une region du centre tunisien.

UNLABELLED: PRÉREQUIS: Viral hepatitis is a public health problem in many parts of the globe. In Tunisia, the respective responsibility of five viruses (HAV, HDV, HBV, HCV and HEV) in the genesis of acute hepatitis in adults is only roughly indicated in the absence of suitable serological studies, given as important to plan appropriate preventive strategies. OBJECTIVES: To approach the role of viral hepatitis in all adult with acute hepatitis, identify the current share of each virus A, B, C and E in the genesis of hepatitis and to study the epidemiological and evolution of these diseases. METHODS: We conducted a prospective study over two years including patients aged from 15 to 65 years old, with clinical and / or biological acute hepatitis. Data were collected through a standard questionnaire wich covered sociodemographic charactereristics and risk factors. Blood samples were collected and were tested for IgM anti-HAV, IgM anti-HEV, HBsAg, IgM anti-HBc, anti-HCV antibodies .When serological tests were negatives, further explorations including immunological test, search for HCV RNA and a pharmacovigilance survey was conducted. Statistical analysis was performed by SPSS version 10.0 RESULTS: 105 patients were included. Acute viral hepatitis was diagnosis in 70 patients (67%). The proportion of patients with acute viral hepatitis A, B, C and E was 51.5% , 38.5%, 4.3% and 5.7% respectively. The risk factors of viral hepatitis A was drinking of untreated water and poor socioeconomic status. In the HBV group, the notion of sexual contact risk was found in 30% of cases. The small numbers of acute hepatitis E and C does not permit us to draw conclusions. CONCLUSION: Our study confirms the shift in age of onset of hepatitis A to the age of adolescence and young adulthood. The respective responsibilities of the different viruses studied in the genesis of acute hepatitis in adults in our area brings us closer of western populations where HAV infection predominates followed by HBV.

Appropiateness of colonoscopy in the university hospital center of monastir. Interest and applicability of criteria established by the European panel on the appropriateness of gastrointestinal endoscopy.

AIM: 1) To assess the applicability of EPAGE criteria in there first version (EPAGE I) in clinical practice, 2) to assess colonoscopy appropriateness using EPAGE I criteria, 3) to compare colonoscopy appropriateness and findings. METHODS: Four hundred and eighty-seven consecutive diagnostic colonoscopies were included. The appropriateness of the indication of colonoscopy was appreciated using a scoring system on the basis of the EPAGE criteria in there first version (EPAGE I). RESULTS: Appropriateness were applied in 86,4% of the colonoscopies. Fifty-one percent were appropriate, 14% uncertain and 18% inappropriate. The difference of 17% represented the procedures indicated for hematochezia and for witch an appropriateness score can not be attributed because of lack of clinical information. The probability of finding a clinically significant lesion was significantly higher in patients aged ≥ 50 years, males, inpatients, those referred by gastroenterologists and those who had the colonoscopy for "appropriate" indication according to the EPAGE I criteria. The independent variables correlated with the diagnostic yield of colonoscopy were the age, the appropriateness of indication and the health care setting. CONCLUSION: EPAGE I criteria were applicable in most patients and were correlated with significant findings. They are thereby useful to rationalize colonoscopy demand. However, they could be regularly updated.

[Epidemiological, clinical features, therapeutic results and evolution of gastrointestinal stromal tumour: about 25 cases]. / Caractéristiques épidémiologiques, cliniques, thérapeutiques et évolutives des tumeurs stromales digestives: à propos de 25 cas.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are mesenchymal tumors occuring in the majority of cases in the stomach and small intestine, rarely in rectum, colon, esophagus or mesentery. They are derived from cells of cajal or their precursor, and are typically CD117/KIT + (95%), CD34 + (70%). AIMS: is to study the epidemiological, clinical, therapeutic and evolution of gastrointestinal stromal tumors. METHODS: retrospective study including all patients with the diagnosis of GIST supported in the department of gastroenterology and surgery in universital hospital of Monastir. RESULTS: 25 patients were included, 12 men and 13 women with an average age of 60.5 years. Digestive symptomatology was dominated by gastrointestinal bleeding (n = 12) and abdominal pain (n = 12). The tumor was discovered incidentally in two patients. The small intestine was the most common site of the tumor (n = 10), followed by the stomach in 9 patients, rectum in two patients, the colon (n = 1), the bulb of water (n = 1), duodenum (n = 1) and liver in a patient. The tumor size ranged from 0.8 to 24 cm. GIST was localized in 16 patients, in whom therapeutic care based mainly on surgery and optimal broad. It was metastatic in 9 patients, in whom treatment using imatinib as first-line in 4 of them with a good response in 3 patients and the possibility of R0 surgery in one patient, initial stabilization and then a secondary exhaust in a patient. The first surgery was necessary in 5 patients in complicated situation or if diagnostic doubt. CONCLUSION: The best characterization of GIST thanks to advances in cancer research has led to improved treatment of these tumors. Surgery is the standard treatment in localized forms. Imatinib is the standard treatment in metastatic GIST first line as well as adjuvant after surgery.

[Duodenal ulcer disease and Ramadan]. / Maladie ulcéreuse duodénale et Ramadan.

Ramadan fasting is accompanied by an increase of the gastric acidity over 24 hours especially in the daytime. Gastric acidity is maximal at the end of the fasting day. So, a patient with duodenal ulcer is exposed to a high risk of disease reactivation. The frequency of ulcer complications is statistically higher during the month of Ramadan than the rest of the year. The frequency of the upper gastrointestinal hemorrhage is multiplied by 2 and perforation by 4. Helicobacter pylori eradication does not seem to play a role in the occurrence of these complications, particularly the perforation. The patient with duodenal ulcer can fast without risks while using a proton pump inhibitor if the ulcer is healed and H. pylori is eradicated. Ramadan fasting seems to us inadvisable when duodenal ulcer is active, but large prospective studies are needed.

Clarithromycin versus metronidazole in first-line Helicobacter pylori eradication. Prospective randomized study of 85 Tunisian adults.

BACKGROUND: Although primary resistance to metronidazole remains high (56,8%), it is more widely used than clarithromycin as a firstline Helicobacter pylori (H. pylori) treatment in the common Tunisian practice. AIM: To compare the eradication rate in two protocols including clarithromycin versus metronidazole in Tunisian adults. METHODS: From July 2005 to December 2007, 85 patients aged 18 to 75 years presenting with gastro-duodenal lesions with H. pylori infection and requiring its eradication were included in the study. They were randomized to receive alternatively a seven-day triple therapy including: Omeprazole + Amoxicillin + Clarithromycin (OAC group) or Metronidazole (OAM group) twice a day. A second endoscopy with new biopsies was carried out 6 weeks after treatment to control eradication. RESULTS: Eighty five patients finished the protocol. The OAC and OAM groups included 46 and 39 patients respectively. They were comparable with respect to age, gender, clinical presentation and initial lesions. The total eradication rate was 60%. It was significantly higher in the clarithromycin group (69.6%) than in the metronidazole group (48.7%): p < 0.05. CONCLUSION: Clarithromycin is more effective than metronidazole in H. pylori eradication. It should be made available in our hospital's nomenclature. This would prevent iterative eradication courses and probably reduce treatment cost.

[Bowel preparation before colonoscopy]. / Préparation intestinale avant coloscopie.

Colonoscopy is a routinely performed procedure in adults. Completion of the procedure and proper visualization of the intestinal mucosa are highly dependent on the quality of the bowel preparation. The ideal bowel preparation should be safe, well-tolerated and effective. No bowel preparation method meets the ideal criteria for bowel-cleansing prior to colonoscopy. However, polyethylene glycol-electrolyte lavage solution and sodium phosphate are the most commonly used bowel preparations before colonoscopy and colon surgery. NaP preparations appear more effective and better tolerated than standard PEG solutions but should be administered with caution in patients with preexisting or at an increased risk for electrolyte disturbances. Timing and dose are important considerations regardless of the method used. The last generation of preparations improves safety and acceptability by reducing volume of liquid ingested.

Upper gastrointestinal bleeding in elderly patients in a Tunisian hospital: A retrospective study.

BACKGROUND AND STUDY AIMS: The older age group presents a major problem in the management of acute gastrointestinal bleeding with a relatively high mortality. The study aims to describe the background characteristics, causes and outcome of acute upper gastrointestinal bleeding in the elderly in Tunisia. PATIENTS AND METHODS: We retrospectively reviewed data of 401 patients aged≥60 years presenting with upper gastrointestinal bleeding. Information collected included history, physical examination findings, laboratory data, endoscopic findings and length of hospital stay. Patients were divided into two groups: group A (65-79 years) and group B (>79 years). RESULTS: Group A included 315 patients and group B 86 patients. There was a male preponderance in both groups. Co-morbidity (p<0.01) and use of non-steroidal anti-inflammatory drugs (NSAIDs) or anti-platelet drugs (p<0.01) were more common in group B. Oesophagitis was the cause of bleeding in 38.37% in group B, as compared with 19% in group A. The main cause of bleeding in group A was peptic ulcer. Rebleeding (6/86) and emergency surgery (1/86) were rare in group B and not different from those in group A. However, the bleeding-related mortality in the very elderly group was higher (13.9% vs. 4.76%; p=0.02). In multivariate analysis, only shock on admission was independently related to mortality (p=0.02). CONCLUSION: Oesophagitis is the major cause of upper gastrointestinal haemorrhage in the very elderly patients. While rebleeding and emergency surgery rates are relatively low, the bleeding-related mortality was higher in the very elderly group.

Gastrointestinal involvement revealing Henoch Schonlein purpura in adults: Report of three cases and review of the literature.

The diagnosis of Henoch-Schonlein purpura (HSP) is difficult, especially when abdominal symptoms precede cutaneous lesions. We report three cases of adult HSP revealed by gastrointestinal (GI) involvement.

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.

[Chronic viral hepatitis and kidney failure]. / Hépatites virales chroniques chez les patients insuffisants rénaux.

Chronic viral hepatitis remains a major problem among patients with chronic renal failure. Hepatitis B and C viruses are frequent among dialysis patients and after renal transplantation and may significantly diminish the survival of both the patient and the graft. Hepatitis B and C viral infection in these patients is often characterized by normal transaminase levels despite viremia and progressive liver lesions. Liver biopsy remains essential for assessing the extent of liver disease. Cirrhosis is a contraindication to transplantation of only a kidney, because of elevated morbidity and mortality. A combined as liver-kidney transplantation may be considered. The best treatment of hepatitis infections is preventive: vaccination against the hepatitis B virus and attentive hygiene, especially to prevent nosocomial transmission. Among patients not awaiting transplant, antiviral treatment should be reserved for patients with active or even fibrotic liver disease. For hemodialysis patients awaiting kidney transplant: Alpha interferon is ineffective and poorly tolerated by dialysis patients. Lamivudine is effective and well tolerated, but its long-term efficacy and its optimal effective dose in dialysis patients remain unknown.