Search

Telemedicine has shown promising results in the follow up of patients with inflammatory bowel disease. This study compared quality of life and disease activity in patients with inflammatory bowel d...

For inflammatory bowel disease, traditional dose escalation approaches that are based on clinical symptoms are being replaced by more aggressive treat-to-target approaches, in which treatment is adjusted promptly when predefined clinical and mucosal targets are not met. There is, however, an ongoing need to combine up-to-date treat-to-target strategies with easy-to-implement recommendations. Herein, we present consensus-recommendations for treatment targets that reflect current best practices in France. Methods Thirty-four gastroenterologists practicing in France participated in a meeting during which consensus statements about treat-to-target strategies for following patients with Crohn's disease (CD) and ulcerative colitis were developed. Targets, their definitions, and the timeframes for reaching them were defined. Consensus was defined as ≥66% of experts agreeing with a statement. Results For both diseases, the agreed targets were: patient related outcomes on disease (PRO-1), patient related outcomes on gastrointestinal symptoms (PRO-2), endoscopic healing and biomarkers of inflammation. Nutritional status has been defined as a target for CD only. Histological healing and transmural healing were not defined as targets. Deadlines to achieve targets and monitoring frequency have been agreed as well. Conclusions These consensus statements provide simple, easy-to-follow guidelines that should help gastroenterologists in France implement treat-to-target approaches, optimize treatments, and thus, reduce the burden of disease.

For the last ten years, several physiopathological mechanisms impli-cated in the irritable bowel syndrome have been highlighted. These mechanisms answer to some interrogations, but nowadays therapeutic options tend to be unsatisfying. The control of the symptoms is difficult on a long run and very often incomplete. This article proposes a review of the mechanisms implicated in this complex pathology, from which arise complementary management to the « classical » treatment.Depuis une dizaine d’années, plusieurs mécanismes physiopa­thologiques impliqués dans le syndrome de l’intestin irritable sont mis en avant. Ils permettent de répondre à certaines interrogations, mais à l’heure actuelle les propositions thérapeutiques qui en ressortent sont régulièrement peu satisfaisantes. Le contrôle des symptômes reste difficile au long cours et très souvent incomplet. Cet article propose une revue des mécanismes impliqués dans cette pathologie complexe, dont découleront des prises en charge complémentaires au traitement dit « classique ».

BACKGROUND AND AIMS The use of telemedicine dramatically increased during the COVID-19 pandemic. We collected patients and physicians experience on telemedicine in the field of inflammatory bowel disease (IBD). METHODS We conducted a nationwide survey between September 2020 and January 2021. A self-administered questionnaire was sent to participants through mailing lists of the national patients' association and IBD expert groups. RESULTS Overall, 300 patients and 110 gastroenterologists filled out the survey. On a 10 points scale of satisfaction with telemedicine, 60% of patients noted a score ≥8 and 52.7% of physicians ≥7. Patients and gastroenterologists felt that the duration of teleconsultations appeared to be shorter than in-person visits in 57.5 and 55.1% of cases, respectively. All participants agreed that telemedicine is appropriate in dedicated situations and not for flare-up consultations. For 55.1% of patients, quality of care was the same via telemedicine, whereas 51.4% of gastroenterologists believed they managed less well their patients. Lack of clinical examination being pointed out as the main limitation of telemedicine. Three-quarters of patients and gastroenterologists would agree to use telemedicine more often in the future. CONCLUSION Patients and gastroenterologists were satisfied with telemedicine and would be willing to use it in the future. However, telemedicine does not replace in-person visits and should be discussed on a case-by-case basis.

Clinical trial registration: ClinicalTrials.gov Identifier NCT01388257; International audience; Aim In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab. Methods This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities. Results Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000). Conclusions Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.

Summary Any gastroenterologist must be trained to properly diagnose anoperineal lesions in patients with Crohn's disease (APLOC). The aim of this study was to establish whether adding pictures would improve teaching effectiveness of the diagnosis of APLOC to French gastroenterology trainees. Method Trainees were asked to answer a first web-based survey consisting of evaluating 12 pictures of APLOC with a closed answer questionnaire. They were then randomized in 2 groups. Group A received an online teaching with typical pictures and APLOC definitions and group B definitions only. Trainees were asked again seven days later to answer a second survey with 12 other pictures of APLOC and 14 experts also answered this survey. Diagnostic scores were expressed in %. The primary endpoint was the comparison of the score of survey 2 between the two groups of trainees. Secondary endpoints were to compare results of survey 2 between trainees of both groups and experts, and assess diagnosis of each lesion. Results Two hundred fourty eight trainees among 465 answered survey 1, and 195 survey 2. The diagnostic score was 71.9% for groups A and B and 74.6% for experts (differences NS). After training diagnosis of ulceration was 72% for group A and 72.9% for group B, fistulae 85.2% versus 85.8%, erythema 44.1% vs. 55.6%, anoperineal scars 67.5% vs. 65.6%, and abscess 100% (differences NS). Conclusion There was no difference between the two teaching methods. Further research should be performed aiming at improving teaching material and quotation baremes.

International audience; BACKGROUND: New treatments and therapeutic approaches repeatedly emerged in the field of inflammatory bowel disease. AIM: to update the French treatment algorithms for Crohn’s disease (CD) and ulcerative colitis (UC). METHODS: A formal consensus method was used to determine changes to the treatment algorithms for various situations of CD and UC. Thirty-seven experts voted on questions that had been drafted by the steering committee ahead of time. Consensus was defined as at least 66% of experts agreeing on a response. RESULTS: Anti-TNF were reinforced as a first-line therapy rather than the use of immunosuppressant alone. Vedolizumab for UC, ustekinumab for CD took place as second-line maintenance therapy and potentially as a first-line therapy in the setting of unrestricted reimbursement for vedolizumab. Tofacitinib was recommended by the experts in case of vedolizumab failure for UC. Algorithms for complicated CD with abscess, intestinal and complex anal fistula were updated according to recent prospective cohort studies. CONCLUSION: The changes incorporated to the algorithms provide up-to-date and easy-to-use guidelines to treat patients with IBD.

Patients with inflammatory bowel disease need close monitoring for an optimal disease management. For this, e-health technologies are promising tools. But the current evidence for the implementation of e-health in inflammatory bowel disease is weak. For this a critical evaluation of the existing evidence is presented. Furthermore some essential conditions need to be full-filled. We need a robust digital infrastructure that is workable for the patient and the healthcare provider. Important legal issues need to be solved to protect the patient. And the e-health technologies will have to proof their durability, feasibility and acceptance for the patient on the long term.

Background Crohn’s disease (CD) is a chronic and disabling condition. There is no curative medical treatment but current treatments provide increasingly sustainable control of the disease and allow patients a better quality of life. There is limited evidence supporting CD management in specific clinical situations, thus precluding an evidence-based approach. Aims To help clinicians in making informed treatment decisions, a group of 59 French gastroenterologists with experience in the management of CD met to develop straightforward and practical algorithms based on the European Crohn’s and Colitis Organisation (ECCO) recommendations. Methods This experts’ opinion was developed following a Nominal Group consensus methodology. Nine clinical situations were identified: mildly active CD; uncomplicated moderately active CD, with, and without poor prognostic factors; uncomplicated severely active CD; perianal CD with a single fistula; perianal CD with complex fistula with or without abscess; complicated CD with abscess; intestinal stricture; and post-operative CD. Two working groups were formed and proposed algorithms that were then approved by a two-thirds majority of the Nominal Group. Results These algorithms represent the pragmatic consensus of a group of experts in gastroenterology on the modalities of therapeutic care in different clinical situations in CD. They are available via a web application at: www.algorithmici.com .

Background Recently, treatment algorithms were developed in France additionally to ECCO recommendations that should be used as reference for ulcerative colitis (UC) management. Nevertheless, their implementation in clinical practice remains challenging. Aims To evaluate the prevalence of the use of these UC management algorithms in 127 patients followed by private gastroenterologists. Methods Charts of all UC patients seen during the year 2015 (n = 127) by 10 gastroenterologists were reviewed. The gastroenterologist’s management was then compared to the corresponding algorithm situation and, in case of disagreement, analysed by an expert committee. Results 94.5% of patients corresponded to a clinical situation described in algorithms. Gastroenterologist’s management was adequate to the corresponding algorithm situation in 74.2% of cases. Among the 31 cases of disagreement, the gastroenterologist’s decision differed from the algorithm position in 21 cases, and in 76.2% of cases the expert committee would have made the same decision. In the remaining 10 cases, the decision differed from the corresponding algorithm for reasons independent from the gastroenterologist (patient’s choice etc.). Conclusions French national algorithms for UC management allowed coverage of 95% of clinical cases in real world. In three quarters of cases, these algorithms were strictly followed by private gastroenterologists. Dissemination of these algorithms could optimize and strengthen the practitioner’s choice.

Introduction : Les donnees sur la gestion actuelle des patients atteints de maladie inflammatoire chronique intestinale (MICI) sont rares.Materiel et methodes : Il s'agissait d'une enquete nationale realisee aupres de gastro-enterologues liberaux, concernant des patients vus en consultation ou en Hospitalisation durant 2 semaines en Juin 2012.Resultats : 375 patients atteints de MICI ont ete inclus : 48 % d'entre eux avaient une rectocolite hemorragique (RCH). Un antecedent d'hospitalisation concernait un tiers des patients atteints de MICI, et un antecedent de chirurgie 40 % des patients atteints de maladies de Crohn (MC). Deux tiers des patients avaient une maladie active le jour de la consultation. Soixante pour cent des patients atteints de RCH etaient traites par 5-aminosalicyles contre 18,5 % de MC (p

Background: Objective control of intestinal inflammation during inflammatory bowel disease (IBD) is becoming the main driver for medical treatment. However, the monitoring tools-related burden remains poorly investigated. We aimed to evaluate their comparative acceptability and utility according to patients with IBD. Methods: After a preliminary phase, the final questionnaire encompassing self-administered and physician questionnaires was prospectively and consecutively submitted to 916 patients with IBD from 20 public and private centers. Acceptability and utility visual analog scales (VAS) were expressed as median with interquartile range. Results: Regarding the group of patients with Crohn's disease (n = 618), venipuncture (VAS = 9.3 [8.8-9.7]) and ultrasonography (VAS = 9.3 [8.7-9.7]) were the most acceptable tools (P < 0.0001, for each comparison), whereas rectosigmoidoscopy was the least acceptable tool (VAS = 4.4 [1.2-7.3]) (P < 0.0001, for each comparison). Wireless capsule endoscopy (VAS = 8.5 [5.2-9.3]), magnetic resonance enterocolonography (VAS = 8.0 [5.0-9.2]), and stools collection (VAS = 7.7 [4.6-9.3]) were more acceptable than colonoscopy (VAS = 6.7 [4.3-8.9]) (P < 0.0001, for each comparison). The acceptability was assessed in 298 patients with ulcerative colitis for venipuncture (VAS = 9.4 [8.8-9.7]), stools collection (VAS = 8.1 [5.7-9.4]), colonoscopy (VAS = 7.5 [4.7-9.2]), and rectosigmoidoscopy (VAS = 6.7 [2.8-9.1]); (P < 0.001 for each comparison). All monitoring tools were considered as highly useful by patients with IBD. Decreased acceptability was related to embarrassment for the collection/transport of stools (60.7%), bowel cleansing (76.3%) for colonoscopy, abdominal discomfort (51.3%) and rectal enema (36.6%) for rectosigmoidoscopy, bowel distension (48.3%) for magnetic resonance enterocolonography, and potential capsule retention (21.4%) for wireless capsule endoscopy. Conclusions: Among the IBD monitoring tools, endoscopy demonstrated the lowest acceptability supporting the development of alternative modalities. Patients' information and examination conditions should be improved to ensure proper monitoring adherence.

Background Ulcerative colitis (UC) is a chronic inflammatory bowel disease of multifactorial etiology that primarily affects the colonic mucosa. The disease progresses over time, and clinical management guidelines should reflect its dynamic nature. There is limited evidence supporting UC management in specific clinical situations, thus precluding an evidence-based approach. Aim To use a formal consensus method – the nominal group technique (NGT) – to develop a clinical practice expert opinion to outline simple algorithms and practices, optimize UC management, and assist clinicians in making treatment decisions. Methods The consensus was developed by an expert panel of 37 gastroenterologists from various professional organizations with experience in UC management using the qualitative and iterative NGT, incorporating deliberations based on the European Crohn's and Colitis Organisation recommendations, recent reviews of scientific literature, and pertinent discussion topics developed by a steering committee. Examples of clinical cases for which there are limited evidence-based data from clinical trials were used. Two working groups proposed and voted on treatment algorithms that were then discussed and voted for by the nominal group as a whole, in order to reach a consensus. Results A clinical practice guideline covering management of the following clinical situations was developed: (i) moderate and severe UC; (ii) acute severe UC; (iii) pouchitis; (iv) refractory proctitis, in the form of treatment algorithms. Conclusions Given the limited available evidence-based data, a formal consensus methodology was used to develop simple treatment guidelines for UC management in different clinical situations that is now accessible via an online application.

International audience; Meeting Abstract: P121

Les therapies actuelles dans les MICI visent a diminuer les reponses immunitaires. Des interventions nutritionnelles et microbiologiques capables de proteger l’intestin contre une inflammation dommageable constituent la prochaine source de therapies pour les MICI. L’elucidation de l’impact de l’apport en nutriments sur l’immunite intestinale, que ce soit par des effets directs sur les cellules immunitaires de l’hote ou des effets indirects sur le microbiote intestinal, nous fournira des informations cruciales. Cet article est une mise au point sur les paradigmes actuels ainsi que les avancees recentes demontrant que les interventions nutritionnelles, y compris la modification du microbiote intestinal par les prebiotiques et les probiotiques, ainsi que la restriction calorique peuvent moduler la reponse immunitaire des muqueuses et diminuer les effets nuisibles de l’inflammation qui caracterise les MICI. Une prise en charge nutritionnelle dediee aux MICI est actuellement a recommander aux patients. L’utilisation du jeune therapeutique dans les MICI demande une evaluation rigoureuse a venir dans un cadre medical et sa pratique non controlee hors cadre medical est a deconseiller principalement a la vue des risques de denutrition propres aux MICI notamment pour les maladies de Crohn.

Introduction: Little is known about the intensity of symptoms of diarrhea-predominant IBS (IBS-D) or the consequences of the disease on patients’ health-related quality of life (HRQOL). This observational investigation assessed the symptoms (abdominal pain, bloating, number of stools per day, and stool consistency), impact on HRQOL, and consequence on anal continence in 297 patients with IBS-D before and after 1 month of probiotic treatment with Lacteol (inactivated Lactobacillus LB plus fermented culture medium). Methods: Functional assessment using a standardized visual analogue scale in order to quantify abdominal pain, bloating, and quality of life before and after 1 month of treatment with 2 capsules/day of Lacteol. The number of symptomatic days per week, number of stools, consistency of stools, secondary fecal incontinence rate, and potential trigger effect of food were quantified. A χ2 test was used to compare qualitative data and the variance of quantitative criteria was analyzed. Results: The pain score decreased from 4.46 ± 0.15 on a scale of 0–10 before treatment to 2.8 ± 0.14 after treatment (p < 0.0001). Bloating decreased from 4.49 ± 0.18 to 2.5 ± 0.15 on a scale of 0–10 (p < 0.0001). The HRQOL score, which is inversely correlated with quality of life, decreased from 5.99 ± 0.14 to 3.92 ± 0.16 (p < 0.0001). In this cohort study, the fecal incontinence rate secondary to diarrhea was clearly higher than that of the general population: 18% versus a prevalence of 9–10%, according to different studies. The mean number of stools per week decreased from 17.59 to 12.83 after treatment (p < 0.0001). Before treatment, 54% of patients had watery stools and 46% had smooth stools; at the end of treatment, only 18.5% of patients still had watery stools, and 34% had normal stools. 52% of patients attributed their symptoms to their diet: 34% to vegetables, 29% to fruit, 15% to milk, 15% to fat, 6% to peppers and spices, and 4% to sugar. Conclusion: This observational investigation shed new light on patients with IBS-D, the HRQOL of which is altered by a fecal incontinence rate twice as high as that of the general population. Correlation with diet is confirmed by 1 out of 2 patients reporting poor tolerance of fiber and dairy products. Nutritional management should thus be part of these patients’ treatment. Inactivated Lactobacillus LB plus fermented culture medium is a probiotic drug that has been used by physicians for a long time to treat patients with diarrhea. Strongly concentrated, it has no side effects and seems to help these patients. Due to a strong placebo effect in patients with this pathology, however, a controlled study is necessary to confirm this result.

Summary Objectives In France, seton drainage followed by fistulotomy is currently the standard treatment for high cryptoglandular fistula-in-ano. Biological or synthetic glues, such as Glubran ® 2, have been recently proposed for sealing the fistula tract. The purpose of this study is to determine the healing rate with glubran 2 and to assess the functional outcome after cure of fistula-in-ano. Patients and methods From July 2006 to July 2008, 34 patients (20 males; median age 48.5 years, range 22–55 years) with high cryptoglandular anal fistulas were treated with glubran 2. Patients were seen for physical examination at 1, 3 and 6 months, then interviewed by telephone at 1 and 2 years, and in September 2009. The Fecal incontinence severity index (FISI) score was used to assess continence. Results The healing rate at 1 month was 67.6% (23 patients); the fistula failed to heal in 11 patients. All 23 patients with a healed fistula remained recurrence-free, with no continence disorders noted, during the median 34-month follow-up period (range 21–43 months). One patient was lost to follow-up after 6 months. Conclusion Glubran 2 provides an effective treatment for high fistula-in-ano, with no change in continence. In future, a randomized comparison of this agent with fibrin glues should be useful.

Background & Aims: Risk factors of metachronous liver metastases and death are not well known in patients with the Zollinger–Ellison syndrome and multiple endocrine neoplasia type 1. These factors were retrospectively determined in 77 patients. Methods: Data chart review was performed. Results: Median follow-up was 102 months (range, 12–366). Surgery was performed on 48 patients, including 9 of the 10 patients with large pancreatic tumors (≥3 cm). Liver metastases developed in 4 patients (40%) with large pancreatic tumors, in 3 (4.8%) without, and in 1 of the 4 patients with pancreatic tumors of unknown size; all had previously undergone surgery. The only independent factor associated with development of liver metastases identified by multivariate analysis was large pancreatic tumors (risk ratio, 29.0; 95% confidence interval [CI], 3.2–260.7). Surgery was not selected. The probability of being free of liver metastases in the 63 patients without large pancreatic tumors was 96% (95% CI, 88–100) at 10 and 15 years. Thirteen (16.9%) patients died. The only independent factors of death selected by multivariate analysis were Zollinger–Ellison syndrome diagnosis before 1980 (risk ratio, 8.2; 95% CI, 1.7–40.6) and age at diagnosis (risk ratio/year, 1.08; 95% CI, 1.03–1.14). Conclusions: Large pancreatic tumors are predictive of the development of metachronous liver metastases, and surgery does not seem to prevent them. GASTROENTEROLOGY 1999;116:286-293

International audience

BACKGROUND & AIMS: Duodenal gastrinomas and peripancreatic lymph nodes are difficult to localize. The aim of this study was to evaluate the ability of Octreoscan scintigraphy to detect such tumors. METHODS: Results of Octreoscan scintigraphy in 21 consecutive patients with Zollinger-Ellison syndrome were compared with those of conventional imaging techniques, including endoscopic ultrasonography, and with the surgical findings. RESULTS: Surgical exploration found 27 duodenal and/or lymph node gastrinomas in 19 patients. None had pancreatic gastrinoma. Octreoscan scintigraphy was the only positive preoperative technique in 32% of the patients. The sensitivities of conventional techniques, Octreoscan scintigraphy, and their association were 58%, 58%, and 90%, respectively, for all resected gastrinomas. The smallest duodenal gastrinoma detected by Octreoscan scintigraphy measured 3 mm. Endoscopic ultrasonography detected all the tumors visualized by any other conventional technique and was considered falsely positive, as was Octreoscan scintigraphy, in 1 patient. Follow-up and comparison between the number of resected gastrinomas and the number of preoperative hot spots suggested that surgeons should find at least as many tumors as the number of hot spots. CONCLUSIONS: Octreoscan scintigraphy improved the preoperative detection of extrapancreatic gastrinomas, mainly by endoscopic ultrasonography. Surgeons should find at least as many gastrinomas as the number of hot spots. (Gastroenterology 1996 Oct;111(4):845-54)

AIM To establish consensual definitions of anoperineal lesions of Crohn’s (APLOC) disease and assess interobserver agreement on their diagnosis between experts. METHODS A database of digitally recorded pictures of APLOC was examined by a coordinating group who selected two series of 20 pictures illustrating the various aspects of APLOC. A reading group comprised: eight experts from the Société Nationale Française de Colo Proctologie group of study and research in proctology and one academic dermatologist. All members of the coordinating and reading groups participated in dedicated meetings. The coordinating group initially conducted a literature review to analyse verbatim descriptions used to evaluate APLOC. The study included two phases: establishment of consensual definitions using a formal consensus method and later assessment of interobserver agreement on the diagnosis of APLOC using photos of APLOC, a standardised questionnaire and Fleiss’s kappa test or descriptive statistics. RESULTS Terms used in literature to evaluate visible APLOC did not include precise definitions or reference to definitions. Most of the expert reports on the first set of photos agreed with the main diagnosis but their verbatim reporting contained substantial variation. The definitions of ulceration (entity, depth, extension), anal skin tags (entity, inflammatory activity, ulcerated aspect), fistula (complexity, quality of drainage, inflammatory activity of external openings), perianal skin lesions (abscess, papules, edema, erythema) and anoperineal scars were validated. For fistulae, they decided to follow the American Gastroenterology Association’s guidelines definitions. The diagnosis of ulceration (κ = 0.70), fistulae (κ = 0.75), inflammatory activity of external fistula openings (86.6% agreement), abscesses (84.6% agreement) and erythema (100% agreement) achieved a substantial degree of interobserver reproducibility. CONCLUSION This study constructed consensual definitions of APLOC and their characteristics and showed that experts have a fair level of interobserver agreement when using most of the definitions.

Objectifs : Un groupe de 37 gastro-enterologues francais ayant une experience dans la prise en charge de la RCH a elabore des algorithmes simples et pratiques afin d’aider les cliniciens dans la prise de decision therapeutique dans cinq situations cliniques particulieres. Il semble que ces 5 algorithmes associes a une partie bien validee des recommandations de L’European Crohn ´s and Colitis Organisation (ECCO) emises en 2012 portant sur la prise en charge du traitement d’attaque et d’entretien de la RCH sous ASA englobent la plupart des situations cliniques actuelles de la RCH. Le but de ce travail est d’evaluer la prevalence de ces algorithmes de prise en charge dans une cohorte de RCH suivi en medecine liberale en 2015 et la qualite de prise en charge reelle par les hepato gastroenterologues de l’etude en comparaison aux referentiels. Materiels et Methodes : 127 patients successifs atteints de RCH vus en 2015 ont ete analyses dans une cohorte de 10 hepatogastroenterologues liberaux competents en MICI. Les consultations ont ete saisies en donnees standardisees sur le logiciel EasyMICI®. Les donnees ont ete classees dans 6 situations : Groupe O : cas patient ne correspondant a aucun des algorithmes ; Groupe 1 : cas patient correspondant aux recommandations ECCO portant sur la prise en charge du traitement d’attaque et d’entretien de la RCH sous ASA (ECCO Statement 5A, 5B, 6B, 6D, 6E) ; Groupe 2 : algorithme RCH moderee a severe ; Groupe 3 : RCH aigue severe hospitalisee ; Groupe 4 : Rectite refractaire ; Groupe 5 : Pochite. Dans les cas de patients concernes par un des algorithmes (groupe 1, 2, 3, 4 ou 5), la prise en charge reelle par le gastroenterologue a ete comparee a la prise en charge correspondante dans l’algorithme. En cas de desaccord, le choix de prise en charge par le gastroenterologue a ete classe en trois rubriques : choix therapeutique du medecin different de l’algorithme, choix du medecin en accord theorique avec l’algorithme mais refuse par le patient, choix du medecin en accord theorique mais non retenu en pratique pour des raisons administratives et/ou financieres. Resultats : Parmi les 127 patients, 120 (94,5 %) correspondaient a un cas de figure decrit dans un des algorithmes. Parmi les 120 patients correspondant a un cas de figure d’un algorithme, la prise en charge reelle par le gastroenterologue etait celle de l’algorithme dans 89 cas (73,9 %) ; 61/68 (89,7 %) dans le groupe 1 vs 8/52 (53,8 %) dans les groupes 2, 3, 4 ou 5 (P< 0,05). Parmi les 31 cas de desaccord, il s’agissait d’un choix therapeutique du medecin non strictement concordant avec l’algorithme dans 21 cas (67,8 %), d’un choix du medecin en accord theorique avec l’algorithme mais refuse par le patient dans 5 cas (16,1 %) et d’un choix du medecin en accord theorique mais non retenu en pratique pour des raisons administratives et/ou financieres dans 5 cas (16,1 %). L’analyse des 21 cas de choix du medecin « discordant » par un comite d’expert a classe le choix du medecin comme discutable et a maintenu cette option therapeutique 16/21 cas (76,2 %) et a propose un changement therapeutique dans 5/21 cas (23,8 %). Conclusions : Les algorithmes disponibles en 2015 pour la prise en charge de la RCH permettent une couverture de 95 % des situations cliniques en medecine liberale. Dans les trois quarts des cas, ces algorithmes sont respectes a la lettre dans la pratique reelle. Le non respect est rarement le fait d’un defaut de connaissance du praticien ayant valide une FMC et la position est le plus souvent maintenue par un comite d’experts. La diffusion de ces algorithmes par l’implementation dans un logiciel permettrait d’optimiser le choix du praticien en confortant son choix ou en suggerant un avis d’expert, de motiver parfois son patient et de recueillir des donnees de qualite de la prise en charge individuelle ou des equipes.

BACKGROUND: Management of patients with Zollinger-Ellison syndrome (ZES) depends on the presence of multiple endocrine neoplasia type 1 (MEN 1) or liver metastases, or both. Somatostatin receptor scintigraphy (SRS) detects previously unknown endocrine tumours. AIM AND METHODS: To evaluate SRS findings susceptible to modifying the management of patients with ZES-that is, relevant findings, and the specificity of these findings. The latter were defined according to our current therapeutic strategy in three subgroups of patients (sporadic, MEN 1, and liver metastases). PATIENTS: 85 consecutive patients without known extra-abdominal metastases were studied between September 1991 and March 1996. RESULTS: Relevant findings were found in 41% of 49 patients with sporadic disease but without liver metastases, in 22% of 18 patients with MEN 1 but without liver metastases, and in 17% of 18 patients with liver metastases. Follow up was available for 20 (74%) of 27 patients who had 23 relevant findings. Nineteen relevant findings (83%) were confirmed at a median of three (range 0.25-45) months of follow up; four (17%) were not confirmed at 30 (range 12-52) months (p = 0.025). Findings located in the duodenopancreatic area (90%), chest (100%), bone (100%), and liver (60%) were confirmed. Most findings for patients with MEN 1 involved the chest. CONCLUSION: SRS detects many anomalies susceptible to modifying management of patients with ZES, especially in those with sporadic disease. The specificity of hot spots located outside the liver seems very high. By contrast, the specificity of hot spots located in the liver remains to be evaluated when conventional imaging is negative.

Introduction Plusieurs options chirurgicales peuvent etre proposees chez les patients presentant une incontinence anale (IA) et une rupture sphincterienne. La sphincteroplastie est la plus largement pratiquee, mais sa morbidite est significative et a moyen terme son efficacite est reduite. Conaghan et Farouk ont observe de bons resultats de la neuromodulation sacree (NMS) pour des patientes presentant une rupture du sphincter externe [1]. Recemment nous avons rapporte l’utilisation de la STP par TENS dans le traitement de l’incontinence anale idiopathique [2]. Cette etude a ete concue pour determiner si les indications STP par TENS pouvaient etre etendues aux patients presentant une incontinence anale et une lesion sphincterienne. Patients et Methodes De juillet 2004 a septembre 2007 nous avons propose ce traitement aux patients qui consultaient pour IA en rapport avec une rupture sphincterienne et qui relevait d’une reparation sphincterienne. Nous avons informe les patients qu’il s’agissait d’un traitement en evaluation et que a tout moment, ils pouvaient opter pour la solution chirurgicale prealablement prevue. L’evaluation pre-therapeutique incluait un examen medical detaille un examen des cahiers de selles, une echographie endo-anale, une manometrie ano-rectale. Le score de Wexner et la version francaise de la qualite de vie de l’incontinence fecale ont ete employes pour mesurer la severite de l’incontinence avant, et apres traitement. En fin de traitement les patients representaient leur satisfaction vis-a-vis de ce traitement sur une echelle analogique de 10 cm (EVA). Une unite TENS (Schwa-medico) delivrait un courant de 200-μs, 10-Hz tous les jours pendant 4 semaines au domicile des patients. Les patients etaient revus a 1 mois, 3 mois 6 mois puis tous les ans. Resultats Nous avons ainsi traite par STP 21 patients (19 femmes) d’âge median de 57,4 ans (48 - 71). Tous les patients avaient un defect du sphincter externe mesure entre 40° et 110°. 7 avaient un defect associe du sphincter interne mesure entre 140° et 180°. L’etiologie de l’incontinence etait 16 fois obstetricale et 3 fois traumatique (fistule), 2 fois traumatique et obstetricale (hemorroidectomie, viol). 12 des 21 patients traitees par STP ont rapporte une diminution des episodes d’incontinence et une amelioration de qualite de la vie, l’EVA median etait de 6,5 (4 - 9). Les 12 patients qui ont repondu a la STP (amelioration du Wexner d’au moins 30 % et ou diminution du nombre d’accident d’IA de 50 %) ont prefere poursuivre le traitement (quotidiennement pendant 3 mois puis 5 jours par semaines) que de subir une reparation sphincterienne et ce sur un recul median de 21 mois (15 - 34). Conclusion Notre etude suggere que dans cette indication, la STP par TENS doit probablement etre essayee avant la NMS. Remerciements, financements, autres Remerciements au Dr Laurent Abramowitz (GREP).