Elise Pommaret

Helpfulness of the combination of acetic acid and FICE in the detection of Barrett's epithelium and Barrett's associated neoplasias

AIM To investigate the mucosal morphology in Barretts oesophagus by chromo and magnifying endoscopy. METHODS A prospective pilot study at a tertiary medical centre was conducted to evaluate the use of acetic acid pulverisation combined with virtual chromoendoscopy using Fujinon intelligent chromoendoscopy (FICE) for semiological characterization of the mucosal morphology in Barretts oesophagus and its neoplastic complications. Upper endoscopy using high definition white light, 2% acid acetic pulverisation and FICE with high definition videoendoscopy were performed in 20 patients including 18 patients who presented with aspects of Barretts oesophagus at endoscopy examination. Two patients used as controls had normal endoscopy and histological results. Prospectively, videos were watched blind from histological results by three trained FICE technique endoscopists. RESULTS The videos of patients with high-grade dysplasia showed an irregular mucosal pattern in 14% using high definition white light endoscopy and in 100% using acid acetic-FICE combined. Videos did not identify irregular vascular patterns using high definition white light endoscopy, while acid acetic-FICE combined visualised one in 86% of cases. CONCLUSION Combined acetic acid and FICE is a promising method for screening high-grade dysplasia and early cancer in Barretts oesophagus.

Colonic mestastasis of an epithelioid hemangioendothelioma: An unusual cause of periumbilical pain and weight loss

A 78-year-old man with a history of epithelioid hemangioenothelioma who had been treated with a T9 vertebrectomy n January 2009 presented with periumbilical pain, alteration f his general condition, and weight loss. One year ago, the atient underwent gastroenterological endoscopy and computed omography scans which appeared normal. Physical examination evealed abdominal pain without other symptoms. Biologial inflammatory syndrome was identified (white blood cell ount was above >100×109/L and C-reactive protein level was 80mg/L). An abdominal computed tomography scan showed thickened cecum (Fig. 1). A colonoscopy showed ulcerations, ecrosis, vascular budding, and a patchy distribution in the olon (Fig. 2) suggesting inflammatory bowel disease rather than etastatic progression. Cecum and right colon biopsies showed colonic mucosal infiltration from an epithelioid hemangioen-

Clinical diagnostic and therapeutic aspects of 221 consecutive anorectal Chlamydia trachomatis and Neisseria gonorrhoeae sexually transmitted infections among men who have sex with men

OBJECTIVES Proctitis caused by Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are known as sexually transmitted infections (STI). This study describes their clinical, diagnostic and therapeutic aspects. METHODS Between 01/2013-03/2015, all MSM consulting for proctitis at proctology Institute-Saint-Josephs Hospital, Paris, were included. Demographic, past-medical history, STI status and medical treatment were collected. Detection of CT/NG was performed by Transcription-Mediated Amplification (TMA) and antimicrobial susceptibilities for Ng by agar diffusion method. RESULTS On 441 rectal samples collected, 221 (50.1%) were positive: 109 Ct (49.3%), 70 Ng (31.7%), 42 positive for both etiologies (19%). Among Ng infections, no resistance was detected to azithromycin and ceftriaxone. However, 84 strains (43.2%) were resistant to fluoroquinolones. More than one episode was diagnosed for 10 (5.1%) and 12 (6.2%) patients with CT and NG infections respectively. Anal abscesses were found for 27 (13.9%) patients, and 14 (7.2%) of them underwent surgery for anal fistula. CONCLUSIONS The prevalence of CT/NG anorectal infections described is high on symptomatic patients, and a significant level of abscess was reported. These results confirm the interest of the association of recommended antibiotics excluding quinolones. Prospective studies would be relevant on complicated forms of anorectal infections.

Main Advantages of Dearterialization of Haemorrhoids and Mucopexy

Haemorrhoidal dearterialization with mucopexy is a minimally invasive method of treating haemorrhoidal disease which is effective for reducing the symptoms of haemorrhoids and improving quality of life. Moreover, it has the obvious advantages of preservation of the anatomy and physiology of the anal canal, absence of external wounds, better tolerance, and a less painful postoperative period, especially compared with haemorrhoidectomy, but also probably compared with stapled haemorrhoidopexy. It is therefore usually provided on a day surgery basis and scores better in terms of general activity and ability to return to social and/or work activities. The procedure is also safe, with low postoperative morbidity and few complications, which are usually minor. There is a probable higher long-term risk of recurrence of prolapse and/or bleeding after haemorrhoidal dearterialization with mucopexy, particularly in comparison with haemorrhoidectomy, but it is not a real problem in a time when patients often prefer a risk-free procedure and a short-term benefit to a potential long-term disadvantage.

Recommandations pour le traitement de la constipation : une aide efficace de plus à la décision thérapeutique ! (1 ère partie)

Les recommandations de pratique professionnelle sont habituellement destinees au plus grand nombre. Classiquement, le texte court est accessible a tous avec une volonte de dissemination aupres des praticiens de medecine generale et du personnel soignant : il est disponible sur les sites des trois societes savantes partenaires. Le texte long developpe un argumentaire detaille qui releve souvent du domaine de l’expertise et de la specialite.La communication des grades de recommandations a l’occasion de journees de formation medicale continue ou d’une publication reste malheureusement une etape souvent insuffisante a leur dissemination. Le texte est de lecture laborieuse et il n’est pas souvent d’un grand secours dans la pratique quotidienne (document trop synthetique, lecture non adaptee pendant la consultation). Ce constat a conduit plusieurs societes savantes et tutelles a abandonner ces grands travaux a l’impact limite.Le choix qui a ete fait cette fois concerne l’elaboration d’algorithmes argumentes, representant une aide a la decision therapeutique dans les situations les plus courantes. Ces algorithmes ont ete elabores de facon independante de la redaction du texte court des recommandations mais ils reposent sur la meme methodologie. Les differentes etapes de chaque algorithme sont documentees par un texte court, des grades de recommandations et les references essentielles. Leur objectif principal est celui d’une meilleure penetration, en pratique de soins, des donnees scientifiques disponibles.

Reconnaître et traiter une rectite infectieuse

La rectite est un probleme courant en gastroenterologie, elle est frequemment associee aux maladies inflammatoires de l’intestin (rectocolite hemorragique). Cependant, face a une rectite, de nombreuses causes doivent etre cherchees, notamment une origine infectieuse, avant de conclure a une rectite inflammatoire. Les maladies veneriennes sont a evoquer en priorite chez les hommes ayant des rapports sexuels avec les hommes (HSH), infectes par le VIH. Ce d’autant que leur incidence est en augmentation ces deux dernieres decennies. Les autres pathogenes frequemment responsable de colite infectieuse, tels que Clostridium difficile, cytomegalovirus, amibiase, Campylobacter, Shigella, etc., peuvent etre responsable d’une atteinte rectale isolee ou d’une rectocolite.Les symptomes sont le plus souvent non specifiques, avec des presentations cliniques tres variees. Il existe egalement des formes pauci- ou asymptomatiques.L’interrogatoire avec le contexte clinique sont indispensables pour etablir un diagnostic. Ils seront soutenus par l’examen physique, les prelevements infectieux et parfois la realisation d’une endoscopie avec prelevements histologiques.Devant une rectite aigue sans cause evidente, un traitement antibiotique empirique doit etre initie apres la realisation des prelevements infectieux.

Liver nodules in Crohn's ileitis†

To the Editor: Pelvic or intraabdominal abscesses are a frequent complication of Crohn’s disease (CD) and may sometimes be inaugurals. Febrile abdominal pain in a young man with a history of chronic diarrhea constitutes the main clinical symptom. We report the case of a 37-year-old man who was admitted with febrile pain in the right iliac fossa. His clinical history revealed nonexplored recurrent episodes of chronic diarrhea occurring in the past 2 years. Laboratory tests revealed leukocytosis (white blood cell count: 14,000/ mL) and high C-reactive protein (CRP) levels (76 UI/mL). A computed tomography (CT) scan showed inflammation of the last ileal loop with a 2-cm right fossa collection. Midgut magnetic resonance imaging revealed a blind fistula in addition to terminal ileitis (Fig. 1). Ileocolonoscopy showed ulcerative lesions on the terminal ileum and normal colonic mucosa. Histological results confirmed chronic inflammation of the terminal ileum suggesting ileal CD. Ciprofloxacin was administered to the patient for 1 month, followed by 2 months of budesonide therapy. CRP levels decreased but the abdominal pain did not. The patient weight loss was 5 kg within 3 months. A control CT scan was performed after 3 months, revealing a persistent right iliac fossa collection with a pelvic right urethral compression associated with multiple lesions of the liver (Fig. 2). Clinical and CT findings suggested the presence of hepatic abscesses complicating Crohn’s iliac fossa collection. The patient received antibiotics and parenteral nutrition. No clinical or biological improvement was noticed within 2 weeks. Extrinsic compression of the right ureter induced by iliac fossa collection suggested neoplastic origin. Laparotomy showed a tumoral aspect of the terminal ileum with locoregional invasion of the right pelvic ureter and the rectum, in addition to hepatic lesions. Histological analysis pointed to small bowel adenocarcinoma and liver metastasis. Small bowel adenocarcinoma is rare and ileum location represents 19.2% of all cases. The relative risk of small bowel carcinoma in CD has been reported to be 28.4 times higher compared to the general population. CDassociated small bowel adenocarcinomas appear at a younger age compared to de novo small bowel adenocarcinomas (median age of 48 vs. 65). Duration of CD and age at diagnosis of CD had no significant influence on the incidence of small bowel adenocarcinoma. Our case supports a nondurationrelated outcome of CD considering the early age of the patient and the absence of old symptoms. The combination of 5-fluorouracil and platinum salt appears to be the most effective chemotherapy. After surgery, our patient received 5-fluorouracil plus oxaliplatinbased chemotherapy. While CD is the most frequent cause of pelvic abscess and antibiotics are preferred for circumscribed collection, ileum adenocarcinoma must be suggested when faced with an atypical disease course and exploratory surgery should be considered as an option.

Quality Indicators for Colonoscopy Procedures

Colonoscopy remains the gold standard for morphologic colon. Despite the development of new methods of morphologic bowel, colonoscopy is still considered the « gold standard » because of its ability at detecting small neoplasic lesions as well as adenomas. Unlike other methods, colonoscopy has the great advantage of carrying out the same time the removal of polyps. Colonoscopy also has a number of limitations. Studies have confirmed that the colonoscopy examination was an improvement over the performance review that fluctuates depending on the quality of it. Thus Pickardt et al showed that colonoscopy could miss up to 10% of polyps greater than 10mm (1). Also, it should be noted that interval cancers after colonoscopy is not uncommon (2). These results underpin the idea that colonoscopy is an examination of improvement and it is necessary to define quality criteria. The most famous of all is the detection rate of adenoma. This simple criterion was used to compare the performance of endoscopists (3). To reduce variation between endoscopists and to generalize the practice of colonoscopy quality, we must have reliable and easily measurable criteria for assessing the quality of examinations. These criteria should ensure that consideration is medically justified. It is carried out by using standard validated, that lesions are diagnosed correctly and appropriate treatments are made. All of it should be done with minimal risk to patients. Moreover, these criteria must evaluate the entire examination and not just the technical act. Those criteria must also take into account: the information provided to the patient, risk assessment, and conditions of the act. Indications for colonoscopy and appropriate intervals have been established by the taskforce in 2006 between the American College of Gastroenterology and the American Society of Digestive Endoscopy (4).

Place de la chimiothérapie adjuvante dans le cancer du côlon chez les patients âgés

Le cancer colorectal (CCR) represente un vrai enjeu de sante publique. Son incidence elevee associee au vieillissement de la population rend de plus en plus frequent le diagnostic de CCR chez les patients de plus de 74 ans. Il n’est donc plus rare d’avoir a discuter en reunion de concertation pluridisciplinaire de l’interet d’une chimiotherapie adjuvante chez un patient de plus de 74 ans. Si le traitement de reference du CCR opere est le schema FOLFOX 4 depuis l’etude MOSAIC en 2004, le benefice d’une intensification de la chimiotherapie par de l’oxaliplatine dans les CCR operes apres 74 ans est discute. Par ailleurs, l’incidence des tumeurs microsatellite instable (MSI+) est de l’ordre de 15 a 20 % dans la population generale. Ces tumeurs MSI+ ont une sensibilite reduite a la chimiotherapie a base de 5FU ce qui rend la connaissance du statut MSI indispensable lors du choix du traitement. Ce choix doit egalement prendre en compte la toxicite de la chimiotherapie et les facteurs de vulnerabilite des patients âges. L’âge chronologique n’est pas un bon element d’orientation therapeutique ; en revanche, l’esperance de vie sans maladie a l’âge de la chirurgie represente une aide a la decision. Elle est a 75, 85 et 95 ans de dix, cinq et deux ans chez l’homme. Une evaluation pluridisciplinaire des risques geriatriques permet de guider au mieux le traitement. La Comprehensive Geriatric Assessment ou evaluation gerontologique multidimensionnelle est un processus d’evaluation globale qui permet d’identifier trois sous-groupes parmi les patients âges : robustes, fragiles, vulnerables. Ce score permet de predire la mortalite a deux ans sans traitement qui est respectivement de 10, 19 et 40 %. L’objectif de cette mini-revue est de faire le point sur la chimiotherapie adjuvante des cancers colorectaux apres 74 ans et de souligner les elements qui guident le choix du traitement chez les sujets âges en prenant en compte leur fragilite.