Search

Copyright of Hépato-Gastro & Oncologie Digestive is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Proctitis is a common problem in gastroenterology, frequently associated with inflammatory bowel disease (ulcerative colitis, Crohn's disease). However, many other causes are possible. Symptoms are usually non-specific, with a variety of clinical presentations. There are also pauci- or asymptomatic forms. Questioning and clinical history are essential to establish a diagnosis. They are supplemented by a physical examination, samples taken for infectious purposes, sometimes -endoscopy with histological samples, and even dynamic pelvic imaging. [ABSTRACT FROM AUTHOR]

Copyright of Hépato-Gastro & Oncologie Digestive is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Résumé: L'injection de cellules souches mésenchymateuses allogéniques représente une avancée majeure dans le traitement des fistules anales complexes de maladie de Crohn. Dans l'essai randomisé ADMIRE, le taux de guérison clinique et radiologique à un an était de 56 %. En vie réelle, les études sont en cours. Une étude suisse a été publiée portant sur 11 patients, elle a rapporté un taux de guérison de 72 % à 10 mois de suivi. Les limites de cette technique sont son coût, sa disponibilité et la nécessité de bien sélectionner les patients candidats à cette technique. En alternative aux cellules souches mésenchymateuses allogéniques, des équipes se sont intéressées à l'injection de tissu adipeux micro-fragmenté et de fraction vasculaire stromale autologue, contenant des cellules souches mésenchy-mateuses mais également des cellules endothéliales, immunitaires ayant des propriétés régénératives et angiogéniques. Les avantages de cette technique sont le plus faible coût et la disponibilité avec un prélèvement réalisé chez le patient lui-même et réinjecté dans le même temps. Nous détaillerons les résultats des études disponibles dans les fistules anales de maladie de Crohn et plus récemment dans les fistules anales crypto-glandulaires. Injection of allogeneic mesenchymal stem cells represents a breakthrough in the treatment of complex anal fistulas in Crohn's disease. In the ADMIRE randomized trial, the 1-year clinical and radiological healing rate was 56%. In real world, studies are underway. A Swiss study was published on 11 patients, it reported a healing rate of 72% at 10 months of follow-up. The limitation of this technique is its cost, its availability, and the need to properly select the patients for this technique. As an alternative to allogeneic mesenchymal stem cells, teams have been interested in the autologous injection of adipose tissue and adipose-derived stromal vascular fraction, containing mesenchymal stem cells but also endothelial and immune cells with regenerative and angiogenic properties. The advantages of this technique are the lower cost and availability with a sample taken from the patient and reinjected at the same time. We will detail the results of the studies available in Crohn's perianal fistulas and more recently in complex idiopathic perianal fistulas. [ABSTRACT FROM AUTHOR]

Résumé: L'IRM est l'examen de référence pour l'étude des suppurations ano-périnéales. Sa prescription est indispensable pour la prise en charge des fistules anales récidivantes, complexes et/ou si elles sont associées à une maladie de Crohn. Afin d'obtenir une imagerie de qualité, un protocole minimal est requis comme suit : acquisition de séquences en pondération T2 sans saturation du signal de la graisse dans les trois plans du canal anal (une de ces séquences peut être faite avec saturation du signal de la graisse), une séquence 3D ou trois séquences 2D dans les trois plans du canal anal en pondération T1 avec saturation du signal de la graisse et après injection de gadolinium. Un compte rendu standardisé est utile pour obtenir une analyse exhaustive d'une suppuration ano-périnéale en IRM. La réalisation d'un schéma anatomique est appréciée des cliniciens pour guider le drainage de la suppuration. Dans les fistules crypto-glandulaires, l'IRM est complémentaire de l'examen proctologique pour confirmer ou infirmer la relation entre la suppuration et l'appareil sphinctérien. Elle guide le geste du chirurgien grâce à une cartographie complète du trajet fistuleux. Elle est utile pour prévoir la stratégie thérapeutique, notamment pour les fistules anales complexes où plusieurs temps chirurgicaux avec mise en place de sétons seront nécessaires. Elle permet enfin, si besoin, de vérifier l'efficacité du traitement. Dans la maladie de Crohn, l'IRM est indispensable avant tout drainage chirurgical d'une fistule anale sauf contexte d'urgence. Outre les intérêts précédemment cités, elle est utile pour différencier l'inflammation liée à la maladie de la fibrose et pour évaluer l'état de la paroi rectale. Après l'instauration d'un traitement par une biothérapie ± un immunosuppresseur associé à la chirurgie, l'IRM évalue la rémission de la suppuration qui est définie par l'absence de collection > 10 mm et une hyperintensité T2 absente ou modérée du trajet fistuleux et de ses extensions secondaires. Anoperineal MRI is the gold standard to study anoperineal suppurations. Its prescription is essential for the management of recurrent or complex anal fistulas or if they are associated with Crohn's disease. To obtain quality imaging, a minimal protocol is required comprising the following sequences like: Acquisition of T2-weighted sequences without fat saturation of the signal in the 3 planes of the anal canal (one of these sequences can be done with fat saturation of the signal), a 3D sequence or 3 2D sequences in the 3 planes of the anal canal in T1-weighting with fat saturation of the signal and after injection of gadolinium. A standardized report is useful to obtain a comprehensive analysis of anoperineal suppuration on MRI. The production of an anatomical diagram is appreciated by clinicians to guide the drainage of suppuration. The main etiology of anoperineal suppurations is crypto-glandular anal fistula. The anoperineal MRI is complementary to the proctologic examination to confirm or deny the relationship between the suppuration and the anal sphincter. It maps the fistula path with precision. It is useful to plan therapeutic strategy, especially for complex anal fistulas which require several anal surgeries with the placement of a seton. Finally, if necessary, it useful to check the effectiveness of the treatment. In fistulizing anoperineal Crohn's disease, anoperineal MRI is essential before any surgery of an anal fistula except in an emergency context. In addition to the interests mentioned above, it is useful to distinguish disease-related inflammation from fibrosis and to assess the rectal wall. After the initiation of treatment with biotherapy ± an immunosuppressant in combination with surgery, MRI assess remission of the suppuration which is defined by the absence of collection > 10 mm and absent or moderate T2 hyperintensity of the fistula path and its extensions. [ABSTRACT FROM AUTHOR]

Résumé: Le prurit anal est une affection fréquente qui peut altérer de manière significative la qualité de vie des patients. Sa prise en charge est complexe du fait d'un éventail étiologique large. Cependant, le prurit anal primaire (essentiel ou idiopathique) en est la cause la plus fréquente. Ce diagnostic est retenu en l'absence de cause secondaire évidente. Sa prise en charge repose essentiellement sur des mesures hygiéno-diététiques associées à des traitements topiques ayant pour but d'assécher et de protéger la peau mais également de rompre le cercle vicieux du prurit anal grâce aux dermocorticoïdes. Les causes secondaires sont multiples, dominées par les maladies infectieuses qui peuvent être suspectées d'emblée en cas d'évolution généralement récente, d'un aspect clinique évocateur et, si besoin, par des prélèvements locaux positifs. Ceci étant dit, un traitement antiparasitaire d'épreuve peut être prescrit d'emblée. Les maladies dermatologiques sont également fréquentes et dominées par le psoriasis inversé mais aussi l'eczéma de contact ou le lichen plan ou scléreux. Leur diagnostic repose sur l'anamnèse et, si besoin, l'analyse histologique. Enfin, un prélèvement à visée histologique est également indiqué en cas d'échec des traitements de première ligne et/ou en cas d'évolution récidivante afin de ne pas méconnaître une affection tumorale comme la maladie de Bowen (High Grade Squamous Intraepithelial Lesion) ou la maladie de Paget qui nécessitent une prise en charge spécifique. Anal pruritus is a common condition that can significantly impair patients' quality of life. Its management is complex due to a wide range of etiologies. However, primary (essential or idiopathic) anal pruritus is the most common cause. This diagnosis is made in the absence of an obvious secondary cause. Its management is essentially based on hygienic and dietary measures associated with topical treatments aimed at drying and protecting the skin, but also at breaking the vicious circle of anal pruritus with dermocorticoids. Secondary causes are multiple, dominated by infectious pathologies which can be suspected from the outset in the case of a generally recent evolution, an evocative clinical aspect and, if necessary, on positive local samples. This being said, a trial antiparasitic treatment may be prescribed from the outset. Dermatological pathologies are also frequent and dominated by inverted psoriasis but also contact eczema or lichen planus or sclerosus. Their diagnosis is based on anamnesis and, if necessary, histological analysis. Finally, a histological sample is also indicated in the event of failure of first-line treatments and/or in the event of recurrent evolution in order not to ignore a tumoral affection such as Bowen's disease (High Grade Squamous Intraepithelial Lesion) or Paget's disease, which require a specific management [ABSTRACT FROM AUTHOR]

Résumé: Les techniques mini-invasives en chirurgie hémorroïdaire, apparues durant les deux dernières décennies, sont en plein essor. Elles représentent une alternative intéressante à l'hémorroïdectomie tripédiculaire classique car elles ne nécessitent pas de soins locaux, sont réalisées en ambulatoire, elles sont moins ou pas douloureuses et elles permettent une reprise d'activité plus rapide. Le traitement mini-invasif hémorroïdaire par laser est à la mode. Deux techniques utilisant ce type d'énergie sont disponibles : l'hémorroïdoplastie laser (LHP) et la HeLP (Hemorroidal Laser Procedure). L'hémorroïdoplastie laser, technique pratiquée en France, a montré des résultats satisfaisants dans les études publiées. Elle consiste à détruire le tissu hémorroïdaire et les branches terminales sous-muqueuses de l'artère hémorroïdaire supérieure par coagulation à l'aide d'une fibre laser introduite via une incision cutanée marginale. Les suites sont simples et les résultats à court et moyen terme sont bons sur la régression des symptômes (saignements, douleurs, démangeaisons) et la réduction du prolapsus hémorroïdaire. Elle représente une nouvelle option dans le traitement chirurgical de la maladie hémorroïdaire interne avec prolapsus minime à modéré. Sa place par rapport aux autres techniques mini-invasives reste encore à évaluer. La HeLP, non réalisée en France, détruit avec une fibre laser par voie transanale, après repérage au Doppler, les branches terminales de l'artère hémorroïdaire supérieure. Minimally invasive hemorrhoid surgery, which have appeared the last two decades, are in full development. They are an attractive alternative to conventional hemorrhoidectomy because they do not require local care, they are performed on outpatient, their postoperative courses are less painful and less longer. Minimally invasive hemorrhoidal laser treatment is popular. Two techniques using this type of energy are available: Laser hemorrhoidoplasty (LHP) and HeLP (Hemorrhoidal Laser Procedure). Laser hemorrhoidoplasty, performed in France, has shown satisfactory results in published studies. The shrinkage of internal hemorrhoidal tissue and the terminal branches of the superior hemorrhoidal artery are achieved by a specific laser device through a skin incision. Its postoperative courses are simple and their short-term results are good in terms of improvement of symtoms (bleeding, pain, itching) and reduction of hemorrhoidal disease grade. It represents a new option in the treatment of symptomatic second to third grade hemorrhoids with minimal internal mucosal prolapse. Its position, compared to other minimally invasive procedures, needs to be evaluated. HeLP, not performed in France, using a diode laser coupled with Doppler into the anal canal for photocoagulation of the distal branches of hemorrhoidal arteries. [ABSTRACT FROM AUTHOR]

Proctitis is a common problem and is frequently associated with inflammatory bowel disease (ulcerative colitis). However, many causes must be sought, especially an infectious origin, before concluding to an inflammatory proctitis. Sexually transmitted infections should be mentioned first for men who have sex with men (MSM), and people who are infected with HIV. Their incidence is increasing in the last two decades. Other pathogens frequently responsible for infectious colitis, such as Clostridium difficile, Cytomegalovirus, Amoebiasis, Campylobacter, Shigella, etc., may be responsible for isolated rectal injury or rectocolitis. The symptoms are mostly non-specific, with very varied clinical presentation. There are also pauci- or asymptomatic forms. The interview and clinical context are essential for a diagnosis. They will be supported by the physical examination, infectious specimens and sometimes the realization of an endoscopy with histology. In case of acute proctitis without any obvious cause, an empirical antibiotic treatment must be initiated after the infectious samples are taken. [ABSTRACT FROM AUTHOR]

Anal Fistulas: SPARING THE SPHINCTER. Fistulotomy is the most used treatment for anal fistula. It is very effective with a cure rate of over 95% but carries a risk of incontinence. This has led to the development of various sphincter sparing techniques. The injection of biological glue or paste and the insertion of a plug have disappointing results and are expensive. The rectal advancement flap is still practised because of its cure rate of around 75% but it may result in some incontinence. Intersphincteric ligation of the fistula track and laser treatment are widely practised in France with cure rates between 60 and 70%. Video-assisted anal fistula treatment as well as injections of adipose tissue, stromal vascular fraction, platelet-enriched plasma and/or mesenchymal stem cells are emerging techniques for which even better results are expected., Competing Interests: V. de Parades déclare avoir participé à des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts. N. Fathallah déclare des interventions ponctuelles pour les entreprises AbbVie, Viatris, Tillotts, Sandoz, Amgen, Biolitec et F Care Systems, et des liens durables avec l’entreprise Takeda. L. Spindler, A. Barré et E. Pommaret déclarent avoir participé à des interventions ponctuelles pour Biolitec. A.-M. Haouari et P. Benfredj déclarent n’avoir aucun lien d’intérêts.

MANAGEMENT OF SECONDARY LESIONS IN ANO-PERINEAL CROHN'S DISEASE. Anoperineal involvement in Crohn's disease is common and affects around 1/3 of patients during their disease. It constitutes a pejorative factor with an increased risk of permanent colostomy and proctectomy and is associated with a major deterioration in quality of life. Secondary anal lesions in Crohn's disease are fistulas and abscesses. They are difficult to treat and often recurrent. A multidisciplinary medico-surgical management in several stages is essential. The classic sequence is based on a first phase of drainage of fistulas and abscesses, a second phase of medical treatment based primarily on anti-TNF alpha and finally a third phase of surgical closure of the fistula tract(s). Conventional closure techniques such as biologic glue, plug, advancement flap and intersphincteric ligation of the fistula tract have limited effectiveness, are not always feasible, require technical skills and some have an impact on anal continence. In recent years, we have witnessed a real enthusiasm generated by the arrival of cell therapy. This has not spared proctology since adipose-derived allogeneic mesenchymal stem cells have had Marketing Authorisation and have been reimbursed in France since 2020 in the treatment of complex anal fistulas in Crohn's disease after failure of at least one biologic therapy. This new treatment offers an additional alternative in patients often in a situation of therapeutic impasse. Preliminary results in real life are satisfactory with a good safety profile. However, it will be necessary to confirm these results in the longer term and to work to determine the profile of the patients who could benefit the most from this expensive therapy., Competing Interests: N. Fathallah déclare des interventions ponctuelles pour les entreprises AbbVie, Viatris, Tillotts, Sandoz, Amgen, Biolitec et F Care Systems, et des liens durables avec l’entreprise Takeda. A. Alam déclare des interventions ponctuelles pour l’entreprise Biolitec. L. Kassouri déclare n’avoir aucun lien d’intérêts. A. Barré déclare des interventions ponctuelles pour les entreprises Takeda, Amgen, Tillotts. L. Spindler déclare des interventions ponctuelles pour Biolitec V. de Parades déclare des interventions ponctuelles pour Biolitec, F Care Systems, THD, Takeda, AbbVie, Amgen, Tillotts.

Proton pump inhibitors (PPIs) are among the most prescribed drugs in the world. While their efficacy in acute management is indisputable, it has long been suggested that PPI therapy is safe in the long term. In recent years, there has been growing and justified concern about the long-term risks of PPIs. The majority of reported side effects are based on observational studies with a low level of evidence. Concerning digestive risks, PPIs seem to increase the risk of Salmonella and Campylobacter infections. However, the link between PPIs and Clostridium difficile infection is not established. Long-term PPIs may be responsible for an increased risk of gastric cancer according to several recent studies. With regard to extra-digestive risks, PPIs are associated with a moderate increase in the risk of chronic renal failure via an interstitial nephritis mechanism. PPIs also provide martial deficiency and may be associated with vitamin B12 and magnesium deficiency in some patients. Other adverse reactions have been suggested without any causal relationship being established (i.e., dementia or bone fractures, cardiovascular risk). In this review we will discuss the different long-term adverse effects of PPIs and their level of evidence., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)