Rendu-Osler disease : A rare cause of ammonia encephalopathy

peer reviewe

Locally advanced pancreatic adenocarcinoma with biliary compression: need for early drainage

The incidence of pancreatic cancer is increasing, but proportion of resectable cases and survival do not increase. Then, our care strategies have to be optimized. Chemotherapy is the principal treatment of locally advanced pancreatic cancer. When the tumour triggers biliary obstruction, chemotherapy-associated morbidity increases, and biliary drainage becomes crucial. Gold-standard is endoscopic retrograde cholangiography, which could be impossible when duodenum or papilla are involved by the tumour. Other options are percutaneous radiologic drainage, surgical double by-pass or EUS-guided drainage. When EUS-guided procedures are available, they are proposed today as the best options

The diagnostic trap of acute pancreatitis with normal pancreatic enzymes

peer reviewedNous rapportons le cas d’une patiente prise en charge aux urgences pour des douleurs abdominales et dont le bilan biologique ne mettait pas en évidence de majoration des enzymes pancréatiques. Le CT-scanner abdominal a mis en évidence une pancréatite de grade E selon le score radiologique de Balthazar. Un diagnostic de pancréatite aiguë nécrotique sur hypertriglycéridémie a ainsi pu être posé. Dans les cas de pancréatite aiguës, le taux d’enzymes pancréatiques peut rarement être normal et ce, pour des raisons peu claires. En cas de présentation clinique évocatrice, le diagnostic de pancréatite aiguë ne peut donc être écarté sur base de ce dosage normal. Un bilan par CT-scanner est alors indiqué pour confirmer le diagnostic.We report the case of a patient admitted in emergency care for abdominal pain and whose biological assessment did not show any increase in pancreatic enzymes. The abdominal CT scan revealed pancreatitis of grade E according to the Balthazar radiological score. A diagnosis of acute necrotic pancreatitis secondary to hypertriglyceridemia was thus made. In cases of acute pancreatitis, the rate of pancreatic enzymes may rarely be normal for unclear reasons. In the case of an evocative clinical presentation, the diagnosis of acute pancreatitis cannot be ruled out on the basis of this normal dosage. A CT scan of the pancreas is then indicated to confirm the diagnosis

Esophago-gastric complications after ablation in atrial fibrillation

Atrial-esophageal fistula (AOF) after ablation in atrial fibrillation has a fatal outcome. Fully documented in 2004, AOF has never completely disappeared despite technological evolvements. Survival depends on early recognition and treatment. Gastroscopy allows early detection of esophageal lesions. We summarize here AOF mechanisms, evoking symptoms and treatment ; contribution of gastroscopy in early detection ; and finally symptoms from vagal and phrenic nerve injuries. This information is useful for emergency doctors, gastroenterologists / endoscopists, and general practitioners.Peer reviewe

Increased neoplastic risks in ulcerative colitis associated with primary sclerosing cholangitis

peer reviewedUlcerative ulcerative colitis (UC) is a chronic inflammatory bowel disease characterized by the presence of continuous, uniform, gapless lesions of healthy mucous membrane extending integrally from the anus over a variable portion of the colon. It is a multisystemic pathology for which we will describe one of its hepatic manifestations, primary sclerosing cholangitis (PSC). We present here the story of a patient, a carrier of the Breast Cancer type 1 gene mutation (BRCA1), who initially presented with epigastric and peri-umbilical abdominal pain associated with several episodes of bloody diarrhea. The initial assessment made it possible to diagnose BRCA1 and the fortuitous discovery of biliary tract stenosis of an undetermined nature. Further investigations led to the conclusion that there was a strong presumption of UC associated with PSC or even cholangiocarcinoma (CCA). In the course of treatment, cancer of the gallbladder was also detected. This clinical case makes it possible to review, in the light of recent publications, the pathophysiological link existing between UC and PSC. This article also presents an in-depth analysis of this entity with malignant potential that can affect different sites of the digestive tract, and its own management, which is the subject of new recommendations

Hypercalcémie refractaire et secretion de calcitone ectopique dans un tumeur pancreatique neuroendocrinienne maligne: effetcs hypocalcémiants du cinacalcet

Introduction: Paraneoplastic hypercalcemia is a sign of poor prognosis, as it is particularly resistant to the usual hypocalcemic treatments. Observation: In 2009, a well differentiated pancreatic neuroendocrine tumor (Ki-67= 2%) is diagnosed in a 52-year-old diabetic man. The tumor is revealed with a splenic and hepatic carcinomatosis. Plasmatic calcium was: 3.54 mmol/L (2.15 - 2.6). Biology showed hypophosphatemia, PTH < 4 ng/ml, high 1-25 OH VitD, calcitonin: 1016 ng/ml (< 12 ng/ml). He had hypercalciuria and hypophosphaturia. He received for two years several cycles of Streptozotocin-ADRIAMYCIN and FOLFOX, with partial control of the tumor mass and calcium levels. In 2012, calcitonin levels are 29 ng/ml whereas calcemia is 3.17 mmol/L. Hypercalcemia is refractory to hyperhydration, diuretics, corticosteroids, and bisphosphonates therapy. Cinacalcet (Mimpara) is prescribed up to 120 mg/day (PO). Calcemia decreases gradually from 3 to 2.87 and then 2.76 mmol/L. PTH and calcitonin-the tumor mass remain unchanged. After two months of Cinacalcet treatment, Sunitinib (Sutent) 37.5 mg per day was added. During the third month, calcium levels dropped to 2.09 mmol/L and PTH raised to 78 pg/ml, requiring discontinuation of Mimpara. Calcitonin normalized, with a further improvement over pancreatic and metastatic lesions. Conclusion: Cinacalcet is a Calcium Sensing Receptor oral agonist. Cinacalcet hypocalcemic effects have not been previously documented in pancreatic paraneoplastic hypercalcemia. In our patient, Cinacalcet has significantly improved cancer prognosis: this drug could be a new alternative in paraneoplastic hypercalcemia

Factors associated with the efficacy and safety of endoscopic dilatation of symptomatic strictures in Crohn's disease: a retrospective cohort study.

peer reviewed[en] OBJECTIVE: Endoscopic balloon dilatation (EBD) is a standard treatment for intestinal strictures in Crohn's disease (CD). No evidence-based guidelines exist regarding the balloon diameter or the balloon pressure to be used, with recent studies suggesting the use of a smaller diameter than classically used. We sought to analyze the factors associated with safety and efficacy of EBD in CD strictures, particularly looking at balloon diameter and dilatation pressure. METHODS: We conducted a monocentric retrospective study of patients who underwent EBD between 2005 and 2020. RESULTS: Our endoscopy department performed EBD in 94 CD patients during the considered period. The mean size of balloon dilatation was 16 mm (±2.5; including 21 patients with balloon <14 mm) and the mean dilatation pressure was 5.3 atm (±1.5). No perforation was observed. Over a median follow-up of 5.6 years, the probability of being operated was 5.4% at 1 year and 10.4% at 3 years. Smaller height (HR = 0.90, p = 0.022) and a higher BMI (HR = 1.23, p = 0.014) were associated with the risk of operation. The probability of being operated or redilated was 30.1% at 1 year and 52.5% at 3 years. No factor was significantly associated with this risk. The size of the balloon had no impact on outcomes. CONCLUSION: In this retrospective cohort, including a significant proportion of CD patients dilated with balloon <14 mm, no perforation was observed and the size of the balloon or the dilatation pressure had no impact on the risk of surgery or redilatation

Alcool and pancreatic complications

Alcohol consumption is the main cause of development of chronic pancreatitis and the second etiology of acute pancreatitis. The mortality of acute pancreatitis depends on its necrotic haemorrhagic character and the initial inflammatory response, while pain, malnutrition and diabetes are the main issues in the management of chronic pancreatitis. As medical and endoscopic techniques progress, surgical indications have become increasingly rare but remain indispensable for some patients. The multidisciplinary approach of these patients is the key to the success of care.La consommation d’alcool est la cause principale de développement d’une pancréatite chronique et la seconde étiologie de la pancréatite aiguë. La mortalité de la pancréatite aiguë dépend de son caractère nécrotico-hémorragique et de la réponse inflammatoire initiale tandis que les complications de type douleur, dénutrition et diabète sont les principaux enjeux de la prise en charge de la pancréatite chronique. Au fur et à mesure de l’avancée des techniques médicales et endoscopiques, les indications chirurgicales sont devenues de plus en plus rares, mais restent indispensables pour certains patients. L’approche pluridisciplinaire de ces patients est la clé du succès de la prise en charge