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INTRODUCTION: The variceal bleeding, main complication of portal hypertension during cirrhosis, is associated with high early mortality riskestimated between 15 and 20%. This highlights the necessity of predictive models that allow identifying high-risk patients raising the issue of amore aggressive therapeutic care. OBJECTIVE: To assess the performance of four scores for the prediction of cirrhotic patients' high early mortality risk due to digestive hemorrhageand to compare them to the Child-Pugh reference score. METHODS: We collected 87 cirrhotic patients admitted to the Gastroenterology Department of Charles Nicolle Hospital for a high digestivehemorrhage by rupture of gastric or esophageal varicose veins. RESULTS: 56 men and 31 women were included in this study. The average value of Rockall, Glasgow Blatchford, MELD and MELD-Na scores,was respectively equal to 6.19, 10.91, and 17.6 and at 20. Early mortality was 30%. The average value of all the scores was significantly higherwith the prematurely deceased patients (p<0.001). The MELD-Na score had higher sensitivity and specificity for the prediction of prematuremortality compared to the other scores but without statistical significantly difference (Area under the ROC curve: MELD-Na=0.867, p<0.001;Child-Pugh=0.809, p<0.001; Rockall=0.777, p=0.001; Glasgow-Blatchford=0.761, p<0.001; MELD=0.838, p<0.001). The predictive value of thecut-off MELD-Na score was equal to 19 with a sensitivity of 70% and a specificity of 82%. CONCLUSION: The studied four scores had a good predictive value of early mortality risk by varicose digestive hemorrhage with cirrhotic patients.

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BACKGROUND: Hepatic hydrothorax is a less common complication of cirrhosis with an estimated prevalence of 10- 15%. In the vast majority of cases, ascites are also present but significant pleural effusion may develop in patients without ascites. Hepatic hydrothorax is associated with cirrhosis whatever its etiology. The prognosis of hepatic hydrothorax remains unclear and is closely related to available therapeutic options. The aim of our study is to determine the prevalence of hydrothorax in cirrhotic patients, detail its clinical and therapeutic characteristics, and study the evolutive profile of cirrhotic patients with hydrothorax by comparing it to those without hydrothorax. We also search predictive factors of development of this complication in cirrhotic patients. METHODS: We conduct a retrospective and case-control study including 63 cirrhotic patients with hepatic hydrothorax hospitalized in gastroenterology department of Charles Nicolle hospital of Tunis, during a period of fiveteen years, from January 2000 to January 2015. RESULTS: The prevalence of hydrothorax was 14.5%. The mean age was 62 ± 14 years (range, 22- 86 years). The sex ratio H/F was 1.52. Hepatic hydrothorax was symptomatic in 35 patients. It was right-sided in 60%, left-sided in 24% and bilateral in 16% of cases. Hydrothorax was on average size abundance in 54% of cases. It was transsudatif in 52.5% of cases. Hepatitis C was the most frequent cause of cirrhosis (54%). Our results show that hepatic hydrothorax was present with important ascites in 35 patients. Hydrothorax was significantly related to Child-Pugh C severity of cirrhosis (p=0.0001). Hydrothorax occurence was significantly associated with a low level of albumin (p=0.001), an important hyponatremia (p=0.001) and a low prothrombin rate (p=0.02). A therapeutic thoracentesis was performed in 57% of cases. Diuretics based on spironolactone and furosemide were indicated in 30 patients. Evolution was favorable in 19 patients. Refractory hepatic hydrothorax was present in 31 patients. Death, in the days which follow the hospitalisation, was in 13 patients. The 5-years survival rate was 60%. The mean survival time of patients with hepatic hydrothorax was 8.41 years against 10.75 years at patients without hepatic hydrothorax. CONCLUSION: Hepatic hydrothorax is a common complication in our study. The improvement of the prognosis of our patients would require a better therapeutic management and especially the possibility of orthotopic liver transplantation which is the optimal therapeutic option for patients with hepatic hydrothorax.

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BACKGROUND: The viral B reactivation is associated to deadly serious forms. There exist populations suffering this risk yet with a possibility of prevention through a pre-emptive treatment. PURPOSES: Establishing the diagnosis of a viral B reactivation. Identifying the patients with risk of exposure to viral B reactivation and implementing the means of prevention of viral reactivation. METHODS: literature review RESULTS: the diagnosis of reactivation is not consensual. It is evoked facing a fast increase of aminotransferases with the ALAT superior to 5-10 times normal or superior to 3 times the basic value, an ascension of the HBV DNA within the serum, a reappearance of anti Hbc of IgM type with, most often, a weak title and /or a reversion Hbs. The reactivation depends on the type of treatment and of the viral B status. It was described under chemotherapy concerning the solid tumors particularly that of the breast, in haematology and increases with the resort to monoclonal antibody (anti-CD20). Under anti-TNFα a reactivation is possible within a variable deadline from the 1st to the 12th perfusion. Besides the type of treatment, the risk is more important with the patients Ag Hbs positive and correlated with the viremia. However, the patients having an occult hepatitis B or even a recovered from hepatitis are equally exposed to the risk of reactivation. CONCLUSION: viral reactivation is frequent since the larger use of immunosuppressive therapy, anti-TNFα and monoclonal antibody. The determination of the initial viral B status by a serology is indispensable. In order to indicate either surveillance or a preemptive treatment.

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The aim of this study was to evaluate the association between the HLA-G 14-bp deletion/insertion (Del/Ins) polymorphism and soluble (s) HLA-G production in patients with Crohn's disease (CD). We analyzed also the sHLA-G molecules by ELISA and western blot in plasma samples. Among unselected patients, the 14-bp Del/Ins polymorphism was not significantly associated with increased CD risk neither for alleles (P = 0.371) nor for genotypes (P = 0.625). However, a significant association was reported between the 14-bp Del/Ins polymorphism and CD, in particular in young-onset CD patients for alleles [P = 0.020, odds ratio (OR) = 2.438, 95% confidence interval (CI): 1.13-5.25] but not with adult-onset CD patients. A significant association was reported concerning the genotype Ins/Ins for young-onset CD patients (P = 0.029, OR = 3.257, 95% CI: 1.08-9.77). We observed also a significant increase in sHLA-G measured by ELISA in CD patients compared to controls (P = 0.002). The 14-bp Del/Del and 14-bp Del/Ins genotypes are the high HLA-G producers. Among sHLA-G(positive) patients, 43% of subjects present dimers of HLA-G. The presence of dimers seems to be related to the advanced stages of the disease. The 14-bp Del/Ins polymorphism is associated with an increased risk of CD particularly in young-onset CD patients and controls sHLA-G plasma levels. Dimers of sHLA-G are frequent in advanced disease stages. The above findings indicate that the genetic 14-bp Del/Ins polymorphism in exon 8 of the HLA-G gene is associated with the risk of CD and suggest a role for sHLA-G as a prognostic marker for progressive disease.

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BACKGROUND: Obesity raises such a healthcare matter throughout the world. Its management is not only complex but also most often multidisciplinary. The medico-dietary treatment is of inconstant efficiency and the surgical treatment, though more efficient, presents a considerable morbidity-death rate. The endoscopic treatment through intra-gastric balloon avails a seducing alternative namely accounting for surgery preparation. AIM: To assess the efficiency of the endoscopic treatment through gastric balloon, both in the short and long term, and this is accounting for weight loss as well as tolerance. METHODS: We have carried out a retrospective study including the patients suffering from severe to morbid obesity and who had a gastric balloon implemented in our Endoscopy Unit between November 2005 and December 2007. RESULTS: Twenty one patients were included. The average age was 32,19 ± 12,65 years with extremes of 16 and 52 years. Fifteen patients suffered from morbid obesity. The patients' average weight was 134, 52 ± 26,46 kg (extremes 88 and 194 kg). Some co-morbidity was found out with 15 patients. Te balloon implementation (Héliosphère®) was carried out with no incidents in all patients. Six months after the balloon implementation, the average weight loss was 17,5% and the average loss of over weigh was 37%. In biological level, we noted a normalisation of fasting glycaemia in 28,6 % of cases, of the cholesterolemia in 100 %, of the triglyceridemia in 33,33%, of the uraemia in 42,8% and hepatic tests in 50 % of the cases. The metabolic syndrome disappeared in 28,57 % of cases. The assessment after a 5-year-period was marked by the need to surgical treatment in 4 patients and this is due to the loss of efficiency of endoscopic treatment. A bad tolerance of gastric balloon was observed in 34 % of the cases, dominated by sicknesses. Only one patient presented incoercible sicknesses with ionic troubles as well as deshydrating requiring the precocious extraction of the balloon after 48 hours of its implementation. CONCLUSION: The endoscopic treatment through intra gastric balloon is well tolerated but efficiently limited in time. It might be recommended in preparation for a surgical treatment or in case of contre- indication or surgery refusal.

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Malignant epithelioid hemangioendothelioma (EH) is a rare tumor of vascular origin. We report a case of a woman who was found to have multiple hepatic masses in the right lobe of the liver on radiologic investigations, initially misdiagnosed as a metastatic carcinoma. The diagnosis of EH was made on histopathological study and confirmed by immunohistochemistry, which showed diffuse response for CD34 marker and no response to tissue CEA, HMB-45 or S-100 protein. Partial hepatectomy was made with good results.

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BACKGROUND: Infections are frequent in cirrhotic patients. They are potentially severe, modifying pejoratively the natural history of the cirrhosis and are suppliers of a heavy mortality. AIM: To determine the predictive factors of hospital mortality in cirrhotic infected patients. METHODS: We conducted a retrospective study including 97 cirrhotic patients hospitalized in the department of gastroenterology of Charles Nicolle's hospital, for a first infectious episode and not having received antibiotics in the previous 15 days. Clinico-biological, bacteriological, therapeutic and evolutionary data were collected. Scores were adopted and calculated such as the score of Child-Pugh, the score MELD (The Model for End-Stage Liver Disease) and the score SOFA (Sequential Organ Failure Assessment). These data allowed a descriptive study and an uni and multi-varied analysis. RESULTS: The median age of the studied population was of 59 ± 12 years with a sex ratio of 0.83. The diabetes was the comorbidity most frequently associated with the cirrhosis (26.8 % of the cases) Viral aetiology of the cirrhosis was dominant (3/4 of the cases) especially the virus C (62.5 % of the cases). The clinical presentation of the infection was polymorphic with presence of symptoms connected to the infection and the other connected to the progression of the liver disease. The fever was absent in 3/4 of the cases. The identified infections were, in order of frequency, urinary, infection of ascite, bronchopulmonary, cutaneous and gynecological. The responsible germs were especially bacilli gram negative of intestinal origin. The estimated scores of gravity were: a score of Child-Pugh C in 60 % of the cases, an average score MELD in 18±8 points and a score average SOFA in 8 ± 4 points. Multivariate study found that only encephalopathy, bilirubin level more than 40 µmol/l and creatinin level more than 120 µmol/l was independent factors predicting mortality. CONCLUSION: Infection in cirrhotic patients was a severe and mortal complication. The hepatic encephalopathy, the hyper bilirubinemia and the renal failure are predictive of the hospital mortality. The use of the scores of gravity: Child-Pugh, MELD and SOFA would an important help for the decision to admit in intensive care unit any infected cirrhotic patient.

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BACKGROUND: Colonoscopy is the standard investigation for colonic disease, but clinicians often are reluctant to refer elderly patients for colonoscopy because of a perception of higher risk and a high rate of incomplete examinations. AIMS: To evaluate feasibility and tolerance of this investigation in elderly and to review the most frequent indications of colonoscopy in these patients. METHODS: A pilot retrospective study including 901 patients from January 2005 to December 2009; divided into two groups. Group (I) included patients 75 years old and more, group (II) included patients 45 years old or less. All those patients underwent colonoscopy at the gastroenterology department of Charles Nicole hospital. RESULTS: The 1st group included 231 patients, and the 2nd group included 670 one. A past history of colorectal cancer was more frequent in the group I (33.3% versus 9.90%; p<0.05) however history of chronic inflammatory bowel disease was more frequent in group II (0 versus 40.6%; p<0.05). The main indication of colonoscopy was constipation in group II (6.1% versus 27%; p<0.05) and chronic diarrhoea in group I (42.9% versus 16.4%; p<0.05). Bowel preparation was poor in 30.4% cases of the group I and 12.9% of group II (p<0.05). The tolerance was similar in the two groups. The incomplete colonoscopy rate was higher in the group I (38.3% versus 23.4%; p<0.05). The most frequent cause of colonoscopy interruption was the poor preparation in group I and the bad tolerance in group II. Diverticular disease, polyps and colorectal cancers prevailed in group I, whereas inflammatory bowel disease was current in group II. CONCLUSION: In elderly patients, colonoscopy is safe, well tolerated and offers a good diagnostic yield. Its non completion was essentially due to the poor preparation. Sedation did not seem essential. The optimisation of results of colonoscopy requires an improvement of quality preparation.

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The risk of thromboembolism is increased in inflammatory bowel disease and its symptoms may be overlooked. The commonest are deep vein thrombosis and pulmonary emboli. Cerebral thrombosis, in a particular stroke, is rare. Furthermore, its treatment can be complex. We present the cases of 4 patients with cerebral vascular involvement.

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BACKGROUND: Autoimmune hepatitis is chronic and uncommon disease. The pathogenesis is a complex process. Several triggers for autoimmune hepatitis particularly viral herpesviridae infection, which may induce the development of autoimmunity in predisposed individuals. AIM: Report a new case. CASE REPORT: We report a case of 17-year- woman presented with autoimmune triggered by cytomegalovirus infection. Cytomegalovirus induced autoimmune hepatitis has not been reported previously. Evolution was favourable under antiviral treatment, corticosteroid and azathioprine.

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AIM: To assess the diagnostic value of Fibrotest in comparison with liver biopsy, for the evaluation of hepatic fibrosis in patients with chronic hepatitis C. METHODS: This prospective study included in 2 years (2006-2007), consecutive patients with chronic hepatitis C naive to treatment. Fibrotest and liver biopsy were performed. Receiver operating characteristics (ROC) curves , the sensitivity, specificity, positive and negative predictive values were used to assess the diagnostic value of Fibrotest in comparison with the METAVIR classification. RESULTS: We recruited a total of 65 patients: 28 males and 37 females (mean age: 50 years); 92% of the patients had genotype 1. The histological fibrosis results were: 3.1% F0; 24.6% F1; 32.3% F2; 29.2% F3 and 10.8 % F4. The diagnostic value of Fibrotest in the detection of significant fibrosis (F2-F4) was 0. 87. A score > 0.5 has a sensitivity of 85. 1%, a specificity of 72. 2%, a positive predictive value of 88. 9%,and a negative predictive value of 65%. The diagnostic value of Fibrotest in the detection of cirrhosis (F4) was 0. 85. There were 13/65 cases of discordance (20%) for fibrosis, 4 cases were attributable to biopsy and 6 cases to Fibrotest. The discordance was unexplained in 3 cases. the size of biopsy< 15 mm [OR=2. 82, 95% CI, 1. 3-6. 07; p = 0. 008] and the stage of fibrosis F0, F1, F2 [OR =3. 35 , 95% CI, 1. 1-10. 2; p=0. 03] were considered as risk factors of discordance in multivariate analysis. CONCLUSION: This prospective study confirmed the good diagnostic value of Fibrotest as compared with the histological analysis of liver biopsy.

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BACKGROUND: Nephrogenic ascites is a clinical entity that manifests as refractory and exsudative ascites with unknown etiology in patients with end stage renal disease and often undergoing hemodialysis. This entity presents in practice many diagnostic and therapeutic difficulties. AIM: The aim of this study is to focus on these difficulties through a new observation. CASE REPORT: We report one case of nephrogenic ascites in chronic renal failure related to an idiopathic neurologic bladder. It's a 38 years old patient on hemodialysis for three years who consulted for exsudative ascites with a low rate of leucocytes. CONCLUSION: We conclude that nephrogenic ascites is rare. Its diagnosis is an exclusion diagnosis based on exclusion of other causes of ascites, particularly exsudative forms with low leucocytes rate. Its management is based essentially on renal transplantation and its prognosis is very poor.

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BACKGROUND: Malnutrition is a frequently reported complication in patients with liver cirrhosis. It has a high clinical and economic impact reflected by an increased morbidity and prolonged hospital stay. AIM: This preliminary prospective study aimed to determine the prevalence of malnutrition in hospitalized cirrhotic patients and to investigate whether biological and anthropometric parameters are a valuable tool for identifying malnutrition in these patients. METHODS: The nutritional status of 44 consecutive cirrhotic patients (21 men, 23 women) was assessed according to the anthropometric measurements and biochemical analysis. The diagnosis of malnutrition was based on diminished values of Mid arm muscle circumference (MAMC) and/or Triceps skinfold thikness (TST) below the 5th percentile or less than 60%. RESULTS: The aetiology of cirrhosis was viral hepatitis in 29 patients (66%). Cirrhosis was classified Child Pugh A, B or C in respectively 9, 26 and 9 patients; 37 patients (84%) have mild or tense ascite. In this study, malnutrition was found in 35 patients (79.5%), whereas 9 patients has a good nutritional status. TST and MAMC less than 60% was found in respectively 72% and 25% of patients. No significant statistical difference in epidemiological characteristics was found between malnourished and well-nourished patients. TST and MAMC decreased significantly according to the Child score (p = 0.014 and 0.032 respectively; a positive correlation was found between these two parameters and the severity of cirrhosis. CONCLUSION: In this study, the high prevalence of denutrition was associated with the severity of cirrhosis. Anthropometric parameters are valuable tools for malnutrition diagnosis.

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