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No recommendation regarding antibiotic prophylaxis and preparation modalities are available for patients with esophageal motor disorders who benefit from Per-Oral Endoscopic Myotomy (POEM). The aim of our study was to evaluate their impact on the POEM's safety.This study was a comparative and multicentric retrospective analysis of a database prospectively collected. Patients over 18 years old with esophageal motor disorders confirmed by prior manometry, who underwent POEM were included. The primary endpoint was the occurrence of adverse events, as classified by Cotton, based on whether or not antibiotic prophylaxis was administered.A total of 226 patients (median age 52.9 ± 19.12 years [18-105], 116 women [51.3%]) were included. The indication for POEM was mainly type 2 achalasia (The antibiotic prophylaxis during POEM does not prevent adverse events, had no impact on their severity and the efficacy of the procedure. A liquid diet before the procedure should be systematically proposed.

Background The aim of this ancillary study of the SARAH trial is to compare health-related quality of life (HRQoL) in patients with locally advanced or inoperable hepatocellular carcinoma (HCC) treated with transarterial radioembolisation (TARE) or sorafenib. Methods This study included randomised patients who received either TARE or at least one dose of sorafenib with no major deviation in the protocol and who had at least one QoL follow-up assessment in addition to the baseline evaluation. QoL was assessed from the date of randomisation using the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire, until disease progression or other reasons for stopping study participation. Data were analysed using linear mixed and time-dependent models. Results A total of 285 patients were included (122 and 163, in the TARE and sorafenib groups, respectively). Questionnaire completion rates were similar (77.5% versus 80.4%, in the TARE and sorafenib groups, respectively, p = 0.25). Longitudinal HRQoL analysis showed a significant treatment and time effects for fatigue and global health status, and significant treatment, time and treatment by time interaction effects for appetite loss, diarrhoea and social functioning. The median time to deterioration for the global health status was 3.9 months (95% confidence interval [CI] 3.7–4.3) versus 2.6 months (95% CI 2.0–3.0) in the TARE and sorafenib groups, respectively. Conclusions HRQoL was preserved longer with TARE than with sorafenib in locally advanced HCC. These data could be used to optimise management of patients with advanced or inoperable HCC.

International audience; Background and aimsIBS patients have an impaired quality of life (QoL) and feel dissatisfaction with medical care. We aim to describe the expectations of members of the French Association of IBS patients (APSSII) concerning health care providers (HCPs) and a patients’ organization.Patients and methodsFrom January to June 2013, APSSII members were asked to answer questionnaires on their expectations and experiences concerning IBS and HCP.Results222/330 (67%) responded (women: 68.5%, 46.5 ± 17.7 years, disease duration: 8.8 ± 0.7 years, IBS-D 33.6%, IBS-C 26.7%, IBS-M 38.2%. IBS-SSS > 300 in 53% and HAD score > 19 in 45%). QoL impairment was correlated with disease severity and HAD score (r = −0.707 and r = −0.484, P < 0.001 respectively), but not with IBS subtype. Expectations for IBS were “improved health”, “better information on causes and treatments” (94%) and “better disease recognition” (86%). A significant gap was observed between expectations and experiences with HCPs. Better information, less isolation, recognition of the disease and a decrease in medical expenses were the main expectations for joining a patients’ organization.ConclusionsFrench IBS patients have a severe disease with a significant psychological impact and impaired QoL in half of the patients, certain unsatisfied expectations concerning HCP and high expectations in joining a patients’ organization.

INTRODUCTION AND OBJECTIVE: To assess clinical characteristics and surgical outcomes of triaged patients undergoing oncological and non-oncological surgery during the first wave of Covid-19 crisis. METHODS: We conducted a cohort-controled, nonrandomized, study in a Covid-19 reference centre in south-eastern France. Participants were consecutive surgical patients after triage and application to prevent from Covid-19 (Tab1). Data were collected prospectively during the propagation period from March 15th to May1st and compared with control data from outside the Covid-19 period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications were assessed. Cancer and non-cancer subgroups during Covid-19 were also compared. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 yo [56-75], sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery (Tab 2). No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid-era patients (Tab 3). CONCLUSIONS: Surgery after triage during the Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be lifethreatening. Altogether, two-thirds of elective surgeries were postponed and now need to be rescheduled, thus increasing the work-load in our centre.

International audience; Purpose: The SARAH (Sorafenib Versus Radioembolization in Advanced Hepatocellular Carcinoma) trial (ClinicalTrials.gov Identifier NCT01482442) did not show a significant survival benefit for patients treated with transarterial radioembolization (TARE) compared with continuous oral sorafenib. The improved toxicity profile of patients treated with TARE in the trial, however, could result in a quality of life benefit in economic evaluations. Our objective was to perform a cost-utility analysis of TARE versus sorafenib for locally advanced and inoperable hepatocellular carcinoma.Methods: This study used patient-level data of the SARAH trial regarding resource use, progression-free and overall survival, and quality of life for the within-trial period for the patients who received at least 1 dose of sorafenib or 1 treatment with TARE according to their randomization arm. Data were extrapolated by using a partitioned survival model that incorporated costs and health outcomes, measured in life-years and quality-adjusted life-years (QALYs).Findings: The use of TARE resulted in an average loss of 0.036 life-year and a gain of 0.006 QALY compared with sorafenib. The aerage cost for the TARE arm was €17,179 (95% CI, 9,926-24,280) higher than the sorafenib arm, for an incremental cost-effectiveness ratio of €3,153,086/QALY. The probabilistic sensitivity analysis revealed a 50% risk that the TARE strategy was dominated. TARE was consistently dominated by sorafenib or had an incremental cost-effectiveness ratio more than €450,000/QALY in all sensitivity analyses.Implications: This economic evaluation of SARAH found that using radioembolization with yttrium-90 microspheres for the treatment of hepatocellular carcinoma was not a cost-effective option at the usually accepted willingness-to-pay thresholds.

Resume Introduction Lors de la premiere vague epidemique Covid-19, des mesures de triage, sans PCR systematique, etaient mises en place pour selectionner les patients a operer. Notre etude a compare leurs resultats chirurgicaux apres triage a ceux d’un groupe controle. Materiel L’analyse portait sur l’ensemble des patients initialement programmes dans un centre Covid de reference et inclus consecutivement, du 15 mars au 1er mai 2020 ( NCT04352699 ). Leurs donnees etaient recueillies prospectivement et ulterieurement comparees a celles des patients operes 1 an auparavant sur la meme periode dans ce centre. Le critere d’evaluation principal etait l’admission post-operatoire en unite de soins intensifs (USI). La morbidite, la mortalite postoperatoire, le report d’interventions, les tests PCR etaient evalues. Des analyses de sous-groupes etaient realises pour les patients operes de cancer. Resultats Apres triage, 96 des 142 interventions programmees ont du etre reportees. Sur les operes, 48 (68 %) l’etaient pour cancer. Au total, aucun cas de pneumonie Covid-19 post-operatoire n’a ete identifie. Trois patients (4 %) ont ete admis en USI, dont un finalement decede pour sepsis urinaire. Chez ces patients, les RT-PCR etaient negatives. Globalement, comparativement au groupe controle, aucune difference d’admission en USI, ni de taux de mortalite post-operatoire n’ont ete rapportees. Conclusions Le triage de la premiere vague n’a pas surexpose les patients selectionnes a un risque de complication ou de deces post-operatoire, particulierement pas pour ceux operes pour cancer. En revanche, 67 % des patients ont ete reportes, avec un risque associe a des retard de soins pouvant conduire au deces. Niveau de preuve 3.

Evaluate the impact of fecal incontinence (FI) and chronic constipation (CC) on the quality of life (QoL) in a large population and determine if a threshold of symptom scores was associated with alterations to QoL. A total of 422 outpatients with FI (n = 186), CC (n = 186), and mixed FI-CC (n = 50) referred for anorectal manometry were included prospectively. All patients completed a set of questionnaires to evaluate the severity of FI and CC (respectively Jorge and Wexner and KESS scores) and their impact on QoL (Gastrointestinal Quality of Life Index (GIQLI)). The study population included 81.8% women. The QoL was altered to the same degree for both FI and CC, with significant more marked impairments in patients with mixed FI-CC (median GIQLI: 91 (71–108) vs. 91 (73–108) vs. 81 (57–97) respectively, p = 0.05). The symptom severity significantly but weekly correlated with the GIQLI score (r2 = − 0.454 for FI and r2 = − 0.483 for CC, p

International audience; Digestive disorders, in particular constipation, are symptoms very often reported by cancer patients as having a major impact on their quality of life. An accurate diagnosis of bowel delayed transit and defecation disorders is required to best adapt therapeutic management. Constipation associated with cancer may be related to several causes, which can be placed in three nosological categories that sometimes overlap: chronic constipation prior to cancer and having its own evolution; constipation related to the cancer condition, in particular the occlusive syndrome, and constipation induced by cancer therapies. The stricter application of diet and lifestyle measures is often necessary and sometimes sufficient. Laxative drug treatments come under various galenic forms and administration routes and must be selected according to the clinical features of constipation. Surgical management can be indicated in case of ileus or pelvic static disorders. In the case of refractory constipation induced by opioids and within the framework of palliative care to treat an advanced pathology, a peripheral morphinic antagonist can offer fast symptom relief. A way forward to improve the patients' quality of life could be to identify the contributing factors (in particular, genetic factors) to determine which patients are the more at risk and anticipate their management.; Les troubles digestifs, et notamment la constipation, constituent des symptômes très fréquemment décrits par les patients atteints de cancer, avec un retentissement important sur leur qualité de vie. Le diagnostic précis du ralentissement du transit et des troubles de la défécation est nécessaire afin d’adapter au mieux la prise en charge thérapeutique. Les étiologies de constipation associées au cancer sont nombreuses et peuvent être séparées en trois cadres nosologiques, s’intriquant parfois entre eux : la constipation chronique antérieure au cancer et évoluant pour son propre compte, la constipation liée à la maladie cancéreuse avec notamment le syndrome occlusif et la constipation liée aux traitements du cancer. Le renforcement des mesures hygiéno-diététiques est souvent nécessaire et parfois suffisant. Les traitements médicamenteux laxatifs présentent des formes galéniques et voies d’administration différentes et seront choisis en fonction des caractéristiques de la constipation. Une prise en charge chirurgicale peut être indiquée en cas d’occlusion intestinale ou de troubles de la statique pelvienne. En cas de constipation rebelle liée aux opioïdes et dans le cadre d’une prise en charge palliative d’une pathologie avancée, un antagoniste morphinique périphérique peut permettre de soulager rapidement les symptômes. Afin d’améliorer la qualité de vie des patients, l’identification de facteurs favorisants notamment génétiques permettrait de déterminer les patients les plus à risque et ainsi anticiper leur prise en charge.

Summary The mucosal immune system (including airway, intestinal, oral and cervical epithelium) is an integrated network of tissues, cells and effector molecules that protect the host from environmental insults and infections at mucous membrane surfaces. Dysregulation of immunity at mucosal surfaces is thought to be responsible for the alarming global increase in mucosal inflammatory diseases such as those affecting the gastrointestinal (Crohn's disease, ulcerative colitis and irritable bowel syndrome) and respiratory (asthma, allergy and chronic obstructive pulmonary disorder) system. Although immune regulation has been well-studied in isolated mucosal sites, the extent of the immune interaction between anatomically distant mucosal sites has been mostly circumstantial and the focus of much debate. With novel technology and more precise tools to examine histological and functional changes in tissues, today there is increased appreciation of the ‘common mucosal immunological system’ originally proposed by Bienenstock nearly 40 years ago. Evidence is amounting which shows that stimulation of one mucosal compartment can directly and significantly impact distant mucosal site, however the mechanisms are unknown. Today, we are only beginning to understand the complexity of relationships and communications that exist between different mucosal compartments. A holistic approach to studying the mucosal immune system as an integrated global organ is imperative for future advances in understanding mucosal immunology and for future treatment of chronic diseases. In this review, we particularly focus on the latest evidence and the mechanisms operational in driving the lung–gut cross-talk.

BACKGROUND: Recent evidence has indicated an increased risk of Barrett's esophagus (BE) in the long term after sleeve gastrectomy (SG). AIM: The aim of the study is to investigate the spectrum of gastroesophageal reflux disease (GERD) symptoms as well as the prevalence of BE, at minimum 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy. PATIENTS AND METHODS: Five high volume outpatient centers dedicated to bariatric surgery that routinely perform upper GI endoscopy before any bariatric procedures were invited to participate in the study. From January 2017 to June 2018, each center during scheduled postoperative evaluation after surgery asked a minimum 10 consecutive patients, which had performed SG at least 5 years before and with no evidence of BE preoperatively, to undergo another upper GI endoscopy. RESULTS: Ninety (66 F) consecutive patients were enrolled. The mean follow-up was 78 +/- 15 months, and the mean total body weight loss was 25 +/- 12%. The prevalence of BE was 18.8% with no significant difference among centers. Weight loss failure was significantly associated with BE (p \textless 0.01). The prevalence of GERD symptoms, erosive esophagitis, and the usage of PPIs increased from 22%, 10%, and 22% before the SG to 76%, 41%, and 52% at the time of follow-up, respectively (p \textless 0.05). CONCLUSIONS: This multicenter study show a high rate of BE at least 5 years after SG. Weight loss failure was significantly associated with BE. We suggest to provide systematic endoscopy in these patients to rule out this condition.

Abnormal gut barrier function is the basis of gut inflammatory disease. It is known that house dust mite (HDM) aero-allergens induce inflammation in respiratory mucosa. We have recently reported allergen from Dermatophagoides pteronyssinus (Der p1) to be present in rodent gut.To examine whether Der p1 is present in human gut and to assess its effect on gut barrier function and inflammation.Colonic biopsies, gut fluid, serum and stool were collected from healthy adults during endoscopy. Der p1 was measured by ELISA. Effect of HDM was assessed on gut permeability, tight-junction and mucin expression, and cytokine production, in presence or absence of cysteine protease inhibitors or serine protease inhibitors. In vivo effect of HDM was examined in mice given oral HDM or protease-neutralised HDM. Role of HDM in low-grade inflammation was studied in patients with IBS.HDM Der p1 was detected in the human gut. In colonic biopsies from healthy patients, HDM increased epithelial permeability (p0.001), reduced expression of tight-junction proteins and mucus barrier. These effects were associated with increased tumour necrosis factor (TNF)-α and interleukin (IL)-10 production and were abolished by cysteine-protease inhibitor (p0.01). HDM effects did not require Th2 immunity. Results were confirmed in vivo in mice. In patients with IBS, HDM further deteriorated gut barrier function, induced TNF-α but failed to induce IL-10 secretion (p0.001).HDM, a ubiquitous environmental factor, is present in the human gut where it directly affects gut function through its proteolytic activity. HDM may be an important trigger of gut dysfunction and warrants further investigation.

Chronic constipation is a common symptom that regularly affects the quality of life of adult patients. Its treatment is mainly based on dietary rules, laxative drugs, perineal rehabilitation and surgical treatment. The French National Society of Coloproctology offers clinical practice recommendations on the basis of the data in the current literature, including those on recently developed treatments. Most are noninvasive, and the main concepts include the following: stimulant laxatives are now considered safe drugs and can be more easily prescribed as a second-line treatment; biofeedback therapy remains the gold standard for the treatment of anorectal dyssynergia that is resistant to medical treatment; transanal irrigation is the second-line treatment of choice in patients with neurological diseases, but it may also be proposed for patients without neurological diseases; and although interferential therapy may be a new promising treatment, it needs further evaluation.

International audience; BACKGROUND: Predicting early death after a comprehensive geriatric assessment (CGA) is very difficult in clinical practice. The aim of this study was to develop a scoring system to estimate risk of death at 100 days in elderly cancer patients to assist the therapeutic decision. METHODS: This was a multicentric, prospective cohort study approved by an ethics committee. Elderly cancer patients aged older than 70 years were enrolled before the final therapeutic decision. A standardised CGA was made before the treatment decision at baseline. Within 100 days, event~(death), oncologic and geriatric data were collected. Multivariate logistic regression was used to select the risk factors for the overall population. Score points were assigned to each risk factor using the β coefficient. Internal validation was performed by a bootstrap method. Calibration was assessed with the Hosmer-Lemeshow goodness of fit test and accuracy with the mean c-statistic. FINDINGS: One thousand fifty patients (mean age: 82 years) joined the study from April 2012 to December 2014. The independent predictors were~metastatic cancers (odds ratio [OR] 2.5; 95% confidence interval [CI], [1.7-3.5] p\textless0 .001); gait speed\textless0.8~m/s (OR 2.1; 95% CI [1.3-3.3] p=0.001); Mini Nutritional Assessment (MNA)~\textless~17 (OR 8; 95% CI; [3.7-17.3] p\textless0.001), MNA =~17 (OR 4.4; 95% CI, [2.1-9.1) p\textless0.001); performance status (PS)~\textgreater~2 (OR 1.7; 95% CI, [1.1-2.6)] p=0.015) and cancers other than breast cancer~(OR 4; 95% CI, [2.1-7.9] p\textless0.001). We attributed 4 points for MNA\textless17, 3 points for MNA between =~17, 2 points for metastatic cancers, 1 point for gait speed \textless0.8~m/s, 1 point for PS~\textgreater~2 and 3 points for cancers other than breast cancer. The risk of death at 100 days was 4% for 0 to 6 points, 24% for 7 to 8 points, 39% for 9 to 10 points and 67% for 11 points. INTERPRETATION: To our knowledge, this is the first score which estimates early death in elderly cancer patients. The system could assist in the treatment decision for elderly cancer patients.

Summary Background Sorafenib is the recommended treatment for patients with advanced hepatocellular carcinoma. We aimed to compare the efficacy and safety of sorafenib to that of selective internal radiotherapy (SIRT) with yttrium-90 ( 90 Y) resin microspheres in patients with hepatocellular carcinoma. Methods SARAH was a multicentre, open-label, randomised, controlled, investigator-initiated, phase 3 trial done at 25 centres specialising in liver diseases in France. Patients were eligible if they were aged at least 18 years with a life expectancy greater than 3 months, had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, Child-Pugh liver function class A or B score of 7 or lower, and locally advanced hepatocellular carcinoma (Barcelona Clinic Liver Cancer [BCLC] stage C), or new hepatocellular carcinoma not eligible for surgical resection, liver transplantation, or thermal ablation after a previously cured hepatocellular carcinoma (cured by surgery or thermoablative therapy), or hepatocellular carcinoma with two unsuccessful rounds of transarterial chemoembolisation. Patients were randomly assigned (1:1) by a permutated block method with block sizes two and four to receive continuous oral sorafenib (400 mg twice daily) or SIRT with 90 Y-loaded resin microspheres 2–5 weeks after randomisation. Patients were stratified according to randomising centre, ECOG performance status, previous transarterial chemoembolisation, and presence of macroscopic vascular invasion. The primary endpoint was overall survival. Analyses were done on the intention-to-treat population; safety was assessed in all patients who received at least one dose of sorafenib or underwent at least one of the SIRT work-up exams. This study has been completed and the final results are reported here. The trial is registered with ClinicalTrials.gov, number NCT01482442. Findings Between Dec 5, 2011, and March 12, 2015, 467 patients were randomly assigned; after eight patients withdrew consent, 237 were assigned to SIRT and 222 to sorafenib. In the SIRT group, 53 (22%) of 237 patients did not receive SIRT; 26 (49%) of these 53 patients were treated with sorafenib. Median follow-up was 27·9 months (IQR 21·9–33·6) in the SIRT group and 28·1 months (20·0–35·3) in the sorafenib group. Median overall survival was 8·0 months (95% CI 6·7–9·9) in the SIRT group versus 9·9 months (8·7–11·4) in the sorafenib group (hazard ratio 1·15 [95% CI 0·94–1·41] for SIRT vs sorafenib; p=0·18). In the safety population, at least one serious adverse event was reported in 174 (77%) of 226 patients in the SIRT group and in 176 (82%) of 216 in the sorafenib group. The most frequent grade 3 or worse treatment-related adverse events were fatigue (20 [9%] vs 41 [19%]), liver dysfunction (25 [11%] vs 27 [13%]), increased laboratory liver values (20 [9%] vs 16 [7%]), haematological abnormalities (23 [10%] vs 30 [14%]), diarrhoea (three [1%] vs 30 [14%]), abdominal pain (six [3%] vs 14 [6%]), increased creatinine (four [2%] vs 12 [6%]), and hand-foot skin reaction (one [ vs 12 [6%]). 19 deaths in the SIRT group and 12 in the sorafenib group were deemed to be treatment related. Interpretation In patients with locally advanced or intermediate-stage hepatocellular carcinoma after unsuccessful transarterial chemoembolisation, overall survival did not significantly differ between the two groups. Quality of life and tolerance might help when choosing between the two treatments. Funding Sirtex Medical Inc.

Background Currently, there are no histological criteria to diagnose irritable bowel syndrome (IBS). Our aims were (i) to examine the distribution of inflammatory cells in the colon of healthy and IBS subjects and (ii) to find histological diagnosis criteria for IBS. Methods Colonic biopsies were taken from four distinct regions of the colon from 20 controls (HC) and 11 patients with IBS (4 with constipation (IBS-C) and 7 with diarrhea (IBS-D) and embedded in paraffin. Macrophages, mast cells, eosinophils, and T lymphocytes were immunostained and positive cells counted. Key Results In both HC and IBS patients, global cellularity decreased from the cecum to the rectum (P

11548 Background: Some previous studies in geriatric oncology have described the GI and their adherence. Today’s challenge is to screen patients needing specific GI and repeated Comprehensive Geriatric Assessments (CGA). We recently analyzed a phenotype of patients requiring more GI (Boulahssass et al, Cancers 2019). The main purpose of the present study is to compare types of GI implemented, according to patient frailty levels, in order to better understand the necessary care plan. Methods: Between April 2012 and May 2018, 3530 consecutive patients with solid tumors were enrolled in this multicentric, prospective cohort. 3140 patients (mean age:82y) were finally included and a CGA was performed at Baseline. Twelve GI were standardized, individualized or based on experience if no guidelines were available. Within 1 month, geriatricians including patients in the cohort received standardized training. Logistic regression was performed to compare types of GI in the 3 groups using the Balducci Score (B1/B2/B3). Results: 8819 GI were implemented for the 3140 patients. On average, fit patients had 1.5 GI (n = 146), vulnerable patients 2.4 GI (n = 1568) and frail patients 3.3 GI (n = 1426). We observed no significant differences between the 3 groups concerning specific pain management (Fit vs B2: p = 0.19; Fit vs B3: p = 0.57) and psychological care (Fit vs B2:p = 0.03; Fit vs B3:p = 0.24). In vulnerable and frail patients, we recorded more significant GI for nutritional care, delirium prevention, comorbidity management, nursing interventions, social worker interventions, treatment modifications for optimization or iatrogenic disorders and physiotherapy, with the highest Odds Ratio for nursing interventions (Fit vs B2 OR:2.9 p = 0.011; Fit vs B3 OR:9 P < 0.001) and physiotherapy (Fit vs B2:OR 4.3 p < 0.001; Fit vs B3:OR:9 p < 0.001). B3 patients had significantly more GI on care pathways modifications (OR:3.1, p = 0.002) and caregiver care (OR:2, p = 0.049). Conclusions: Fit patients also needed GI. We observed differences in types of GI between the groups. However, the aims and levels also seemed to differ and need further studies to analyze their impact.

Resume Le lactose, principal sucre du lait, est un disaccharide dont l’absorption au niveau de l’intestin grele est dependante de son hydrolyse en glucose et galactose par la lactase, enzyme presente au niveau de la bordure en brosse des enterocytes. En cas de deficit de cette enzyme, le lactose non hydrolyse est metabolise par la flore bacterienne anaerobie du colon. Les metabolites generes, acides gras a courte chaine, hydrogene, dioxyde de carbone et methane, sont retenus responsables des symptomes tels que douleur abdominale, meteorisme, flatulence, diarrhee. Le deficit en lactase peut etre d’origine congenitale, d’origine primaire acquise ou d’origine acquise secondaire a des pathologies lesant la muqueuse intestinale. La malabsorption du lactose est la consequence de l’hypolactasie dont l’expression clinique est l’intolerance au lactose : dans la pratique clinique courante, la malabsorption est diagnostiquee grâce au test respiratoire a l’hydrogene apres ingestion de lactose, qui doit etre couple au recueil des symptomes d’intolerance eventuellement provoques par ce test. Le traitement repose sur l’exclusion ou la reduction du lactose de l’alimentation, traitement qui doit etre reserve aux sujets symptomatiques (« intolerants »). Un suivi dietetique est souhaitable afin de ne pas meconnaitre d’eventuelles carences nutritionnelles, notamment calcique.

To determine the role of colonic barrier defects and low-grade inflammation in irritable bowel syndrome (IBS)-like symptoms in quiescent inflammatory bowel disease (IBD).Caecal biopsies were collected from 51 IBS, 49 quiescent IBD (31 Crohn's disease (CD) and 18 ulcerative colitis (UC)) patients and 27 controls. IBS was assessed using the Rome III criteria and the IBS severity score. Epithelial barrier integrity was evaluated by determining the paracellular permeability of biopsies mounted in Ussing chambers and the mRNA expression of tight junction proteins (ZO-1, α-catenin and occludin). Low-grade inflammation was evaluated by counting cells, including intraepithelial lymphocytes (IELs), eosinophils and mast cells, and by determining the mRNA and protein expression of tumour necrosis factor (TNF)-α in biopsies and culture supernatants.IBS-like symptoms were present in 35.4 and 38% of CD and UC patients, respectively. Paracellular permeability was significantly increased in both quiescent IBD with IBS-like symptoms and IBS compared with quiescent IBD without IBS-like symptoms (p0.01, respectively) or controls (p0.01, respectively). Significantly lower expression of ZO-1 and α-catenin was detected in IBS and quiescent IBD with IBS-like symptoms. IELs and TNF-α were significantly increased in quiescent IBD with IBS-like symptoms, but not in IBS.In quiescent IBD, IBS-like symptoms related to persistent subclinical inflammation associated with increased colonic paracellular permeability. A persistent increase in TNF-α in colonic mucosa may contribute to the epithelial barrier defects associated with abdominal pain in quiescent IBD, but not in IBS. Optimisation of anti-inflammatory therapy may be considered in quiescent IBD with IBS-like symptoms.

International audience; Faecal microbiota transplantation is effective for treating recurrent forms of Clostridium difficile infection and its use in this indication is recommended in the most recent European and North American guidelines. In this context, faecal microbiota transplantation is beginning to be performed in France in clinical practice, while the rules governing this procedure have been defined in France only for clinical trials. To unify, secure, and evaluate practice in this field in France, the French Group of Faecal microbiota Transplantation (FGFT) was created in October 2014 with the support of the French National Society of Gastroenterology, the French Infectious Disease Society, and the National Academy of Pharmacy. We present here the deliberations of this group regarding the use of faecal microbiota transplantation for recurrent Clostridium difficile infection. The issues addressed are the indications, therapeutic sequence, delivery procedures, donor selection, methods and conditions of specimen preparation, and traceability.

Summary Background Irritable bowel syndrome (IBS), one of the most common gastrointestinal disorders, markedly impairing patients' quality of life. Drug development for IBS treatment has been hampered by the lack of understanding of IBS aetiology. In recent years, numerous data have emerged that suggest the involvement of immune activation in IBS, at least in a subset of patients. Aim To determine whether immune activation and intestinal permeabilisation are more frequently observed in IBS patients compared with healthy controls. Methods The scientific bibliography was searched using the following keywords: irritable bowel syndrome, inflammation, immune activation, permeabilisation, intestine, assay, histology and human. The retrieved studies, including blood, faecal and histological studies, were analysed to provide a comprehensive and structured overview of the available data including the type of assay, type of inflammatory marker investigated or intestinal segment studied. Results Immune activation was more frequently observed in IBS patients than in healthy controls. An increase in the number of mast cells and lymphocytes, an alteration in cytokine levels and intestinal permeabilisation were reported in IBS patients. No consistent changes in the numbers of B cells or enterochromaffin cells or in mucosal serotonin production were demonstrated. Conclusions The changes observed were modest and often heterogeneous among the studied population. Only appropriate interventions improving irritable bowel syndrome symptoms could highlight and confirm the role of immune activation in this pathophysiology.

Aliment Pharmacol Ther 2011; 33: 961–968 Summary Background Fatigue is an important determinant of altered quality of life in patients affected by chronic hepatitis C or the irritable bowel syndrome (IBS). Aim In this study, we aimed at determining the contributory role of plasma levels of leptin and carnitine on fatigue in chronic hepatitis C and IBS. Methods We enrolled 81 patients with chronic hepatitis C, 42 with IBS and 44 healthy subjects. Fatigue was evaluated using the Fatigue Impact Scale questionnaire. Body composition was assessed through impedance analysis. Plasma carnitine and leptin were measured. Results Fatigue scores were significantly more elevated in patients with chronic hepatitis C and IBS than in healthy subjects. Patients with chronic hepatitis C but not IBS, had significant lower plasma levels of total and free carnitine adjusted for fat mass compared with healthy subjects. In patients with chronic hepatitis C and not with IBS, fatigue scores were negatively correlated with plasma levels of carnitine. Levels of free carnitine were significantly and independently associated with the severity of fatigue in patients with chronic hepatitis C [OR = 2.019, P = 0.02, CI 95% (1.01–1.23)]. Conclusions In patients with chronic hepatitis C, the severity of fatigue is associated with a low level of carnitine, suggesting that an oral supplementation may be effective to relieve fatigue in chronic hepatitis C. The underlying mechanism of fatigue in IBS does not seem to involve carnitine.

Background & Aims Little is known about the magnitude of the risk of anal and rectal cancer in patients with anal and/or perineal Crohn's disease. We aimed to assess the risk of anal and rectal cancer in patients with Crohn's perianal disease followed up in the Cancers Et Surrisque Associe aux Maladies Inflammatoires Intestinales En France (CESAME) cohort. Methods We collected data from 19,486 patients with inflammatory bowel disease (IBD) enrolled in the observational CESAME study in France, from May 2004 through June 2005; 14.9% of participants had past or current anal and/or perianal Crohn's disease. Subjects were followed up for a median time of 35 months (interquartile range, 29–40 mo). To identify risk factors for anal cancer in the total CESAME population, we performed a case-control study in which participants were matched for age and sex. Results Among the total IBD population, 8 patients developed anal cancer and 14 patients developed rectal cancer. In the subgroup of 2911 patients with past or current anal and/or perianal Crohn's lesions at cohort entry, 2 developed anal squamous-cell carcinoma, 3 developed perianal fistula–related adenocarcinoma, and 6 developed rectal cancer. The corresponding incidence rates were 0.26 per 1000 patient-years for anal squamous-cell carcinoma, 0.38 per 1000 patient-years for perianal fistula–related adenocarcinoma, and 0.77 per 1000 patient-years for rectal cancer. Among the 16,575 patients with ulcerative colitis or Crohn's disease without anal or perianal lesions, the incidence rate of anal cancer was 0.08 per 1000 patient-years and of rectal cancer was 0.21 per 1000 patient-years. Among factors tested by univariate conditional regression (IBD subtype, disease duration, exposure to immune-suppressive therapy, presence of past or current anal and/or perianal lesions), the presence of past or current anal and/or perianal lesions at cohort entry was the only factor significantly associated with development of anal cancer (odds ratio, 11.2; 95% CI, 1.18-551.51; P = .03). Conclusions In an analysis of data from the CESAME cohort in France, patients with anal and/or perianal Crohn's disease have a high risk of anal cancer, including perianal fistula–related cancer, and a high risk of rectal cancer.

Aliment Pharmacol Ther 2010; 32: 225–232 Summary Background Life-threatening bleeding caused by early spontaneous slippage of rubber bands has been described after variceal ligation in cirrhotic patients. Aim To determine the predictive factors of this complication in cirrhotic patients. Methods Among 605 patients, 21 patients (mean age 56.6 ± 13.5 years) developed 23 spontaneous band slippages with bleeding on post banding ulcer, as confirmed by endoscopy. Cirrhosis was alcoholic in 13 patients (62%), post viral hepatitis in three (14%) and from other causes in five (24%). A case-control study was performed comparing 17 from these patients who presented the complication after a first ligation with 84 of the 584 controls who underwent first endoscopic variceal ligation without bleeding complication. Results Bleeding occurred 13.5 days ± 7.3 (2–29) following ligation. Eleven patients died following the bleeding complication (52%). Using a multivariate analysis, previous upper variceal digestive bleeding [OR 12.07, 95%CI (2.3–63.43)], peptic oesophagitis [OR 8.9, 95%CI (1.65–47.8)], high platelet ratio index (APRI) score [OR 1.54, 95%CI (1.11–2.16)] and low prothrombin index [OR 0.54, 95% CI (0.31–0.94)] were independent predictive factors of bleeding. Conclusions Bleeding related to post-banding ulcer is a rare, but severe complication. The proposed predictive factors should be looked for and minimized before variceal ligation.

Resume Le syndrome de l’intestin irritable (SII) est une pathologie digestive tres frequente qui concerne environ 5 a 15 % de la population generale. Le SII a un impact medicoeconomique important et encore sous-estime. La physiopathologie du SII repose sur un modele biopsychosocial dans lequel des alterations de l’integrite de la barriere epitheliale intestinale sont influencees par le systeme nerveux central. En particulier, une augmentation de la permeabilite paracellulaire participe a l’entretien d’un etat inflammatoire muqueux de bas grade et de l’hypersensibilite viscerale. Les mediateurs mastocytaires et une augmentation de l’activite proteasique fecale ont ete identifies a l’origine de ces alterations et constituent des cibles therapeutiques pour le SII.

The irritable bowel syndrome (IBS) is a common bowel disorder that markedly impairs quality of life of patients. The causes of IBS symptoms are not well known. Motility and sensibility disorders, a genetic susceptibility, stress, previous GI infections and food intolerance have been involved in the pathogenesis of IBS. Recent investigations suggest that alterations of the intestinal epithelial barrier integrity, in particular increased permeability, could modify the cross-talk between bacterial microflora and the host, thus leading to persitent "low-grade" inflammation and alterated GI motility and sensitivity.

Summary Background Radiofrequency (RF) energy delivery is an endoscopic procedure developed for the treatment of gastro-oesophageal reflux disease. Aim To compare RF and a proton pump inhibitor strategy (PPI) in PPI-dependent patients by carrying out a prospective, randomized trial. Methods Patients with PPI-dependent typical reflux symptoms were randomly allocated to either RF or PPI regimen alone. The primary endpoint, evaluated at 6-month, was defined as the possibility for the patient to stop or to decrease PPI use to

Digestive disorders, in particular constipation, are symptoms very often reported by cancer patients as having a major impact on their quality of life. An accurate diagnosis of bowel delayed transit and defecation disorders is required to best adapt therapeutic management. Constipation associated with cancer may be related to several causes, which can be placed in three nosological categories that sometimes overlap: chronic constipation prior to cancer and having its own evolution; constipation related to the cancer condition, in particular the occlusive syndrome, and constipation induced by cancer therapies. The stricter application of diet and lifestyle measures is often necessary and sometimes sufficient. Laxative drug treatments come under various galenic forms and administration routes and must be selected according to the clinical features of constipation. Surgical management can be indicated in case of ileus or pelvic static disorders. In the case of refractory constipation induced by opioids and within the framework of palliative care to treat an advanced pathology, a peripheral morphinic antagonist can offer fast symptom relief. A way forward to improve the patients' quality of life could be to identify the contributing factors (in particular, genetic factors) to determine which patients are the more at risk and anticipate their management.

A subset of patients with irritable bowel syndrome (IBS) have an increased number of mast cells (MCs) in the colonic mucosa. Psychological factors are believed to contribute to the course of IBS.To examine associations between fatigue, depression and MCs of the colonic mucosa in IBS.Colonic biopsies were taken from 50 Rome II IBS patients, 21 healthy controls and 11 depressed/fatigued patients without IBS. The cellularity of the lamina propria was determined as the number of inflammatory cells per high power field (hpf) through a 400x microscope. The Fatigue Impact Scale (FIS) and the short form Beck Depression Inventory (BDI) evaluated the severity of fatigue and depression.IBS patients had a significant increase in the cellularity of the lamina propria compared with controls or with depressed patients (mean (SD) 94.5 (48-110) vs 68 (58-82) and 78 (87-90) cells per hpf, p = 0.005 and p = 0.05, respectively), in particular of MCs (9.3 (5.6-11.7) vs 4.0 (2.7-6.8) and 4.3 (2.8-7.8) cells per hpf, p = 0.001 and p = 0.005, respectively). Both the FIS and BDI scores were significantly higher in IBS or in depressed patients than in controls (p0.001). In IBS, the FIS score correlated significantly with the cellularity of the lamina propria (r = 0.51, p0.0001) and MCs (r = 0.64, p0.0001). In IBS, the BDI score correlated significantly with MCs (r = 0.29, p = 0.03).Elevated MCs counts are a key feature of the low-grade inflammatory infiltrate in the caecal mucosa of IBS. Fatigue and depression are associated with mucosal cell counts, in particular MCs, suggesting that psychological factors are associated with the low-grade inflammatory infiltrate in IBS.

Vertical banded gastroplasty (VBG) is associated with a significant rate of revision because of regain of weight due to staple-line disruption, gastric pouch and stoma dilation, change to sweet eating, outlet stenosis with vomiting and reflux. To avoid reflux, some surgeons added an antireflux wrap. We report laparoscopic revision of VBG with antireflux wrap to Roux-en-Y gastric bypass (RYGBP) in 4 patients. The indication for revision was insufficient weight loss in all 4 patients, with stenosis of the stoma resistant to endoscopic balloon dilation in one and reflux esophagitis in one, who shifted to high-calorie liquids. Revision was performed 73.5 months (range 57–84) after the primary procedure, at mean BMI 39.5 (range 37–41). Mean operative time was 193.7 min (165–220). There was no conversion to open surgery. There was no mortality. One patient developed a stenosis at the gastrojejunostomy that was managed successfully with endoscopic balloon dilation. Mean length of stay was 6.8 days (range 4–9). At mean follow-up of 11.2 months (range 11–18), mean BMI is 28.5 (range 27–30), and all patients were free of co-morbidities. Laparoscopic revision of VBG with an antireflux wrap into an LRYGBP is feasible and effective in achieving weight loss, but the safety requires assessment by a larger series.

ummary Background Probiotics are defined as live micro-organisms which confer a health benefit on the host. Although most probiotics are bacteria, one strain of yeast, Saccharomyces boulardii, has been found to be an effective probiotic in double-blind clinical studies. Aims To compare the main properties that differentiates yeast from bacteria and to review the properties of S. boulardii explaining its potential benefits as a probiotic. Methods The PubMed and Medline databases were searched using the keywords ‘probiotics’, ‘yeast’, ‘antibiotic associated diarrhea’, ‘Saccharomyces boulardii’,‘bacterial diarrhea’ and ‘inflammatory bowel disease’ in various combinations. Results Several clinical studies have been conducted with S. boulardii in the treatment and prevention of various forms of diarrhoea. Promising research perspectives have been opened in terms of maintenance treatment of inflammatory bowel diseases. The mechanism of S. boulardii’s action has been partially elucidated. Conclusion Saccharomyces boulardii is a strain of yeast which has been extensively studied for its probiotic effects. The clinical activity of S. boulardii is especially relevant to antibiotic-associated diarrhoea and recurrent Clostridium difficile intestinal infections. Experimental studies clearly demonstrate that S. boulardii has specific probiotic properties, and recent data has opened the door for new therapeutic uses of this yeast as an ‘immunobiotic’.

Fatigue has received little attention in the irritable bowel syndrome. Emerging evidence exists that leptin may be involved in the pathogenesis of fatigue in several conditions. We aimed to evaluate the occurrence of fatigue and its characteristics in irritable bowel syndrome and to analyze the relationship between fatigue and leptin.We enrolled 51 consecutive irritable bowel syndrome patients and 22 healthy controls without fatigue. None of them were depressed. The Fatigue Impact Scale was used to evaluate fatigue.In all, 62.7% of irritable bowel syndrome patients verbally expressed fatigue and rated more than 4 on the visual analog scale. The total score of fatigue was significantly higher in irritable bowel syndrome than in controls. In irritable bowel syndrome patients, but not in controls, a significant association was found between the total score of fatigue and leptin and this association was more pronounced in 32 irritable bowel syndrome patients who verbally expressed fatigue (r=0.60; P=0.0003). In irritable bowel syndrome, leptin correlated with fatigue independently from age, sex, fat mass and body mass index.Our study shows that fatigue occurs in 62.7% of irritable bowel syndrome patients when systematically asked for. Fatigue influences all three domains of the Fatigue Impact Scale in irritable bowel syndrome, the most being the physical and the psychosocial domains. Fatigue is associated with circulating leptin levels independently from age, sex, fat mass and body mass index in irritable bowel syndrome. The metabolic sequence involved in the occurrence of fatigue remains to be determined.

(1) Service d’Hepato-Gastroenterologie et Nutrition Clinique, Nice ; (2) Service d’Hepato-Gastroenterologie, Clermont-Ferrand ; (3) Laboratoire de Nutrition Humaine, CRNH Auvergne ; (4) Service de Geriatrie, Rouen ; (5) Service de Gastroenterologie, Hopital Louis Mourier, Paris ; (6) Service de Chirurgie Viscerale, Rennes ; (7) Service de Chirurgie Viscerale, Nice ; (8) Service de Gynecologie Obstetrique, Clermont-Ferrand ; (9) Service de Gastroenterologie, Vichy ; (10) Service de Gynecologie Obstetrique, Tours ; (11) Hepato-Gastroenterologie liberale, Châteauroux ; (12) Service d’explorations fonctionnelles digestive, Lyon ; (13) Service de Gastroenterologie, Mont-de-Marsan ; (14) Medecine Generale, Villeneuve-le-Roi ; (15) Proctologie, Hopital Leopold Bellan, Paris.

OBJECTIVE: The incidence of postinfectious irritable bowel syndrome (IBS) ranges between 4% and 32% of individuals after bacterial or parasitic infection. This study analyzed IBS symptoms in hospitalized patients three months after a symptomaticClostridium difficileinfection.PATIENTS AND METHODS: All patients with a proven, symptomaticC difficileinfection identified in the department of bacteriology over a four-month period were considered for enrolment. Patients were excluded in cases of pre-existing IBS or other organic gastrointestinal diseases. Patients completed both modified Talley and Rome II questionnaires within five days of clinical improvement with metronidazole and at three months postinfection, when stools were cultured andC difficiletoxins were examined to exclude ongoing infection.RESULTS: Twenty-three patients were evaluated three months after infection withC difficile. Just after infection, 15 patients were symptom free, whereas eight patients exhibited symptoms suggestive of IBS. Three months after infection, 22 patients remained symptom free, whereas one patient presented with symptoms indicative of IBS. That female patient had a prolonged infection without vomiting.CONCLUSIONS: We have shown that while transient functional bowel disorder occurred in 34.7% of patients (eight of 23 patients) recently infected withC difficile, only 4.3% of patients (one of 23 patients) had symptoms indicative of IBS after three months (ie, postinfectious IBS). Because an age-related reduction in immune responsiveness has been documented, it can be speculated that the low incidence of postinfectious IBS may be explained by the older age of the study population. Therefore, it cannot be excluded that the findings may be different in younger patients.

Only a few recent reports have suggested a correlation between obesity and irritable bowel syndrome (IBS). We aimed to determine the prevalence and severity of IBS in a prospective cohort of obese patients undergoing bariatric surgery in Nice Hospital (France). One hundred obese patients were included prospectively before bariatric surgery. A diagnosis of IBS and each subtype was performed according to Rome-III criteria using a Bristol scale for stool consistency. Patients provided information on IBS-related comorbidities, including chronic fatigue, migraine, lower back pain, gastroesophageal reflux disease (GERD), genitourinary problems, and dyspepsia. Patients completed questionnaires to assess the severity of IBS, GERD, psychological factors (anxiety, depression), fatigue, and quality of life. Thirty patients fulfilled the Rome-III criteria for IBS. There was no difference in age, gender, or BMI between obese patients with or without IBS. Obese patients with IBS reported a significantly higher prevalence of GERD, migraines, lower back pain, genitourinary problems, chronic fatigue, and dyspepsia. Obese patients with IBS had significant higher scores of fatigue, anxiety, depression, and poorer quality of life. Obese patients that had both IBS and GERD had significantly higher IBS severity scores than those without GERD. In a logistic regression model including BMI, anxiety, depression, gender, and GERD score, only anxiety was significantly and independently associated with IBS. Thirty percent of obese patients had IBS: its severity was not correlated with BMI. However, anxiety was independently associated with IBS, suggesting that psychological factors are key features of IBS, whatever the presence of obesity.

Although proton pump inhibitors have become the mainstay of treatment in gastro-oesophageal reflux disease (GORD), there are still unmet needs in the management of this very common disorder. For example, all current proton pump inhibitors have a relatively slow onset of action and their activity is limited mainly to the post-prandial period with far less effective inhibition of nocturnal acid secretion. In order to achieve more potent, rapid and sustained acid inhibition several compounds are currently under development, such as new proton pump inhibitors with a prolonged plasma half-life, potassium competitive ATPase blockers (PCABs), histamine H3 agonists, and gastrin antagonists. Acid suppression does not, however, cure the disease and relapses are frequently observed after discontinuation of proton pump inhibitor therapy. Among the different abnormalities involved in the pathophysiology of this multifactorial disease, transient lower oesophageal sphincter relaxations represent the major mechanism responsible for episodes of reflux. Baclofen, the prototype GABA(B) receptor agonist, is one of the most potent inhibitors of transient lower oesophageal sphincter relaxations identified. To date the transfer of these relaxation-controlling pharmacological agents into clinical practice has however been hampered by the occurrence of unacceptable side effects. Beside "anti-relaxation therapy", the potential of novel prokinetics such as motilin agonists has been explored, especially since the motilin receptor has been cloned. Thus far the broad therapeutic value of prokinetics in GORD does, however, seem very limited in terms of efficacy with respect to oesophageal motility and acid exposure. Lastly, further research is necessary to better understand the complex mechanisms involved in oesophageal sensitivity and mucosal defence.

But - Le but de cette etude etait de determiner la tolerance et l'efficacite du l'association gemcitabine/oxaliplatine, en premiere ligne therapeutique, chez des malades porteurs de tumeurs du pancreas metastatiques ou loco-regionalement evoluees. Malades et methodes - Les malades ont beneficie de l'administration de gemcitabine a la dose de 1000 mg/m 2 delivree en 10/mg/m 2 /min au jour 1 suivie au jour 2 par l'administration en 2 heures d'oxaliplatine a la dose 100 mg/m 2; l'intervalle entre chaque cycle etait de 15 jours. Tous les malades avaient une tumeur du pancreas histologiquement prouvee avant l'inclusion dans l'etude. Les malades ont ete traites jusqu'a progression de la maladie ou pendant 12 cycles en l'absence de progression. Un bilan tomodensitometrique etait realise tous les 2 mois pour evaluer l'evolution de la maladie. Resultats - Entre janvier 2001 et janvier 2003, 32 malades ont ete eligibles pour entrer dans l'etude. Le taux de reponse objective a ete de 28,1 % avec 12,5 % de reponse complete. La survie sans progression et la survie globale de l'ensemble des malades ont ete respectivement de 7 et 9 mois. Cependant, la survie globale etait significativement plus importante pour les tumeurs loco-regionalement evoluees par rapport au tumeurs metastatiques (25 mois versus 7 mois, P < 0,0007). Onze malades etaient en vie a 1 an (34,4 %), six a 2 ans (18,8 %) et deux a 3 ans (6 %). Quatorze malades (43,8 %) ont presente un benefice clinique selon les criteres d'Anderson. Conclusion - Ces resultats confirment la bonne tolerance de l'association gemcitabine/oxaliplatine et suggerent que cette association peut avoir une activite anti-tumorale durable pour les tumeurs loco-regionalement evoluees.

In the last decade, laparoscopic gastric banding has become an increasingly popular surgical option for morbidly obese patients, because of the minimally invasive and easy surgical technique, its reversibility, and the possibility to calibrate the stoma. Gastric necrosis, as a complication of laparoscopic gastric banding, has been only rarely reported. Herein described is the case of a 45-year-old obese patient with gastric necrosis occurring 2 years after the placement of the band. After initial conservative management, the patient underwent urgent surgery. A huge anterior gastric prolapse through the band was found to be responsible for necrosis of the herniated stomach. An upper polar gastrectomy was performed. The mechanisms responsible for this life-threatening complication are discussed.

Hormonal control of gallbladder motility is still unclear in patients with cholelithiasis. In a case-control study, we determined the characteristics of gallbladder emptying evaluated sonographically and the hormone levels of somatostatin, gastrin, and pancreatic polypeptide, before and after a fatty meal in 10 gallstone patients compared with 20 healthy subjects. Patients with lithiasis had a larger residual volume (median 12,0 ml vs 6,5 ml; P = 0.01) and a lower gallbladder ejection fraction (43% vs 70%, P = 0.02) than healthy subjects. During fasting, plasma pancreatic polypeptide concentrations were significantly higher in lithiasis patients (P0.03). In contrast, no differences between the two groups of patients were observed during the post prandial period. Somatostatin and gastrin plasma levels were similar in the two groups. Lastly, the serum bile salt levels were in the normal range and were not different between groups both during fasting and postprandial states. We conclude that large basal plasma concentrations of pancreatic polypeptide, a gut peptide inducing gallbladder relaxation, may constitute a factor facilitating lithogenesis.