[Controlled 15-year trial on screening for colorectal cancer in families with hereditary nonpolyposis colorectal cancer].

https://air.unimi.it/bitstream/2434/588501/2/Hern-ndez-Gea_et_al-2018-Hepatology.pdf

Preemptive-TIPS Improves Outcome in High-Risk Variceal Bleeding: An Observational Study

GOALS The aim of this study was to assess the use of thromboelastography (TEG)-directed blood product transfusion in cirrhotic patients with acute variceal bleeding compared with conventional transfusion for correction of coagulopathy. BACKGROUND Coagulopathy is common in patients with cirrhosis. Recommendations for correction of conventional parameters of coagulation-platelets and the international normalized ratio before endoscopy in patients with acute variceal bleeding-need more validation. STUDY In this randomized controlled trial, cirrhotic patients with severe coagulopathy and acute variceal bleeding were randomized to either TEG-guided blood product transfusion or conventional transfusion from March 2017 to December 2017. The primary outcome was the difference in the amount of fresh frozen plasma and platelet units transfused between the groups. Secondary outcomes were rebleeding at 5 days and 42 days, and 6-week mortality. RESULTS Of the 60 recruited patients, 30 each were randomized to the TEG and conventional transfusion groups. There were no differences in baseline characteristic and endoscopic findings between the 2 groups. Four subjects in the TEG group received blood product transfusions versus all in the conventional transfusion group (13.3% vs. 100%; P<0.001). The control of bleeding on initial endoscopy was similar in the 2 groups. Rebleeding in the TEG and conventional transfusion groups at 5 days was similar [1 (3.3%) vs. 4 (13.3%), P=0.167], whereas it was significantly less in the TEG group at 42 days [3 (10%) vs. 11 (36.7%), P=0.012]. Mortality at 6 weeks was seen in 4 (13.3%) in the TEG group and in 8 (26.7%) patients in the conventional transfusion group (P=0.176). CONCLUSIONS TEG-guided strategy was associated with reduced blood product transfusion to correct coagulopathy without compromising hemostasis in cirrhotic patients (Clinical trial ID: CTRI/2017/02/007864).

Thromboelastography-guided Blood Product Transfusion in Cirrhosis Patients With Variceal Bleeding: A Randomized Controlled Trial.

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.

Recent advances in the management of variceal bleeding.

Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.

Diagnosis and management of acute esophageal necrosis

The upper gastrointestinal bleeding from esophageal or gastric varices is the most dangerous complication of portal hypertension. The purpose of this study was to identify the predictors of early rebleeding and mortality after a bleeding episode. Patients and Methods: It was a retrospective study including 215 patients admitted in our department of hepatology and gastroenterology at the Hassan II University Hospital of Fez, from January 2001 to January 2010. Results: The mean age of our patients was 51 years. Thirty percent of patients had cirrhosis due to virus (B or C). The majority of patients (79%) had only esophageal varices. Fifty patients (23%) had a bleeding recurrence. Twenty-five patients (11.5%) died during the first ten days, of which 52% had presented rebleeding (p = 0.01). In 30% of cases, the rebleeding was secondary to a fall of pressure ulcers. Univariate analysis showed that early mortality of patients was significantly associated with advanced age (p = 0.018), low prothrombin time (PT) (p = 0.022), low serum sodium (p = 0.03), low platelet count (p = 0.05), and elevated transaminases (p = 0.02). Conclusion: The survival of cirrhotic patients after a bleeding episode was influenced by advanced age, a low rate of PT, of serum sodium, and of the platelet count, and elevated transaminases.

/pdf/predictors-of-early-rebleeding-and-mortality-after-acute-4qsey6n8hd.pdf

Predictors of early rebleeding and mortality after acute variceal haemorrhage in patients with cirrhosis

Acute esophageal necrosis, commonly referred to as “black esophagus” or “acute necrotizing esophagitis”, is a rare clinical disorder with an unclear etiology. The definition excludes patients with a history of recent caustic ingestion. Oesophageal necrosis can be diagnosed at endoscopy by the presence of black necroting appearing oesophagus. Contrary to the caustic oesophagitis whose treatment is often surgical, treatment of the acute necrositing oesophagitis is primarily medical. The prognosis for patients who develop acute necrotizing oesophagitis is generally poor. We report a new case of acute necrotizing oesophagitis and undertook a literature review of this rare diagnosis.

https://www.panafrican-med-journal.com/content/article/14/109/pdf/109.pdf

Acute esophageal necrosis: a case report and review.

Amiodarone chlorhydrate is a diiodated benzofuran derivative used to treat cardiac rhythm abnormalities. Hepatotoxicity is a relatively uncommon side effect of amiodarone and symptomatic hepatic dysfunction occurs in less than 1% to 3% of patients taking amiodarone. We report here on an unusual case of amiodarone-induced hepatotoxicity. A 29 year old woman with normal liver function was given amiodarone intravenously to treat her atrial fibrillation. She developed acute toxic hepatitis after 24 h. The intravenous form of amiodarone was immediately avoided and replaced by the oral form, using conventional loading doses as soon as the deranged liver function tests had normalized, without recurrence of the hepatitis. These observations show that the occurrence of acute hepatic impairment with intravenous amiodarone does not necessarily preclude the use of this drug by mouth and the necessity of monitoring the hepatic function of patients treated with amiodarone.

Acute hepatitis secondary to parenteral amiodarone does not preclude subsequent oral therapy.

Intra-hospital mortality in cirrhotic patients is variable depending on the studies reported in literature. Several studies have demonstrated independent predictors of mortality. The aim of this work is indeed to identify these predictors. Patients and Methods: We conducted a retrospective study of 1080 cirrhotic patients hospitalized in our department of gastroenterology and hepatology between January 2001 and August 2010. A descriptive study of the study population was performed, and a univariate analysis looking for an association between intra-hospital mortality, and clinical, biological, etiological and sociodemographic characteristics of our patients. Results: The average age of our patients was 54 years, with an equal number of men and women. 41.1% of patients had cirrhosis secondary to hepatitis C and 18.5% had cirrhosis secondary to hepatitis B. 26.1% of our patients were CHILD C. Intra-hospital mortality was 8.7% (97 deaths) with a mean of 23.4 ± 35.8 months. Univariate analysis showed that the intra-hospital mortality was significantly associated with higher age (p = 0.049) as well as the reasons for admissions like hepatic encephalopathy, and hematemesis (p < 0.0001), melena, jaundice and ascites (p = 0.001). Among the biological parameters analyzed in univariate analysis, significant associations with mortality were objectified for high white blood cell count (p = 0.035), and high serum bilirubin and creatinine (p < 0.0001); low rate of prothrombin time (PT) (p < 0.0001), of albumin (p = 0.0001) and of serum sodium (p < 0.0001). Among the complications analyzed, significant associations with mortality were objectified for jaundice, ascites (p = 0.001), hemorrhagic decompensation, hepatic encephalopathy, and spontaneous bacterial peritonitis (p < 0.001). Univariate analysis of the etiology of cirrhosis objectified significant associations for cirrhosis secondary to hepatitis B (p = 0.001) and hepatitis C (p = 0.022). Multivariate analysis objectified four independent predictors of mortality: hepatic encephalopathy, infection (hyper leukocytosis ≥ 10,000/mm3), renal failure (serum creatinine ≥ 15 mg/l) and hyponatremia. Conclusion: In our series, we identified four independent predictors of intra-hospital mortality in cirrhotic patients: hepatic encephalopathy, infection, renal failure and hyponatremia.

/pdf/predictors-of-intra-hospital-mortality-in-patients-with-33rsuppvve.pdf

Predictors of Intra-Hospital Mortality in Patients with Cirrhosis

Le cancer de l'estomac est represente essentiellement par Les adenocarcinomes gastriques, ces  derniers demeurent l'une des dix premieres causes mondiales de mortalite avec un pronostic qui est pejoratif. Son incidence reste variable a travers le monde, elle est caracterisee par une importante disparite geographique. Le but de notre travail est de decrire les caracteristiques epidemiologiques de l'adenocarcinome gastrique dans notre contexte a travers une etude retrospective, observationnelle etalee sur une periode de 10 ans (Janvier 2001- Janvier 2011), incluant tous les malades admis au service d'hepato-gastroenterologie du CHU Hassan II de Fes pour prise en charge d'un adenocarcinome gastrique. Durant cette periode, 343 patients etaient admis pour prise en charge d'une tumeur gastrique, dont 170 patients avaient un adenocarcinome gastrique (49.5%). L'âge moyen de ces patients etait de 58±13.4 ans [16 ans-0 ans]. Dans 43.7% des cas, les patients provenaient de la region de Fes, souvent du milieu rurale. On note une nette predominance masculine, avec une difference significative entre les 2 sexes (p< ;0.05). Les patients âges de moins de 60ans representaient la tranche d'âge predominante (63%) par rapports aux patients âges de plus de 60ans (p=0.02). 61% des patients consultaient dans un delai allant de 1 mois a 6 mois, 30.4% des patients etaient tabagiques, ce facteur avait une relation statistiquement significative avec l'adenocarcinome gastrique (p=0.02). la non consommation de l'alcool est inversement liee et de facon significative a l'apparition de l'adenocarcinome gastrique (p=0.03) dans notre contexte. L'infection par Helicobacter pylori n'etait mentionnee que chez peu de malades. Les formes  metastatiques au moment du diagnostic depassaient 50% avec un taux de deces au cours de  l'hospitalisation de 2.6%. Sur le plan endoscopique, la localisation antropylorique, et la forme ulcero-vegetante etaient predominantes, elles presentaient successivement 49 % (p=0,002) et 66%  (p=0.00001) .Une chirurgie curative n'etait proposee que chez 50 patients (30.2%). L'adenocarcinome gastrique represente le type histologique le plus frequent, son pronostic reste fâcheux dans notre region, touchant une population jeune, minimisant ainsi les chances de tout traitement curatif. Key words : Cancer de l’estomac, epidemiologie, pronostic, Helicobacter pylori

https://www.ajol.info/index.php/pamj/article/download/131067/120659

Adil Ibrahimi

Papers

Predictors of early rebleeding and mortality after acute variceal haemorrhage in patients with cirrhosis

Acute esophageal necrosis: a case report and review.

Acute hepatitis secondary to parenteral amiodarone does not preclude subsequent oral therapy.

Predictors of Intra-Hospital Mortality in Patients with Cirrhosis

Epidémiologie du cancer gastrique: expérience d’un centre hospitalier marocain