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Viral hepatitis is a major health problem. Despite preventive efficacy with hepatitis B vaccine and therapeutic efficacy with nucleosi(ti)de analogs against B hepatitis or new direct acting anti-virals against C hepatitis, number of cases remain undiagnosed. In case of B hepatitis (positive HBsAg) or C hepatitis (positive HCV RNA) in a member of the couple, the use of assisted reproductive therapy (ART) is always dictated by the cause of infertility and there is currently not enough evidence to recommend one technique (IUI/IVF/ICSI) over another in patients infected with hepatitis. Overall, the data from the literature regarding the impact of B or C hepatitis on fertility and ART outcomes are controversial. The results are mainly reassuring and live birth rates are not different from couples without hepatitis and the risk of transmission remains very low. It has been reported that the positivity of HCV RNA in gametes cannot be excluded, which encourages to reinforce the washing procedure in a laboratory agreed for the viral risk. Providing a successful vaccination course, the risk of HBV horizontal transmission seems to be eliminated. Finally, it is important to inform the couple that ART procedure does not prevent mother to child transmission in case of maternal infection with hepatitis B or C. [ABSTRACT FROM AUTHOR]

Résumé: Les hépatopathies gravidiques sont les atteintes hépatiques les plus fréquentes au cours de la grossesse et peuvent être classées en fonction de leur survenue précoce (hyperemesis gravidarum) ou plus tardive (cholestase gravidique, foie toxémique incluant le HELLP syndrome et stéatose hépatique aiguë gravidique) au cours de la grossesse. Les anomalies du bilan hépatique associées aux vomissements sévères de la grossesse se corrigent après arrêt des vomissements. La cholestase gravidique est l'affection la plus fréquente et se caractérise par un prurit associé ou non à une augmentation des transaminases. L'acide ursodésoxycholique doit être débuté précocement et poursuivi jusqu'à l'accouchement. Le taux des acides biliaires est utile au diagnostic en cas de prurit sans anomalie du bilan hépatique et a une bonne valeur pronostique pour prédire le risque de mort fœtale in utero et la nécessité d'un accouchement prématuré. Les anomalies du bilan hépatique avec ou sans HELLP, associées à une pré-éclampsie se caractérisent par une cytolyse avec un risque d'hématome sous-capsulaire du foie. La stéatose hépatique aiguë gravidique est une maladie rare et grave qui se caractérise par des anomalies initialement modérées du bilan hépatique puis rapidement un ictère et une insuffisance hépatocellulaire. Le diagnostic se fait essentiellement par les critères composites de Swansea et par l'évolution de la stéatose à l'IRM en post-partum. Le traitement dans les formes graves repose sur l'évacuation utérine. En cas de retard de diagnostic et de prise en charge, le pronostic de la mère et de l'enfant est engagé. Pregnancy-related liver diseases are the most common cause of liver dysfunction in pregnancy. They can be classified as early (hyperemesis gravidarum) and later (intrahepatic cholestasis of pregnancy, pre-eclampsia with hepatic involvement including HELLP syndrome and acute fatty liver of pregnancy) specific liver diseases. Abnormal liver blood tests associated with severe vomiting of pregnancy resolve on cessation of vomiting. Intrahepatic cholestasis of pregnancy is the commonest pregnancy-specific liver disease and characterized by pruritus associated or not with elevated transaminases. Ursodeoxycholic acid should be prescribed early and continued until delivery. Serum bile acids level is useful for diagnosis in the event of pruritus without abnormal liver blood tests and has a good prognostic value for predicting stillbirth and the need of preterm delivery. Abnormal liver blood tests with or without HELLP syndrome, associated with pre-eclampsia are characterized by high transaminases levels with a risk of sub-capsular liver hematoma. Acute fatty liver of pregnancy is a rare and severe complication characterized by initially moderate liver tests abnormalities, rapidly evolving towards jaundice and hepatocellular insufficiency. The diagnosis is based on the Swansea composite criteria and by the resolution of steatosis on MRI during post-partum. The treatment in the severe forms is based on the rapid uterine evacuation. In the event of delayed diagnosis and/or need of supportive care, the prognosis is poor for the mother and the foetus. [ABSTRACT FROM AUTHOR]

The screening for HBsAg is a medical obligation in France during pregnancy. A serovaccination with antiHBs immunoglobulins (100 IU) and a 1st dose of vaccine (10 μg) has to be realized during the first 12 hours of life when the mother is HBsAg+. The serovaccination failures are related to high maternal viral load (HBV-DNA>7 log IU/mL). In this case, a treatment with analogue (tenofovir) associated with serovaccination could be performed during the last trimester of pregnancy. The risk of mother-to-child transmission of virus C is around 3 to 5% in case of HCV-RNA positive without co-infection with HIV. The mode of delivery is unchanged in case of maternal HBV or HCV. Breast-feeding is not contra-indicated in case of maternal HBV or HCV infection., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Alcoholic liver disease (ALD) causes more than 5000 deaths per year in France. Most of those deaths could be prevented by an early diagnosis, which would give the patients the opportunity to modify their alcohol consumption while liver lesions are still reversible. Hepatic histology is the main parameter that predicts morbidity and mortality in patients with ALD. Non-invasive methods such as biomarker tests (e.g. FibroTest(®) or FibroMetre A(®)) or hepatic elastography (FibroScan(®)) may allow diagnosing alcohol-induced liver lesion without systematic biopsy. Despite promising preliminary results, those methods are not validated yet in ALD. A validation of non-invasive methods for ALD could allow a large screening of the severe forms of this pathology., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

A hyperferritinemia has to be interpreted in relation with age and sex. The clinical evaluation begins with the interpretation of transferrine saturation which has to be controlled with a second fasting blood test. In case of high transferrine saturation associated with hyperferritinemia, HFE testing has first to be realized since the first diagnosis suspected is a HFE hemochromatosis. In case of normal transferrine saturation associated with a hyperferritinemia, the more frequent diagnosis is a metabolic syndrome, an inflammatory syndrome, a syndrome of cellular lysis or an excessive alcohol consumption. In case of HFE hemochromatosis, phlebotomy prevents complications. The goal is to obtain and to maintain a normal-low ferritin level. In case of metabolic syndrome, phlebotomy could be useful in case of high hepatic iron concentration measured with MRI or in case of on-alcoholic steato-hepatitis., (Copyright © 2012. Published by Elsevier Masson SAS.)

The current treatment of chronic hepatitis C since several years, the association of pegylated interferon and ribavirine, allows to obtain a virological eradication in 55% of patients, all genotypes and 45% of those infected with the genotype 1, the most prevalent. The cure, defined by an undetectable viremia 24 weeks after the discontinuation of treatment is associated to a improvement of the prognosis of the patients with a decrease of mortality and morbidity. The development of news antiviral C molecules, efficient against the genotype 1, two protease inhibitors, boceprevir or telaprevir (which approval has been recently obtained), in association with pegylated interferon and ribavirine, allows to obtain a viral eradication in 70 to 75% of cases, with a reduction of treatment duration to 24 weeks in half of patients. This evolution will modify the therapeutic indications, the therapeutic schemas, the virologic follow-up, the risk factors of sustained virological reponse, the tolerance with the appearance of new adverse effects., (Copyright © 2011. Published by Elsevier Masson SAS.)

Since highly active antiretroviral therapies became available, the future of HIV-infected patients has been transformed. However, 20 to 25% of HIV patients are co-infected with hepatitis B or C viruses, and the course of these diseases has worsened, since these patients have an enhanced sensitivity to the hepatic toxicity of antiretrovirals. The relation between high antiretroviral concentrations and toxicity has been clearly demonstrated with certain protease inhibitors and non-nucleoside reverse transcriptase inhibitors (NNRTI) that have a predominantly hepatic metabolism (CYP4503A4). The nucleoside reverse transcriptase inhibitors (NRTI) are not predominantly metabolized by the liver, but may nevertheless be toxic for the liver through mitochondrial involvement. The hepatic toxicity observed in a patient treated with early or delayed antiretrovirals may be due to a cytolytic, cholestatic or mixed, direct or indirect, mechanism. Before initiating antiretroviral treatments, hepatic fibrosis must be explored (punch biopsy, biological fibrosis test, and Child-Pugh's score). It is recommended that the most hepatotoxic drugs be avoided, notably didanosine, didanosine+stavudine, nevirapine, and full-dose ritonavir. Although it is possible to initiate an antiretroviral at the standard dose in patients with cirrhosis (the therapeutic margin with antiretrovirals is wide), early assays are essential, particularly with PI and NNRTI, to adjust the dose and avoid adverse events. In any event rigorous monitoring is a must.

Introduction: Carcinomatous meningitis is a rare complication of gastric cancer., Case: A 46 year-old man with an unremarkable medical history was hospitalized for treatment of suspected meningitis. Despite treatment, his clinical state rapidly worsened and he died without regaining consciousness, shortly after transfer to the ICU. Autopsy showed that he had anchorage-independent cell gastric carcinoma, with simultaneous lymphatic, pulmonary, cutaneous and meningeal metastases., Discussion: The rising incidence of secondary meningeal lesions in the last two decades is probably associated with the treatment-related improvement in life expectancy. Prognosis is very grave, and median survival time is only several weeks. Carcinomatous meningitis is difficult to diagnosis, especially as the first sign of a primary tumor. This rare presentation of gastric cancer indicates diffuse metastatic spread and extremely poor prognosis.

Unlabelled: Criteria for appropriateness of colonoscopy have been elaborated by an European Panel (EPAGE)., Objectives: 1) To assess the feasibility of EPAGE criteria in clinical practice, 2) to assess colonoscopy appropriateness using EPAGE criteria, 3) to compare colonoscopy appropriateness and findings., Patients and Methods: Four hundred and six consecutive examinations were included. The referral indication was judged using a scoring system on the basis of the EPAGE criteria., Results: Appropriateness could be assessed in 94% of the colonoscopies. Fifty-four percent were appropriate, 40% equivocal, and 6% inappropriate. Rate of abnormal colonoscopy was not different between the 3 groups, however endoscopic findings were more severe when the indication was appropriate. In the appropriate group, adenomatous polyps were more frequent (24%) than in the two other groups (13% and 12%; P<0.05) and tended to be larger in size. In the inappropriate group, patients were significantly younger, and no cancer was found. There were 5 colonic cancers in the inappropriate group and 12 in the appropriate group., Conclusion: Colonoscopy is generally not overused according to EPAGE guidelines. However, on an individual basis it could be rather difficult to determine colonoscopy appropriateness using a scoring system. Indeed, a third of the indications was judged equivocal and the endoscopic findings were no different whether indication was appropriate or equivocal.