Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Prospective multicenter evaluation of colon capsule examination indicated by colonoscopy failure or anesthesia contraindication

BACKGROUND AND STUDY AIMS

In France, in about 5% of cases colonoscopies are incomplete or temporarily contraindicated.We tested the diagnostic yield of colon capsule endoscopy (CCE) in these patients.

PATIENTS AND METHODS

In a prospective study, in 17 French centers, inclusion criteria were colonoscopy failure or general disease that excluded colonoscopy with anesthesia. Patients underwent CCE using the first-generation PillCam Colon capsule. The main end point was CCE diagnostic yield, defined as identification of a colorectal lesion that directly explained symptoms or necessitated a diagnostic or therapeutic examination. A secondary objective was to test a simplified Movi-Prep colon cleansing. Follow-up to identify missed symptomatic cancer was scheduled.

RESULTS

CCE showed positive findings in 36 patients (diagnostic yield 33.6 %), among whom 23 subsequently underwent therapeutic intervention. Among 64 patients with negative capsule findings, 9 had a complementary procedure showing adenomas in only 1 case. CCE was incomplete in 7/107 patients. Colonoscopy was done in one patient to retrieve a capsule retained in the left colon, and sigmoidoscopy in 11 because the rectum was not reached. No colorectal cancer was diagnosed during the follow-up period. Colon cleansing with MoviPrep was rated good or excellent in 75.9% of cases.

CONCLUSION

This study shows the feasibility and the usefulness of CCE in the situation of colonoscopy failure or contraindication. The colon capsule modality should be tested against other available approaches, such as virtual colonoscopy or repeat colonoscopy by an expert.

Colon capsule endoscopy vs. colonoscopy in patients at average or increased risk of colorectal cancer

BACKGROUND

Colon capsule endoscopy (CCE) is a new, non-invasive technology.

AIM

To conduct a prospective, multicentre trial to compare CCE and colonoscopy in asymptomatic subjects enrolled in screening or surveillance programmes for the detection of colorectal neoplasia.

METHODS

Patients underwent CCE on day one and colonoscopy (gold standard) on day two. CCE and colonoscopy were performed by independent endoscopists.

RESULTS

A total of 545 patients were recruited. CCE was safe and well-tolerated. Colon cleanliness was excellent or good in 52% of cases at CCE. Five patients with cancer were detected by colonoscopy, of whom two were missed by CCE. CCE accuracy for the detection of polyps ≥ 6 mm was 39% (95% CI 30-48) for sensitivity, 88% (95% CI 85-91) for specificity, 47% (95% CI 37-57) for positive predictive value and 85% (95% CI 82-88) for negative predictive value. CCE accuracy was better for the detection of advanced adenoma, in patients with good or excellent cleanliness and after re-interpretation of the CCE videos by an independent expert panel.

CONCLUSIONS

Although well-tolerated, CCE cannot replace colonoscopy as a first line investigation for screening and surveillance of patients at risk of cancer. Further studies should pay attention to colonic preparation (Clinicaltrial.gov number NCT00436514).

The safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract

BACKGROUND

Confocal laser endomicroscopy (CLE) is rapidly emerging as a valuable tool for gastrointestinal endoscopic imaging. Fluorescent contrast agents are used to optimize imaging with CLE, and intravenous fluorescein is the most widely used contrast agent. Fluorescein is FDA-cleared for diagnostic angiography of the retina. For these indications, the safety profile of fluorescein has been well-documented; however, to date, fluorescein is not cleared for use with CLE.

AIMS

To estimate the rate of serious and total adverse events attributable to intravenous fluorescein when used for gastrointestinal CLE.

METHODS

We performed a cross sectional survey of 16 International Academic Medical Centres with active research protocols in CLE that involved intravenous fluorescein. Centres using i.v. fluorescein for CLE who were actively monitored for adverse events were included.

RESULTS

Sixteen centres performed 2272 gastrointestinal CLE procedures. The most common dose of contrast agent was 2.5-5 mL of 10% sodium fluorescein. No serious adverse events were reported. Mild adverse events occurred in 1.4% of individuals, including nausea/vomiting, transient hypotension without shock, injection site erythema, diffuse rash and mild epigastric pain. The limitation is that only immediate post procedure events were actively monitored.

CONCLUSIONS

Use of intravenous fluorescein for gastrointestinal CLE appears to be safe with few acute complications.

Diagnostic accuracy of esophageal capsule endoscopy versus conventional upper digestive endoscopy for suspected esophageal squamous cell carcinoma

BACKGROUND AND STUDY AIM

A video capsule similar to that used in small-bowel capsule endoscopy is now available for esophageal exploration. The aim of our study was to compare the accuracy of upper endoscopy (esophageal gastroduodenoscopy [EGE]) with esophageal capsule endoscopy (ECE) in patients at risk of esophageal squamous cell cancer (SCC).

PATIENTS AND METHODS

68 patients at risk of SCC secondary to a history of head and neck neoplasia were included in this comparison of techniques for detecting SCC and dysplasia. ECE was done using the first generation Pillcam ESO and EGE was performed in accordance with the usual practice of each center, followed by examination with 2 % Lugol staining and biopsy of unstained areas (39 neoplasia comprising 5 low grade dysplasia, 8 high grade dysplasia and 26 SCC).

RESULTS

Compared with EGE with and without Lugol staining, the sensitivities of ECE for neoplasia diagnosis were 46 % and 54 %, respectively. On a per-patient basis, the sensitivity, specificity, and positive and negative predictive value of ECE were 63 %, 86 %, 77 % and 76 %, respectively, compared with EGE without staining, and 61 %, 86 %, 77 % and 73 % compared with EGE with iodine staining. Neither the ECE transit time nor the distance between the esopharyngeal line and the neoplastic lesion differed between the 21 false-negative and 18 true-positive cases diagnosed by ECE; the only difference was a smaller median diameter among false negatives ( P < 0.001).

CONCLUSION

In a cohort at high risk for esophageal SCC, ECE is not sensitive enough to diagnose neoplastic lesions.

A French prospective observational study of the treatment of chronic hepatitis C in drug abusers

The objective of this prospective, multicenter, observational study was to evaluate healthcare for hepatitis C virus (HCV)-infected drug abusers in France and to determine predictors of successful therapeutic intervention. A total of 170 drug users were recruited from 40 French centers. Three centers recruited 66 participants (38.8%), and one to eight patients each were enrolled from 37 other centers (n=104). A sustained viral response (SVR) was seen in 65 (38.2%) patients. SVR rates were significantly higher in compliant than in non-compliant patients (43.5% versus 23.9%; P=0.019), in patients from high- rather than low-recruiting centers (54.5% versus 27.9%; P<0.001) and in patients receiving Buprenorphine rather than methadone (48.1% versus 21.8%; P=0.001). In patients, who completed both the treatment and follow-up (n=94), SVR rate was 57.4%. Buprenorphine substitution therapy and genotypes 2 or 3 HCV infection were associated with significantly higher rates of SVR (P<0.01, for both comparisons). In conclusion, successful care of hepatitis requires an active treatment policy of every center toward drug addicts. Additional studies are needed to explore the difference in SVR with methadone versus Buprenorphine therapy.

[Hepatitis C, cirrhosis and hepatocellular carcinoma]

The screening for the detection of hepatocellular carcinoma is based on ultrasound sonography which should be realised in patients with post-hepatitis C cirrhosis with a delay between 3 and 6 months according to the most identified risk factors, in particular age and sex male. In the case of discovery of hypoechogen nodule < or = 1cm, a follow-up is mandatory because it is usually untypical by ultrasound sonography and to propose a liver biopsy in the case of an increasing in size is shown. The ultrasound guided cutting biopsy can precise the histological characteristics of the nodule, the grade, and indicate prognostic factors. The liver biopsy is also mandatory in the case of a nodule > 2 cm and when the ultrasound sonography is not contributive, especially when the nodule is between 1 and 2 cm in size.

The efficacy and safety of duodenal stenting: a prospective multicenter study

BACKGROUND AND STUDY AIMS

Duodenal stenting has become a popular treatment in cases of malignant stenosis. However, a prospective evaluation of the efficacy and morbidity of this procedure has not been performed. A prospective multicenter study of duodenal stenting was conducted by the Société Française d'Endoscopie Digestive (SFED).

PATIENTS AND METHODS

A total of 51 patients were selected (mean age 72), the majority (69%) having pancreatic adenocarcinoma. Palliative treatment was chosen because of irresectability (61.2%), inoperability (18.4%), or both (20.4 %). Enteral Wallstent prostheses were used, and the patients were followed up on day 3, after 1 month, and then every month, with weight measurement, and symptomatic and laboratory evaluation.

RESULTS

One prosthesis was sufficient in 46 patients. Stent positioning and deployment were correct in 50/51 patients (98%). Twenty patients also underwent biliary stenting in addition to the duodenal stenting. On day 3, 43 patients (84%) were able to tolerate soft solids or a full diet. Six complications were attributed to stenting: three intestinal hemorrhages, two cases of peritonitis due to bowel perforation, and one case of septicemia, and these led to five deaths (mortality 9.8%). Stent dysfunction was observed in 12 cases (23.5%) after a mean delay of 75 days, comprising 11-malignant obstructions and one migration: a new stent was inserted inside the first one and was effective in eight cases; and no treatment was given in the other four patients because of their clinical state. The median survival was 71.5 days.

CONCLUSIONS

Palliative endoscopic treatment of malignant duodenal stenosis using metallic prostheses is highly feasible, even with associated biliary stenting. Symptomatic improvement is fast. However, the mortality and the obstruction rate are high, suggesting that a prospective trial comparing this treatment with surgery is still required.

[Incidence and risk factors of HCV infection in a cohort of intravenous drug users in the North and East of France]

BACKGROUND

In order to evaluate the incidence and risk factors of infection by hepatitis C virus (HCV) among intravenous drug users we conducted a prospective cohort study of HCV and HIV negative IVDU in the North and East of France.

METHODS

Two hundred and thirty-one IVDU who had injected drug at least once in their lifetime and were negative for anti-HCV and anti-HIV were followed-up every three months over a 12-month period. Serum anti-HCV and anti-HIV antibodies were tested at inclusion in the study and at the end of the follow-up. Data on injection practices and behaviours were collected at inclusion and at each visit, and a test for anti-HCV antibodies was performed on a saliva sample. When this proved positive, an ELISA test for serum anti-HCV antibodies was carried out.

RESULTS

Of the 231 participants included, 165 (71.4%) underwent a final HCV and HIV serum test. The incidence was nil for HIV infection and 9% (95% CI: 4.6-13.4) person-years for HCV infection. Among IVDU who injected at least once during the last 6 months HCV infection incidence was 11% (95% CI: 4.7-17.1) person-years. The multivariate analysis carried out on the inclusion data found female sex alone to be an independent predictive factor of HCV seroconversion. In a Cox proportional hazard multivariate analysis that took into account time-dependent exposures and covariates, we found that syringe and cotton sharing were, after adjusting for other covariates, the only independent predictive factors of HCV seroconversion: hazard ratio: 6.3 [corrected] (95% CI: 1.1-35.4; [corrected] p<0.05) and 16.4 (95% CI: 1.4-190.6; [corrected] p<0.05), respectively.

CONCLUSION

The transmission of the HCV virus persists among French IVDU despite an ongoing national harm reduction program. Injecting material and cotton sharing are the two major determinants of transmission in this cohort.

Incidence and risk factors of HCV and HIV infections in a cohort of intravenous drug users in the North and East of France

In order to evaluate the incidence and risk factors of infection by hepatitis C virus (HCV) among injecting drug users (IDUs), we conducted a prospective cohort study of HCV- and human immunodeficiency virus (HIV)-negative IDUs in the North and East of France. A total of 231 HCV and HIV IDUs who had injected drugs at least once in their lifetime were followed up every 3 months over a 12-month period. Serum anti-HCV and anti-HIV were tested at inclusion in the study and at the end of the follow-up. Data on injecting practices were collected at inclusion and at each visit. Of the 231 participants included, 165 (71.4%) underwent a final HCV and HIV serum test. The incidence was nil for HIV infection and 9/100 person-years (95% CI 4.6-13.4) for HCV infection. In a multivariable analysis, we found that syringe and cotton sharing were the only independent predictive factors of HCV seroconversion.

[Feasibility of prosthesis insertion by laparotomy as palliative treatment for malignant duodenal stenosis]

The authors report a preliminary series assessing the feasibility of duodenal stenting using a surgical approach. The study included 16 patients with a malignant duodenal outlet obstruction for whom a biliaryobstruction necessitated a laparotomyor following an endoscopic stenting failure. The stent was efficient in 15 patients with a complete relieve of obstruction. These patients could have oral intake at the end of the first postoperative week. No stent obstruction occurred. The duodenal stenting by laparotomy could be a good alternative to palliative gastroenteral anasotomosis.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]

OBJECTIVES

To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis.

METHODS

A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis.

RESULTS

Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

Noninvasive imaging of insulinomas and gastrinomas with endoscopic ultrasonography and somatostatin receptor scintigraphy

BACKGROUND

Classic morphological techniques are of limited value for imaging endocrine duodenopancreatic tumors, and invasive procedures such as intraarterial stimulation are often used. Two noninvasive procedures, endoscopic ultrasonography (EUS) and somatostatin receptor scintigraphy (SRS), were recently described with promising results.

METHODS

In this study we correlated the results of preoperative EUS (n = 34) and SRS (n = 30) with operative findings in patients with histologically proven insulinoma (n = 20) or gastrinoma (n = 21).

RESULTS

The sensitivity and positive predictive value (PPV) of EUS were respectively 77% and 94% for pancreatic tumors (insulinomas and gastrinomas), 40% and 100% for duodenal gastrinomas, and 58% and 78% for metastatic lymph nodes. The sensitivity and PPV of SRS for insulinoma were 60% and 100%, respectively. In patients with gastrinoma, the sensitivity and PPV of SRS were respectively 25% and 100% for pancreatic gastrinomas, 72% and 100% for duodenal gastrinomas or periduodenal metastatic lymph nodes, and 67% and 80% for liver metastasis. In patients with multiple endocrine neoplasia, neither one of the two techniques detected all tumors. Overall sensitivity of combined EUS and SRS was 89% for insulinoma (n = 9) and 93% for gastrinoma (n = 14).

CONCLUSIONS

EUS and SRS for gastrinomas and insulinomas should be considered as the initial preoperative imaging procedures and may render invasive procedures unnecessary for most patients.

[Rapid progress of cirrhosis in hepatitis C: the role of age at the time of viral contamination]

OBJECTIVE

The aim of this study was to assess predictive factors for the progression to liver cirrhosis in hepatitis C.

METHODS

One hundred thirty six patients (79 men; 57 women; mean age 39 years) with transfusion or intravenous drug use-associated hepatitis C virus (HCV) infection were studied. Sex, cause of infection, duration of contamination, and genotype were studied as predictive factors of progression to liver cirrhosis.

RESULTS

One hundred twenty three patients presented with chronic hepatitis without cirrhosis and 13 had cirrhosis. At the time of liver biopsy, rates of cirrhosis were: 0% before 40 years, 10% between 40 and 60 years, and 47% after 60 years. (p < 0.05). Rates of cirrhosis according to the age at the time of contamination were as follows: 3% before 30 years; 16% between 30 and 50 years; 46% after 50 years even though duration of the disease was comparable in the three groups. In multivariate analysis, two independent factors were associated with liver cirrhosis: age at contamination and duration of infection.

CONCLUSION

Duration of infection and especially age at contamination seem better correlated with the probability of cirrhosis than the route of transmission or the genotype 1b. The results of this study suggest that progression to cirrhosis is slower in cases of contamination before 30 years of age than later on. Age at the time of contamination is an important predictive factor of progression to cirrhosis.

[Results of laparoscopic cholecystectomy for acute cholecystitis in elderly patients]

OBJECTIVES

The aim of this retrospective study was to evaluate the feasibility and the morbidity of laparoscopic cholecystectomy for acute cholecystitis in elderly patients.

METHODS

Among 891 consecutive patients who underwent cholecystectomy, 151 had acute cholecystitis. Fifty three patients of > or = 70 years of age (group 1) were compared to 98 younger patients (group 2). Analysis was made in "intention to treat" so directly open cholecystectomies during the same period were also included.

RESULTS

Elderly patients had a lower success rate of laparoscopic treatment (52.8% versus 70.4%; p < 0.05). This difference was due to higher rate of directly open cholecystectomy in the elderly (17% versus 2%). There was no difference between both groups in conversion rate to laparotomy (30.2% versus 26.5%). Surgical morbidity was 7.5% in group 1 and 4% in group 2 (NS). General complications were more frequent in the elderly (p < 0.05). Five patients in group 1 (9.4%) died of general complications of which 3 were operated on directly by open cholecystectomy. There was no mortality in group 2.

CONCLUSION

Acute cholecystitis in the elderly remains a severe disease in which laparoscopic treatment is only possible in about fifty percent.

Efficacy and tolerance of mesalazine suppositories vs. hydrocortisone foam in proctitis

BACKGROUND

Topical treatments with steroids or mesalazine are the most effective treatments for idiopathic proctitis.

AIM

To compare the efficacy and tolerance of mesalazine suppositories vs. hydrocortisone acetate foam in the treatment of acute proctitis.

PATIENTS AND METHODS

242 patients with active idiopathic proctitis were randomized to receive once daily either one Pentasa suppository (mesalazine 1 g) or 100 mg hydrocortisone (Colofoam) for 14-21 days (until remission). Disease activity and tolerance of the treatments were assessed using a daily questionnaire, by physician assessment, and endoscopy score.

RESULTS

Both treatments induced a significant reduction in disease activity. Mesalazine suppositories were significantly more effective than hydrocortisone on rectal blood loss (P = 0.002) and mucus (P = 0.02) parameters, and on the degree of the decrease in endoscopy score (P = 0.02). No significant difference was observed between treatments concerning histology or tolerance.

CONCLUSION

Mesalazine suppositories were as well-tolerated as hydrocortisone foam, but were more effective for some parameters of disease activity.

[Hepatocellular carcinoma in asymptomatic primary biliary cirrhosis]

Hepatocellular carcinoma is an uncommon complication of primary biliary cirrhosis. Hepatocellular carcinoma occurs generally in the end stage of the disease. We report a case of asymptomatic primary biliary cirrhosis complicated by a hepatocellular carcinoma in a 66 year-old man.

[Adenocarcinoma of the appendix. A propos of a case complicated by double local and parietal recurrence]

Adenocarcinoma of the appendix is rarely encountered and is usually discovered fortuitously at pathology examination of the surgical specimen. Six years after surgery for degenerative villous tumor of the appendix, local and parietal recurrence led to surgery in our patient. We present here the indications for complementary hemicolectomy and management of parietal scars resulting from the initial appendectomy.

[Prevalence of hepatitis C, B and D markers and histopathological aspects in a group of intravenous drug addicts]

OBJECTIVES

The aim of this study was to assess the prevalence of infection by HCV, HBV, HDV and HIV and their biological and histopathological patterns in 104 intravenous drug users.

METHODS AND RESULTS

Seventy-five patients (72%) had anti-HCV antibodies. Transmission was rapid because 33% of those who had been drug users for 6 months or less had anti-HCV antibodies. The contamination rate was very high because 90% of those who had been drug users for 2 years or less had anti-HCV antibodies. Thirty-four (33%) had an HBV marker, and 6 were HBs Ag carriers. None of the patients had anti-HDV antibodies. Only one patient had anti-HIV antibodies. Twenty-five anti-HCV antibody positive drug users underwent liver biopsy. Seven (28%) had normal ALAT levels and 18 (72%) had permanently or intermittently elevated ALAT levels. The mean histological activity on the Knodell index was 4.1 (range: 1-8).

CONCLUSIONS

This study indicates that contamination by HCV is almost inevitable after 2 years of intravenous drug use. The low prevalence of HBV, HDV, and HIV infection might be explained by a low endemic state of these viruses in our area.

Double-blind comparison of cisapride and cimetidine in treatment of reflux esophagitis

In a double-blind, randomized, comparative trial of the prokinetic drug cisapride and the H2-blocker cimetidine, mucosal healing and changes in symptoms of gastroesophageal reflux were evaluated in patients with erosive reflux esophagitis. The patients were treated with either cisapride, 10 mg four times a day (N = 36) or cimetidine, 400 mg four times a day (N = 37) for six weeks, or for 12 weeks if mucosal healing was not obtained by week 6. Upon entry, two thirds of the patients in each group had grade I (Savary-Miller) esophagitis, and the remainder grade II or III. At the end of treatment, endoscopy showed mucosal healing in 56% (38-72%; 95% confidence interval) of cisapride and 57% (39-73%; 95% confidence interval) of cimetidine patients. After six weeks, both drugs significantly (P less than 0.01) decreased the intensity and frequency of heartburn, regurgitation, and the postural syndrome. No significant intergroup differences were found regarding endoscopic parameters or the improvement of heartburn and regurgitation. Concomitant antacid use was also comparable. Adverse effects were reported by four cisapride and nine cimetidine patients. These results indicate that the effects of cisapride compare well with those of cimetidine in terms of both esophageal mucosal healing and symptom relief.