Diarrhées aiguës: propositions de prise en charge ambulatoire [Acute diarrhea: proposal for outpatient management]

Dans la majorité des cas, les diarrhées aiguës sont bénignes et d'évolution spontanément favorable. Il faut cependant savoir reconnaître les situations pouvant mener à des complications, en l'occurrence identifier les diarrhées invasives, inflammatoires, caractérisées par la présence de fièvre, de douleurs abdominales, de ténesmes, de mucus et, ou de sang dans les selles. Celles-ci sont à distinguer des diarrhées sécrétoires, non invasives, non inflammatoires, sans fièvre, généralement aqueuses et volumineuses. En cas de doute diagnostique, l'identification de leucocytes par microscopie ou test à la lactoferrine dans les selles permet d'évoquer une gastroentérite invasive. Les indications à une antibiothérapie empirique dans l'attente du résultat de la coproculture sont la présence d'un syndrome dysentérique (T > 38°C, > 6 selles/24 heures, douleurs abdominales, diarrhées mucopurulentes), l'âge avancé, des comorbidités significatives, une immunosuppression et la présence d'une prothèse endovasculaire. In the majority of the cases, an acute diarrhea is mild and of spontaneously favorable evolution. It is however necessary to know how to recognize the situations being able to lead to complications, in particular to identify the invasive, inflammatory diarrheas, characterized by the presence of fever, abdominal pains, mucus and\or blood. The identification of leukocytes by microscopy or lactoferrine test is helpful. Empiric quinolones treatment is recommended in the presence of dysenteric syndrome (T > 38 degrees C, > 6 stods/24 h 00, abdominal pain muco-purulent diarrhea), advanced age, significant comorbidities, immunosuppression or presence of an endovascular prothesis

Zinc et diarrhées chez les enfants de moins de cinq ans: les recommandations de l'OMS applicables en Suisse [Zinc and diarrhea in children under 5 years: WHO recommendations implemented in Switzerland].

In Europe, acute diarrhea, particularly caused by rotavirus are frequently the cause of epidemics in nurseries, schools, and even hospitals. Studies in many developing countries show that taking 10 to 20 mg per day of zinc for 10 to 14 days, during and after diarrhea, decreases the severity and reduces the number of episodes of diarrhea occurring within 2 to 3 months following the intake of zinc. However, the few studies conducted in developed countries do not confirm or deny its effectiveness in these countries, thereby limiting the global implementation of WHO recommendations for acute diarrhea. The ongoing study at the HEL (Children hospital - Lausanne) aims to promote this additional therapy in children under 5 years of age, perhaps allowing the helvetic application of the new WHO recommendations.

Boerhaave Syndrom: an unusual complication of acute vomiting in a child

Introduction: Boerhaave syndrome (BS) is a spontaneous esophageal perforation, described in aged, alcoholic males, secondary to forceful vomiting. BS has rarely been described in children. Case presentation: The patient is a 7-year-old Nigerian girl. She has a past history of clinical gastro-esophageal reflux (treated conservatively with prokinetics and good evolution), malaria at the age of 3 months and an episode of acute pancreatitis at 5 years. One week prior admission, she had stopped atovaquone-proguanil (AP) prophylaxis after a trip in an endemic area. Two days prior admission, she presented several bouts of isolated acute vomiting, without fever or diarrhea. On admission, she complained of chest pain. Cardiac auscultation revealed crepitus. No subcutaneous emphysema nor respiratory distress was present. Chest radiography and CT-scan confirmed a pneumomediastinum extending to the neck. Esophageal perforation was suspected. An upper gastrointestinal endoscopy was performed and showed a small esophageal tear, grade II-III esophagitis and a single gastric ulcer without any sign of H. Pylori infection. Enteral feeds were stopped and a nasogastric sucking tube inserted. The patient made a full recovery on intravenous antibiotics and conservative treatment. Of note a second episode of subclinical acute pancreatitis, treated conservatively, probably drug-induced. Discussion: BS is a complete rupture of all layers of the esophagus, secondary to an increased intra-abdominal pressure due to incomplete opening of the cricophayngeal sphincter occurring during vomiting or cough. Rarer causes include eosinophilic or Barrett's esophagitis, HIV and caustic ingestion. Esophageal perforation in children is rare, most of time secondary to necrotizing esophagitis in the newborn, medical intervention (endoscopy, sucking, or intubation) or trauma in the older child. Our patient had none of those risk factors and it is still unclear what predisposed her to this complication. However, we believe that preceding forceful vomiting with increased abdominal pressure acting on a weakened oesophagus due to esophagitis might be responsible. We could not find any association in the literature between AP and BS nor between BS and acute pancreatitis. The origin of her recurrent pancreatitis remains unclear, reason for which genetic testing for mutations in the trypsinogen, trypsin inhibitor and CFTR genes will be performed in case of a third episode.

Goodpasture's disease presenting with acute renal failure

A 15-year-old boy was admitted for vomiting, diarrhea, fatigue, crampy abdominal pain and oliguria. A renal failure was diagnosed (creatinine 2523 μmol/, urea 53,1 mmol/l) with severe aregenerative anemia (80 g/l), metabolic acidosis, hyperkalemia, elevated inflammatory markers and normal platelet count. A nephrotic proteinuria was noticed (350 g/mol). Patient's creatinine was normal 4 months before. The diagnosis of rapidly progressive glomerulonephritis was suspected. C3 and C4 were normal, ANA and ANCA were negative; anti-glomerular basement membrane antibody (anti-GBM) was positive (1/320) which lead to the diagnosis of Goodpasture's disease. Chest X-ray showed bilateral hilar infiltration and CT-scan revealed multiple alveolar haemorrhages, confirmed by broncho-alveolar lavage. Renal ultrasound showed swollen and hyperechogenous kidneys with loss of corticomedullary differentiation. Renal biopsy revealed a global extracapillary necrotising glomerulonephritis, with IgG lining the membrane at immunofluorescence. The patient was treated with continuous venovenous hemodia- filtration, plasmapheresis and immunosuppressive therapy (cyclophosphamid and corticoids) which lead to normalisation of anti-GBM level and favourable respiratory evolution with no sequelae. The renal evolution was unfavourable and the patient developed end stage renal disease and was treated with haemodialysis. Goodpasture's disease is an autoimmune process in which anti-GBM are produced against collagen IV present in the kidneys and pulmonary alveolae, resulting in acute or rapidly progressive glomerulonephritis and altering the pulmonary alveolae. It is a rare disease concerning mostly infants and young adults. Clinical presentation consists in an acute renal failure with proteinuria. Pulmonary symptoms (60-70% of the total cases) are dyspnea, cough, and haemoptysis. Diagnosis is made with the dosage of immunological anti-GBM and with renal biopsy. Factors of poor prognosis are initial oliguria, alteration of >50% of the glomerulus, very high creatinine or need of dialysis. Anti-GBM dosage is used for follow up. Patients are treated with immunosuppressive therapy for 6 to 9 months and plasmapheresis. Few recurrences are seen. Goodpasture's disease should be evoqued whenever a young patient is seen with glomerulonephritis, especially if pulmonary abnormalities are present. The disease requires an aggressive treatment in order to prevent respiratory and kidney failure.

Granulocyte macrophage colony stimulating factor improves mucosal repair in a mouse model of acute colitis (P278)

Background and Aims: Granulocyte-macrophage colonystimulating factor (GM-CSF), a cytokine modulating the number and function of innate immune cells, has been shown to provide symptomatic benefit in some patients with Crohn's disease (CD). Since, it becomes widely appreciated that a timely and spatially regulated action of innate immune cells is critical for tissue regeneration, we tested whether GM-CSF therapy may favours intestinal mucosal repair in the acute mouse model of dextran sulfate sodium (DSS)-induced colitis. Methods: Mice treated with GM-CSF or saline were exposed for 7 days to DSS to induce colitis. On day 5, 7 and 10, mice were subjected to colonoscopy or sacrificed for evaluation of inflammatory reaction and mucosal healing. Results: GM-CSF therapy prevented body weight loss, diarrhea, dampened inflammatory reactions and ameliorated mucosal damages. Mucosal repair improvement in GM-CSF-treated mice was observed from day 7 on both by colonoscopy (ulceration score 1.2}0.3 (GM-CSF-treated) vs 3.1}0.5 (untreated), p = 0.01) and histological analysis (percentage of reepithelialized ulcers 55%}4% (GM-CSF-treated) vs 18%}13% (untreated), p = 0.01). GM-CSF therapy can still improve the colitis when hematopoietic, but not non-hematopoietic cells, are responsive to GM-CSF, as shown in WT→GM-CSFRKO chimeras. Lastly, we observed that GM-CSF-induced promotion of wound healing is associated with a modification of the cellular composition of DSS-induced colonic inflammatory infiltrate, characterized by the reduction of neutrophil numbers and early accumulation of CD11b+Gr1lo myeloid cells. Conclusion: Our study shows that GM-CSF therapy accelerates the complex program leading to tissue repair during acute colitis and suggests that GM-CSF promotion of mucosal repair might contribute to the symptomatic benefits of GM-CSF therapy observed in some CD patients.

Acute toxicity of curative radiotherapy for intermediate risk localized prostate cancer in the EORTC trial 22991

Introduction: EORTC trial 22991 randomly assessed the addition of concomitant and adjuvant short-term hormonal therapy to curative conformal/intensity-modulated radiotherapy (RT) for intermediate risk localized prostate cancer. We report the acute toxicity (assessed weekly during RT) for the organs at risk (genito-urinary (GU) and gastro-intestinal (GI)) in relation to radiation parameters. Material and Methods: Eligibility criteria were age _80 years, PSA _ 50 ng/ml, N0M0 and either tumour stage cT2a (1997 UICC TNM) or cT1b-c combined with PSA_10 ng/ml and/or Gleason score _7. We report toxicity for all eligible patients who received the planned RT with documented acute toxicity (CTCAEv.2) and RT-quality assurance parameters. The RT dose (70 Gy, 74 Gy or 78 Gy) and technique (3DCRT vs IRMT) were per institution choice, the randomization was stratified for institution. Statistical significance was set at 0.05. (ClinicalTrials.gov: NCT00021450) Results: Of 819 randomized patients, 28 were excluded from the analysis (3 with <60 Gy RT, 25 with missing information). Of the 791 analysed patients, 652 (82.4%) were treated with 3D-CRT, 139 with IMRT. In the 3DCRT group, 195 patients (29.9%) were treated with a total prescribed dose of 70 Gy; 376 (57.7%) with 74 Gy and 81 (12.4%) with 78 Gy. In the IMRT group, 28 (20.1%) were treated to a total dose of 74 Gy and 111 (79.9%) with 78 Gy. Overall, only 7 of 791 patients (0.9%) had grade 3 GI toxicity during RT: diarrhea (N = 6), rectal bleeding (N = 1) and proctitis (N = 1). Fifty patients (6.3%) had grade 3 GU toxicity: urinary frequency (N = 38, 4.6%), dysuria (N = 14, 1.7%), urinary retention (N = 11, 1.3%), urinary incontinence (N = 2) and hematuria (N = 1). No grade 4 toxicity was reported. Hormonal treatment did not influence the risk of side effects (p>0.05). The risk of grade _2 GI toxicity significantly correlated to D50%-rectum (p = 0.004) with a cut-of value of 44 Gy. The risk of grade _2 GU toxicity was moderately affected by Dmax-bladder (p = 0.051). Overall, only 14 patients (1.8%) had residual grade 3 toxicities one month after RT. Conclusion: 3D-CRT and IMRT up to 78 Gy is well tolerated. Dmaxbladder and D50%-rectum were related to the risk of grade_2 GU and GI toxicity, respectively. IMRT lowered D50% rectum and Dmax-bladder. An irradiated volume >400 cc for 3D-RT and a dose of 78 Gy, even for IMRT, negatively affected those parameters and increased the risk for toxicity.

Recurrent Acute Pancreatitis and Therapy for Ulcerative Colitis.

Drugs are a rare cause of pancreatitis. Whereas some drugs are well known to induce an attack of pancreatitis, some people may be more prone to develop pancreatitis because of personal susceptibility. We describe a recurrent case of acute pancreatitis after administration of several drugs in a patient with intestinal inflammatory bowel disease that needed to be treated with subsequent antiinflammatory agents. Genetic mutation in the CFTR gene was found in the patient that led us to postulate that CFTR was a trigger for drug-induced acute pancreatitis. In conclusion, genetic analysis should be advised in case of recurrent pancreatitis in patient with intestinal inflammatory bowel disease.

An episode mimicking a versive seizure in acute bilateral pontine stroke.

Pontine ischemia usually results in focal deficits such as hemiparesis, facial palsy, dysarthria, disorders of eye movements or vertigo. Although rarely described, involuntary abnormal movements and "convulsions" due to pontine lesions can also occur. Here we describe a 67-year-old woman with hypertension who presented with a tonic movement mimicking a versive seizure in the acute phase of bilateral pontine ischemia. Post-stroke movement disorders are well known. They are usually associated with supratentorial lesions and rarely occur in the acute phase, but "seizure-like" episodes can be seen in pontine ischemia. Awareness of this rare phenomenon is useful for the management of acute stroke patients.

Acute flare induced by the calcific tendonitis of the rotator cuff: inhibition of IL-1 a potential therapeutic target?

Introduction: Calcific tendonitis of rotator cuff is observed on plainradiographs in 10% of adults, but remains asymptomatic in half thesecases. Sometimes, these calcifications induce acute flares withmassive inflammation similar to gout or CPPD crisis. Analgesics/anti-inflammatory medications are usually not sufficient to controlssymptoms in these situations. Local steroid infiltration with or withoutremoval of the calcific deposition with a needle aspiration may beuseful. A new approach could be IL-1 inhibitors. Indeed, basic calciumphosphate crystals are capable of stimulating the release of activeIL-1β in vitro. These crystals trigger IL-1β release, in an analogousmanner to MSU crystals in acute gout, suggesting that IL-1β blockademay be clinically useful.Case presentation: This report describes a 70-year old woman withacute rest pain of the right shoulder since 48 hours. On examination,we found massive limitations of active and passive movements. Thepatient evaluated, on the visual scale, her symptoms at 10/10 the nightand 5/10 the day. The radiography and showed a rounded, 8 mmcalcification in the subscapularis tendon. The ultrasound aspectrevealed a heterogeneous calcification partially non solid, surroundedby massive inflammation on Doppler. C-reactive protein anderythrocyte sedimentation rate were high (74 mg/ml, 54 mm/hour).The patient received subcutaneous injections of anakinra: 100 mgdaily for 3 days (D1-D3). We evaluated the patient in our consult at dayD1, D2, D3, D7, D16 and by phone at D70.This treatment rapidly relieved the inflammatory symptoms (within afew hours with no relapse). The mobility of the shoulder, the biologicsparameters improved and the size of the calcification as well thedegree of inflammation regressed on ultrasound after 3 days.Conclusion: This is the first report of a woman with an acute flareinduced by calcific tendonitis who received anakinra. IL-1 inhibitionmay be a therapeutic target in calcific tendonitis. To analyse thisresponse more precisely and elaborate definitive conclusions, aprospective pilot study is on-going in our ambulatory institute.

Acute Eosinophilic and Neutrophilic Pneumonia following Transarterial Chemoembolization with Drug-Eluting Beads Loaded with Doxorubicin for Hepatocellular Carcinoma: A Case Report.

At an intermediate or advanced stage, i.e. stage B or C, based on the Barcelona Clinic Liver Cancer classification of hepatocellular carcinoma (HCC), transarterial chemoembolization (TACE) may be offered as a treatment of palliative intent. We report the case of a patient suffering from acute respiratory distress syndrome after TACE with drug-eluting beads loaded with doxorubicin for HCC. To our knowledge, this is the first case described where a bronchoalveolar lavage was performed, and where significant levels of alveolar eosinophilia and neutrophilia were evident, attributed to a pulmonary toxicity of doxorubicin following liver chemoembolization. © 2014 S. Karger AG, Basel.

Neuroendocrine, metabolic, and immune functions during the acute phase response of inflammatory stress in monosodium L-glutamate-damaged, hyperadipose male rat.

In rats, neonatal treatment with monosodium L-glutamate (MSG) induces several metabolic and neuroendocrine abnormalities, which result in hyperadiposity. No data exist, however, regarding neuroendocrine, immune and metabolic responses to acute endotoxemia in the MSG-damaged rat. We studied the consequences of MSG treatment during the acute phase response of inflammatory stress. Neonatal male rats were treated with MSG or vehicle (controls, CTR) and studied at age 90 days. Pituitary, adrenal, adipo-insular axis, immune, metabolic and gonadal functions were explored before and up to 5 h after single sub-lethal i.p. injection of bacterial lipopolysaccharide (LPS; 150 microg/kg). Our results showed that, during the acute phase response of inflammatory stress in MSG rats: (1) the corticotrope-adrenal, leptin, insulin and triglyceride responses were higher than in CTR rats, (2) pro-inflammatory (TNFalpha) cytokine response was impaired and anti-inflammatory (IL-10) cytokine response was normal, and (3) changes in peripheral estradiol and testosterone levels after LPS varied as in CTR rats. These data indicate that metabolic and neroendocrine-immune functions are altered in MSG-damaged rats. Our study also suggests that the enhanced corticotrope-corticoadrenal activity in MSG animals could be responsible, at least in part, for the immune and metabolic derangements characterizing hypothalamic obesity.

Bradykinin in blood and cerebrospinal fluid after acute cerebral lesions: correlations with cerebral edema and intracranial pressure.

Abstract Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain barrier disruption, and brain edema. The aim of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI, 7; SAH,: 10; ICH, 8; ischemic stroke, 4) were collected for up to 8 days after insult. Seven patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. Though all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and early (≤72 h) measurements (n=55; 4.3±6.9 and 5.6±8.9 fmol/mL), compared to 1.2±0.7 fmol/mL of controls (p=0.05 and 0.006). Within 72 h after ictus, patients suffering from TBI (p=0.01), ICH (p=0.001), and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with extent of edema formation (r=0.53; p<0.001) and with ICP (r=0.49; p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with extent of edema evolution and ICP. BK-blocking agents may turn out to be effective remedies in brain injuries.

Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients : does it matter ?

RESUME DE THESEContexte de l'étudeLe but de cette étude est de comparer le drainage percutané (DP) et la chirurgie d'urgence (CU) de la vésicule biliaire (VB) pour le traitement de la cholécystite aiguë lithiasique/alithiasique dans un groupe homogène de patients gravement malades et hospitalisés aux soins intensifs (SI).Patients et méthodeEntre les années 2001 et 2007, tous les patients successivement traités par DP ou CU pour cholécystite aiguë aux SI ont été rétrospectivement analysés. Les cas ont été collectés à partir d'une base de données prospective. Le DP était effectué par voie trans-hépatique et la chirurgie par voie ouverte ou laparoscopique. L'état général des patients et la dysfonction des organes étaient évalués par deux scores validés (SAPS Π et SOFA, respectivement). L'analyse des données s'est portée sur les complications à court terme (morbidité, mortalité hospitalière) et à long terme (récurrence des symptômes) après drainage ou chirurgie en urgence.RésultatsQuarante-deux patients (âge médian 65 ans, 32-94 ans) ont été inclus dans l'étude ; 45% ont eu une CU (10 laparoscopics, 9 voies ouvertes) et 55% un DP (n=23) de la vésicule biliaire. Le DP et la CU ont eu des taux de succès respectifs de 91 et 100% pour la résolution du sepsis lié à la cholécystite aigiie. Après drainage et chirurgie de la VB, la dysfonction des organes secondaire au sepsis s'est résolue dans les 3 jours. Malgré le drainage, deux patients ont nécessité une cholécystectomie en urgence pour cholécystite gangréneuse. Le taux de conversion de la laparoscopic à la voie ouverte était de 20%. La morbidité majeure était de 0% après drainage et 21% après chirurgie en urgence (p=0.034). Finalement, la mortalité hospitalière était similaire (13% après DP vs. 16% après CU, p=1.0) et uniquement liée aux co-morbidités des patients. La récurrence des symptômes liés à la VB n'est apparue que chez des patients initialement drainés pour cholécystite lithiasique.ConclusionsChez les patients gravement malades des soins intensifs, le drainage percutané et la chirurgie en urgence de la VB sont tous deux efficaces pour la résolution d'un sepsis lié à une cholécystite aigiie. Cependant, la chirurgie d'urgence est associée à une morbidité majeure accrue et l'approche par laparoscopic n'est pas toujours réalisable. Le drainage percutané de la VB est donc une modalité de traitement valable, mais nécessite à distance de l'épisode aigu une cholécystectomie par laparoscopic, surtout après une cholécystite lithiasique.

Volvulus de l'intestin grêle comme cause primaire d'abdomen aigu [Volvulus of the small intestine as a cause of primary acute abdomen].

As a cause of small intestine occlusion, volvulus is often a consequence of a band or adhesions. Except in infants, it is rarely the primary cause of symptomatology. Between January 1976 and December 1992, 13 patients (7 women and 6 men, mean age of 56.8 years) were admitted in our department for an acute abdomen due to a spontaneous primary volvulus of the small bowel. Clinical examination and laboratory tests did not help in preoperative diagnosis. All patients underwent an explorative laparotomy. Six patients had had prior abdominal surgery but none of them presented adhesion or band. In 8 patients (62%), detorsion was sufficient. Resection of a segment of small bowel was necessary in 4 patients. Gangrenous of the entire bowel was observed in one patient who rapidly died. Two patients presented minor complications. One patient with Down syndrome died of bronchoaspiration. One patient has been reoperated on one year later for recurrence of the volvulus, and underwent a Noble procedure. We conclude that volvulus of the small bowel is a rare cause of acute abdomen that must be remembered. Early surgery is mandatory to reduce the risk of gangrene, which is known to double the mortality. Laparoscopy will be helpful in early diagnosis and therapy.

Outpatient treatment of acute psychotic episode with neuroleptic infusions: a retrospective study.

In this retrospective pragmatic study, we define the necessary conditions that allow outpatient low dose intravenous neuroleptization, when hospitalization should otherwise be required. Intravenous neuroleptization is infrequently used in the outpatient treatment of acute psychotic decompensation. Rapid tranquilization with high dosage neuroleptics is controversial, and has a high risk of side effects. The indications for and potential advantages of this method in the perspective of a long-term ambulatory treatment are discussed by comparing a group of outpatients treated with infusions to a group of hospitalized patients. The method offers a satisfactory alternative to hospitalization for subjects who are not in imminent danger (current GAF rating between 20 and 40) and whose normal functioning is good (past year GAF rating = 70). Previous repeated hospitalizations favor the choice of hospitalization over infusion. Its potential advantages are the rapid evolution of the condition, with controlled regression but without psychosocial withdrawal, and an improvement in the patient's attitude towards treatment.