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The finding of a terminal ileitis after kidney transplantation can cause a diagnostic challenge. Because the development of Crohn's disease under immunosuppressive therapy is unlikely, this diagnosis should only be considered after exclusion of infectious disease and drug-related intestinal toxicity. Defining the underlying cause of terminal ileitis is often hampered by a shortage of specific diagnostic tests or their lack of sensitivity. We present three patients with terminal ileitis after kidney transplantation resulting from different etiologies. Subsequently, we describe the characteristics that can help to make the differential diagnosis.

We present a case of a 41-year-old woman with severe abdominal pain caused by two jejuno-jejunal intussusceptions. Further investigation showed coeliac disease as the underlying cause. The patient recovered rapidly on a gluten-free diet. So coeliac disease could be the underlying cause of idiopathic intussusception more often than previously thought and intussusception should be suspected in patients with known coeliac disease presenting with abdominal pain. (Acta gastro-enterol. belg., 2016, 79, 000-000).

Diverticulosis of the colon is a common disease with an increasing incidence in Western countries. Recent literature has shown some changes in the traditional approach of this disease. The theory that diverticulosis is caused by a reduced intake of dietary fibre, is doubtful. There might be some chemical and histological overlap between diverticulitis, inflammatory bowel disease and irritable bowel disease. High quality clinical study found no effect for antibiotics in acute, uncomplicated diverticulitis. Cyclic administration of mesalazine and rifaximin result in reduced symptoms of diverticular disease. For the treatment of diverticular abscesses, percutaneous drainage shows promising results. Recurrence of acute diverticulitis is rare and most serious complications are linked to the first episode. Recent evidence does not support the traditional recommendation for elective surgery after two episodes of acute diverticulitis any more. This review summarizes the last evidence in diverticular disease and diverticulitis.

Distal intestinal obstruction syndrome (DIOS) - the incomplete of complete intestinal obstruction by intestinal contents in the terminal ileum and proximal colon- is frequently seen in cystic fibrosis (CF) patients. Diagnosis is based on suggestive symptoms of abdominal pain in the right lower quadrant, a palpable mass on examination and signs of obstruction on plain radiography. Treatment consists of intensive laxative treatment with oral laxatives and enemas. Surgery only serves as the last resort for patients not responding to medical therapy, because of the well-known high rate of peri- and postoperative morbidity of surgery in CF patients. In this article we present 3 cases of DIOS, followed by a review of the relevant literature.

Reflux into the esophagus after partial or total gastrectomy is a well known problem. Even a Roux-en-Y reconstruction is not always a definitive solution. Bile reflux might occur and cause disabling symptoms, unresponsive to the classic anti-acid or anti-reflux therapy. Endoscopy and a Tc-99m-BrIDA hepatobiliary (HIDA) scan can be used to make the diagnosis. Clinical studies have shown that lanreotide (somatuline), which strongly inhibits many gastro-intestinal hormones, reduces the bile salts outputs. We present a case of a patient with bile reflux after Roux-en-Y. After administration of lanreotide he had a good clinical improvement and mucosal healing on endoscopy. Lanreotide can be a good treatment option for bile reflux when classic treatment fails, but clinical trials with more patients will have to confirm this.

Crohn's disease is often accompanied by extraintestinal inflammation. Acute pancreatitis can be a rare manifestation of Crohn's disease. The present report describes a patient who developed two episodes of pancreatitis before the diagnosis of Crohn's disease. Clinical and laboratory evaluation excluded other causes of pancreatitis, confirming a direct association of the pancreatitis with Crohn's disease. This case report supports the hypothesis that acute pancreatitis may precede the clinical manifestations and diagnosis of the underlying inflammatory bowel disease.

Acid peptic diseases such as peptic ulcer and gastrointestinal reflux disease have a high prevalence; they can have an important impact on the patient's quality of life and generate a considerable health care cost. Proton pump inhibitors are the most potent pharmacological inhibitors of gastric acid secretion currently available and are the mainstay medical therapy for acid peptic diseases. This review provides primary care clinicians with best practice guidelines for optimal use of these drugs.

Estimation of prevalence and risk factors for Helicobacter pylori (H. pylori) infection in children and young adults in Belgium.Five hundred and sixteen schoolchildren between 12 and 25 years old were tested for H. pylori infection using 13C-UBT in different regions in Belgium. A questionnaire was used to evaluate risk factors.Fifty six (11%) tested positive. In children born in Belgium, with parents from Belgium, 13 (3,2%) tested positive. In children born in a foreign country, 20 (60%) tested positive; if born in Belgium but 1 or 2 parents were from a foreign country, 15 (30%) tested positive. Differences were significant (p0.001). In the multivariate analyses, significant risk factors were staying in a day nursery, a birthplace of child or father outside Belgium, and lower education levels of mother.In this cohort of Belgian asymptomatic children and young adults, the prevalence of H. pylori infection is 11%, ranging from 3,2% in Belgian born children with Belgian parents to 60% in children born in high prevalence countries from foreign parents. The most significant risk factor found in this study was origin.

The increasing antimicrobial resistance of Helicobacter pylori jeopardizes the efficiency of the classical eradication triple therapy. In this article we assessed the primary resistance rates of Helicobacter pylori to the commonly used antibiotics for eradication in the area of Brussels and determined prospectively, through a questionnaire, the possible risk factors for resistance. Gastric biopsies were taken for histology and culture in all adult patients in whom Helicobacter pylori was searched from February 2009 to April 2010 at the UZBrussel hospital. Clinical and demographic data were collected through a questionnaire. Histology was positive in 222 out of 507 patients tested (43.7%). Culture was successful in 189 patients with a positive histology (85.1%), 4 patients had a positive culture with a negative histology. Resistance to clarithromycin, metronidazole, ciprofloxacin, and amoxicillin was tested. Primary resistance rates were 13.3% for clarithromycin, 26.1% for metronidazole, 23.9% for ciprofloxacin, 0.8% for amoxicillin. Dual resistance to claritromycin and metronidazole was seen in 3.9%, triple resistance (claritromycin, metronidazole and ciprofloxacin) in 1.7% and resistance to the 4 antibiotics in 0.6% of patients. We conclude that there is a decreasing resistance for clarithromycin, metronidazole resistance is stable and rapidly increasing ciprofloxacin resistance. Resistance to any of the tested antibiotics was not associated with origin, age, gender, number of siblings, level of education or status (p > 0.05).The increasing antimicrobial resistance of Helicobacter pylori jeopardizes the efficiency of the classical eradication triple therapy. In this article we assessed the primary resistance rates of Helicobacter pylori to the commonly used antibiotics for eradication in the area of Brussels and determined prospectively, through a questionnaire, the possible risk factors for resistance. Gastric biopsies were taken for histology and culture in all adult patients in whom Helicobacter pylori was searched from February 2009 to April 2010 at the UZBrussel hospital. Clinical and demographic data were collected through a questionnaire. Histology was positive in 222 out of 507 patients tested (43.7%). Culture was successful in 189 patients with a positive histology (85.1%), 4 patients had a positive culture with a negative histology. Resistance to clarithromycin, metronidazole, ciprofloxacin, and amoxicillin was tested. Primary resistance rates were 13.3% for clarithromycin, 26.1% for metronidazole, 23.9% for ciprofloxacin, 0.8% for amoxicillin. Dual resistance to claritromycin and metronidazole was seen in 3.9%, triple resistance (claritromycin, metronidazole and ciprofloxacin) in 1.7% and resistance to the 4 antibiotics in 0.6% of patients. We conclude that there is a decreasing resistance for clarithromycin, metronidazole resistance is stable and rapidly increasing ciprofloxacin resistance. Resistance to any of the tested antibiotics was not associated with origin, age, gender, number of siblings, level of education or status (p > 0.05).

Finding small bowel metastases of melanoma can be important because surgical removal of unique small bowel metastasis of melanoma could improve survival. In this study, we evaluated if capsule endoscopy provides additional information after Pet CT has been performed. In this series of 9 patients collected from 3 university centers, capsule endoscopy influenced the therapeutic decision (to perform or not a surgical segmental resection) in 2/9 patients. All metastatic lesions were found in the proximal bowel. Capsule identified jejunum metastases in one case while Pet CT was negative, and identified metastases while Pet CT result was not conclusive. In one case PET CT identified mesenteric metastases while capsule was negative. SBCE influenced therapeutic decision in 2/9 patients concerning the decision of performing small bowel resection or not. In 1 patient SBCE changed the stage of the disease without affecting medical therapeutic strategy. The prognosis of patients with positive PET and/or capsule findings is very limited (2/3 died within the year). In selected patients, capsule endoscopy can provide complementary information once PET CT has been performed.

A 33-year-old man presented with recurrent episodes of hyperemesis with symptom-free intervals since eight years. The diagnosis of cyclic vomiting syndrome due to longstanding and daily cannabis use was retained, after exclusion of any organic cause of vomiting. Although the patient was informed that the clinical response after cessation of smoking is proven to be spectacular, he continued the use of cannabis and kept on presenting with cyclic symptoms of hyperemesis.

Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a syndrome of inappropriate secretion of the antidiuretic hormone (SIADH) was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodium returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unexplained SIADH, bacterial meningitis or bacterial septicaemia, who originally come from endemic countries.

Hypophosphatemia is a rare but potentially lethal complication of the refeeding of cachectic patients. Up until now a careful monitoring of the serum phosphor level was recommended and the deficit was corrected as needed. Illustrated by two case reports we propose the use of a preventive schedule in patients with a normal renal function. We show that preventively treated patients do not develop hypophosphatemia and thereby avoid serious complications such as sudden death. In the presence of normal kidney function we propose to administer phosphor at 2 × 10 mmol/day orally or between 10 and 30 mmol IV depending on the initial phosphor levels. Further treatment is then adapted to measured levels. In the presence of kidney malfunction we propose to keep the corrective schedule.

Background. The intake of proton pump inhibitors may interfere with the reliability of the urea breath test. Aim. Prospective study to assess the accuracy of the urea breath test during the first days of therapy with proton pump inhibitors. Patients. Thirty patients who needed to start proton pump inhibitors therapy and 53 volunteers. Methods. A 13C-urea breath test was performed respectively before starting proton pump inhibitors therapy and every morning before its intake up until 10 days. The test was considered positive for values of 13CO2 ≥ 3.0‰ delta over baseline. The coefficient of reproducibility for 95% interval of confidence of the urea breath test was calculated in both groups. Results. Of the 30 patients receiving proton pump inhibitors, 47% were positive for Helicobacter pylori. Among these, 43% developed false negative breath tests in the first 10 days. False positive results occurred in 37.5% of H. pylori-negative subjects in the first 10 days. The coefficient of reproducibility of the urea breath test was significantly higher in the group treated with proton pump inhibitors (11.0 versus 1.8 for the control group, p Conclusion. The intake of proton pump inhibitors impairs the accuracy of the 13C-urea breath test. False negative and false positive 13C-urea breath tests are common, occur as soon as after 1 day and increase with prolonged duration of treatment. The coefficient of reproducibility of the test in patients receiving proton pump inhibitors is not acceptable for clinical purpose and the test should not be performed once the medication has been started.

The aim of the study was to assess the value of the 13C Aminopyrine Breath Test (ABT) when performed using the NonDispersive InfraRed Spectrometry (NDIRS), which is a simple and cheap alternative to the mass spectrometry.The results obtained by using the NDIRS method for performing the ABT were compared to the results obtained by a reference method, the 14C Aminopyrine Breath Test. For this purpose, in 32 patients admitted for various liver problems, an ABT was performed by using the 2 methods simultaneously. The repeatability of the results obtained at 120 minutes by the NIDRS method as compared to the 14C test was assessed by the method of Bland and Altman.The mean of difference between the results obtained by both methods at 120 minutes was 0.06 +/- 0.46. The coefficient of repeatability between the two tests was 0.92 for a confidence interval of 95%. A good correlation (r = 0.93) was found between all individual results obtained in breath samples at different times of collection (30, 60, 90, 120 minutes), and between the results obtained at 120 minutes for both 13C and 14C tests (r = 0.94).The 13C ABT performed using NDIRS is a valid alternative to the 14C technique in routine clinical practice.

A 66-year-old man with Child-B alcoholic cirrhosis presented with melaena due to hemorrhagic gastritis. Clinical examination revealed cyanosis and clubbing accompanied by severe hypoxaemia without signs of obstructive or restrictive lung disease. Contrast-enhanced echocardiography showed right to left shunt due to intrapulmonary shunting leading to the diagnosis of hepatopulmonary syndrome. Hypoxaemia in patients suffering from chronic liver disease can have different causes but in the presence of cyanosis and clubbing without signs of lung disease the hepatopulmonary syndrome should be suspected. When presence of intrapulmonary shunts has been proven by contrast-enhanced echocardiography, a 100% oxygen test can determine the need for pulmonary angiography and thus determine the indication for interventional therapy or liver transplantation. The patient described was treated supportively with long-term oxygen therapy 6 l/min. Three months later his clinical condition was stable. An attempt to reduce the need for nasal oxygen failed.

L’endoscopie digestive haute dans le reflux gastro-œsophagien permet de poser un diagnostic et conditionne la prise en charge du patient a long-terme. Elle permet d’identifier les patients porteurs d’un œsophage de Barrett, et de traiter les complications liees au reflux, telles les stenoses. Par ailleurs, le traitement endoscopique du reflux connait un certain essor, mais reste limite aux essais cliniques dans des centres specialises.

Proton Pump inhibitors and laparoscopic techniques have had a dramatic impact on the therapy of gastroesophageal reflux disease. These techniques have introduced new complications associated with the treatment. This study compares the results of a laparoscopic Nissen fundoplication with life-long proton pump inhibitor treatment.Between May 1991 and February 1996, 274 patients were treated by laparoscopic Nissen fundoplication (LNF). Two hundred twenty-four patients were included in this prospective study. Thirteen patients presented stage V esophagitis (Barrett); 4 had esophagitis stage IV; 16 had stage III, 181 had stage II and 11 had stage I. Five trocars were needed for the operation. After mobilization of the greater curvature, a fundic wrap of 5 cm was created and fixed on the esophagus.Median operating time was 60 min (39-300). There were 5 perioperative complications (a gastric perforation, three pleural perforations, and one liver laceration treated by coagulation). Three conversions to laparotomy were necessary. There were 4 early complications: two pulmonary infections and two re-operations; one case of wrap necrosis with peritonitis, and one case of small bowel perforation. Gastroscopy was performed in 133 cases. The esophagus was normal in 121 cases, an esophagitis stage I was present in 9, esophagitis stage II in 2, esophagitis stage III in one. Median lower esophageal sphincter pressure was 10 mmHg (2.9-30) preoperatively and 19 mmHg (9-40) post-operatively. Median reflux time was 10% (0-65) preoperatively and 1% (0-38) post-operatively. One hundred fifty-four patients were interviewed with a median follow up of 30 months (1-58). One hundred thirty patients were Visick I, 11 Visick II, 8 Visick III and 5 patients needed re-operation; three reoperations because of dysphagia, 1 because of epigastric pain and 1 for heartburn recurrence.From these results, we conclude that LNF seems to be an attractive alternative to long term medical treatment.

The aim of this work was to assess the contribution of thallium-201 chloride (Tl-201) per rectal scintigraphy in long term prognostic evaluation of alcoholic, cirrhotic patients.The data obtained from 170 biopsy-proven cirrhotic patients have been used in this 4-yr survival study. The severity of the liver disease was assessed by using the classic Child-Turcotte score as modified by Pugh (CTP score).In patients belonging to CTP class A and CTP class B, the Tl-201 test allowed the identification of subgroups with different survival rates. In these two classes of patients, the Tl-201 per rectal scintigraphy could be used for improving prognostic evaluation. In patients of class C on the other hand, 4-yr survival rates were very low, and the Tl-201 test did not bring significant additional prognostic information.Therefore, we suggest performing the Tl-201 test in cirrhotic patients of classes A and B as defined by the CTP score.

In a 4-yr survival study, the prognostic value of the inferior mesenteric shunt, as evaluated by 201Tl per rectum scintigraphy, was assessed in 170 alcoholic cirrhotic patients. The global severity of the hepatic disease was assessed by the Child score, and specific hepatocellular function was evaluated by the aminopyrine breath test. Using 201Tl scintigraphy, three groups were considered: group I, heart-liver activities ratio (H/L ratio)or = 0.5, n = 55; group II, H/L between 0.5 and 0.85, n = 50; and group III, H/L0.85, n = 65.The 4-yr survival rates in the three groups were 76%, 36% and 18%, respectively. The log-rank test showed that the differences between the groups were statistically significant. Regression analysis using Cox's proportional-hazards model showed that the three parameters, Child score, aminopyrine breath test results and H/L ratio were significantly related to survival.The inferior mesenteric shunt per se has a prognostic value in alcoholic cirrhosis. Moreover, the H/L ratio provides additional information on survival after the Child score and the aminopyrine breath test results have been taken into account.

To define the physiopathological significance of 201Tl per rectum scintigraphy, we compared results obtained using this method with direct measurement of inferior mesenteric shunting, portal pressure, liver cellular function as evaluated by the Aminopyrine Breath Test and the size of esophagogastric varices and spleen, constituting, respectively, indirect representation of azygos and splenic shunts. Results indicated that a high correlation exists between the measures of portal systemic shunt estimated by the per rectal method and those obtained by direct administration of the tracer in the inferior mesenteric artery. No correlation was observed between 201Tl per rectal results and portal pressure or with azygos and splenic shunting. Fair correlation was observed with the Aminopyrine Breath Test. This could be explained by the fact that both methods are altered in advanced liver disease. These results suggest that the 201Tl per rectal scintigraphy explores the portal systemic shunt, which depends almost exclusively on the inferior mesenteric territory. While the limited territory explored by the method constitutes, undoubtedly, a limiting factor in detection and quantitation of total portal-systemic shunt, the specific information provided by the test could be useful in defining clinical and biological profiles of cirrhotic patients with inferior mesenteric shunting.

In a long-term survival study, we compared the prognostic significance of the hepatic venous pressure gradient and of the aminopyrine breath test (ABT) in 99 alcoholic cirrhotic patients. Thirty patients survived and had a complete follow-up for at least 4 yr. Mean hepatic venous pressure gradient was 19.1 +/- 5.8 mm Hg (range 8-35 mm Hg). Variceal rupture occurred only when the gradient wasor = 12 mm Hg. Variceal bleeding was observed exclusively in patients with large varices. Survival was not influenced by the level of gradient. We used the ABT to classify patients into three groups (group I, ABTor = 2%; group II, 1%or = ABT2%; and group III, ABT1%). Survival was significantly higher in group I than in group II (p0.05) or III (p0.01), indicating a better prognosis at a residual functional hepatic cellular mass of about 50% of the lower limit of normal value.

Cholestasis in patients with acquired immune deficiency syndrome was systematically investigated by ultrasonography and endoscopic retrograde cholangiopancreatography. The two procedures were found to be complementary, and showed similar results in 56.2% of the cases. Ultrasonography was superior in detecting common bile duct wall thickening, whereas endoscopic retrograde cholangiography was superior in demonstrating intrahepatic narrowing of the biliary tract.

To assess the value of serum insulin-like growth factor I (IGF-I) determination in liver disease, 21 patients hospitalized for active alcoholic cirrhosis (19 males, 2 females), 56 +/- 2 y (mean +/- SE) were studied at admission. Individual scores of hepatic alterations (Child score) ranged from 6 to 12 (mean: 9 +/- 1). Basal IGF-I levels were dramatically decreased, averaging 0.11 +/- 0.02 U/ml vs 0.70 +/- 0.08 U/ml in 15 control subjects. In cirrhotic patients, IGF-I values were inversely correlated with the modified Child index (r = 0.57, p less than 0.01). A highly significant positive correlation (r = 0.68, p less than 0.001) was evidenced between IGF-I levels and aminopyrine breath test values (which provide quantitative estimates of the hepatic functional capacity). In contrast, no significant relationship was found between IGF-I levels and various nutritional parameters (albumin, prealbumin, retinol binding protein) after partial correlation analysis. The present data suggest that, in alcoholic cirrhosis, the decrease of circulating IGF-I values is mainly related to alterations of liver function, and that IGF-I can be used as a good indicator of functional hepatocellular capacity.

We report a case of perirenal urinoma secondary to benign prostatic hypertrophy. This rare complication of bladder outlet obstruction was due to subsequent hydronephrosis and increased pressure in the renal cavities, leading to rupture of caliceal fornix and allowing perirenal extravasation of urine. Complete resolution of the urinoma was obtained with bladder decompression and conservative management.

Background: Data on factors affecting treatment satisfaction in European women with chronic constipation are limited. Objective: To assess factors associated with treatment satisfaction among European women with chronic constipation. Methods: A 2011-2012 internet survey was conducted in men and women from 12 European countries. Respondents analysed were female with self-reported chronic constipation (>= 1 symptoms for >= 6 months of lumpy/hard stools, feeling of incomplete evacuation, and pain during defecation, as well as