Human cystic echinococcosis in Morocco: Ultrasound screening in the Mid Atlas through an Italian-Moroccan partnership

Background

Cystic echinococcosis (CE) is a neglected parasitic zoonosis with considerable socioeconomic impact on affected pastoral communities. CE is endemic throughout the Mediterranean, including Morocco, where the Mid Atlas is the most prevalent area for both human and animal infection. The highest hospital annual incidence of human CE is recorded in the provinces of Ifrane and El Hajeb. However, hospital-based statistics likely underestimate the real prevalence of infection, as a proportion of cases never reach medical attention or official records.

Methodology/Principal findings

In 2012, a project on clinical management of CE in Morocco was launched with the aims of estimating the prevalence of human abdominal CE in selected rural communes of the above mentioned provinces using ultrasound (US) screening and training local physicians to implement US-based focused assessment and rational clinical management of CE according to the WHO-IWGE Expert Consensus. A total of 5367 people received abdominal US during four campaigns in April-May 2014. During the campaigns, 24 local general practitioners received >24 hours of hands-on training and 143 health education sessions were organized for local communities. We found an overall CE prevalence of 1.9%, with significantly higher values in the rural communes of Ifrane than El Hajeb (2.6% vs 1.3%; p<0.001). CE cysts were predominantly in inactive stage, especially in older age groups. However, active cysts were present also in adults, indicating acquisition of infection at all ages. Province of residence was the only risk factor consistently associated with CE infection.

Conclusions/Significance

Our results show a high prevalence and on-going, likely environmental transmission of CE in the investigated provinces of Morocco, supporting the implementation of control activities in the area by national health authorities and encouraging the acceptance and divulgation of diagnosis and treatment algorithms based on imaging for CE at both national and local level.

Cystic Echinococcosis (CE) is a parasitic infection whose natural domestic cycle develops between dogs and sheep (and other livestock). Human infection is endemic in pastoral communities, where close contact with the dog-sheep cycle occurs. In humans, as well as in livestock, the parasite develops as fluid-filled cyst mainly in the liver. CE is a neglected disease, as it is a disabler without high mortality, it affects mainly poor communities, and requires complex and expensive clinical management and long-term integrated public health control strategies. The prevalence of infection in an area is often unknown or largely underestimated, therefore the problem is perceived as not important. In Morocco, the Mid Atlas is the most prevalent area for human and animal infection. We performed an ultrasound survey on 5,367 people in Ifrane and El Hajeb provinces, and found an overall prevalence of 1.9%. CE cysts were predominantly inactive, however, active cysts were present also in adults. Our results show a high prevalence and on-going transmission of CE, encouraging the prompt strengthening and complete implementation of control activities envisaged by Moroccan health authorities in the area and the adoption of diagnosis and treatment algorithms based on imaging at both national and local level, to avoid a risk-associated and expensive treatment of inactive cysts.

Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking

Waterpipe tobacco usage is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world, waterpipe usage surpasses cigarette smoking. Waterpipes and cigarettes are both mechanisms for inhalation of tobacco smoke and therefore have serious health consequences. However, because of the many differences between the two products, prevention and control strategies that have proven effective for cigarettes may not transfer readily to waterpipe. This report highlights the differences between waterpipes and cigarettes in toxicant exposure and physiologic effects, patterns of use, social norms, the extent of evidence, and the policy environment. There is little evidence to date around effective interventions for waterpipe prevention and control. The current state of evidence for intervention to curb or control waterpipe is at ground zero and critically needs attention from both scientists and policy makers. National and global efforts aimed at cigarette prevention have succeeded, particularly in developed countries. We suggest the time has come to harness what we know works for cigarette prevention and control and adapt it to tackle the growing epidemic of waterpipe tobacco use.

Long-Term Results of Percutaneous Management of Liver Hydatid Cysts: - Experience of a University Hospital in Endemic Region

Background and objective: Surgery was considered for years the standard treatment for all stages of liver hydatid cysts (LHC). Percutaneous treatment has becomes a fast, reliable and more efficient method in selected cases. The purpose of this study is to evaluate the effectiveness of percutaneous treatment of LHC on the basis of our department long-term results. Patients and Methods: This study includes all patients who benefited from percutaneous treatment for LHC from December 1998 to April 2012. Puncture aspiration, injection, and re-aspiration (PAIR) were used for hydatid cysts smaller than 6 cm. Larger cysts, infected cysts and those with biliary fistula were treated by puncture associated to drainage (PA-PD). Absolute alcohol was used as sclerosing agent. Reduction of the size of the cyst more than 50%, pseudo-tumour echo pattern and disappearance of the cyst at the follow-up were retained as criteria of treatment efficacy. Results: Two hundred thirty patients (136 female and 94 male; mean age: 35 years old) with 278 LHC underwent percutaneous treatment. Mean initial cyst diameter was 76.8 mm [20-180 mm]. According to Gharbi's classification, types I and II LHC accounted for 74% and 25% respectively. Fourteen patients (6%) presented with an infected cavity and 27 patients (12%) had a biliary fistula at diagnosis (12%). PA-PD was initially performedin 23 patients. No mortality, abdominal dissemination, or tract seeding occurred. Minor complications like urticaria, cutaneous rash and fever were reported in 24 patients (10%). One case of anaphylactic shock was reported with good evolution. Mean hospitalization time was 3 days ± 1.5 for uncomplicated cases and 16.5 days± 4.2 for complicated cases. 229 out of 230 patients were cured, whereas one recurrence has been reported. Conclusion: Percutaneous treatmentis efficient and safe and offers complete cure in selected patients with the advantage of short hospitalization. Keywords: Drainage, Hydatid Cyst, Liver, Morocco, Percutaneous Puncture, Ultrasound (US)

Hepatocellular carcinoma screening is indicated even after sustained virological response: -Moroccan University Hospital Experience-

Introduction: Hepatitis C is the first aetiologic agent for HCC in Morocco. Antiviral treatment reduces the risk of developing HCC in patients with chronic hepatitis C but few cases of HCC have been still reported. We aimed to define population with high risk of HCC occurrence, confirm the protective role of SVR and to identify predictive factors of developing HCC after SVR. We'll try to present suggestions about screening strategies (indications and interval) after antiviral therapy according to level of HCC occurrence risk. Patients and Methods: We included all patients with chronic hepatitis C treated in our department from January 2002 to April 2010. We compare HCV-treated patients with no developed HCC to HCC population using khi-2 and Fisher Exact analysis. Results: 369 patients treated for hepatitis C were considered, and 20 HCC were reported. The risk of HCC occurrence was not significant according to gender and genotypes. Advanced age and severe fibrosis were significant risk factors. HCC was reported in 2.3% of sustained virological responders versus 12.5% of non responders. SVR is a significant protective factor. Conclusion: In our series, 5% of previously treated HCV carriers developed HCC and 2.3% of sustained virological responders developed. Achieving SVR after antiviral therapy is a protective factor. Advanced age (> 50 y. o), severe fibrosis (F>2) and lack of SVR at HCV diagnosis are predictive factors of HCC development in treated patients. Regular bi-annual ultrasonography screening should be indicated necessarily in patients with advanced fibrosis stage (F3- F4) even after SVR, particularly when co-morbid conditions are associated (advanced age, NASH, diabetes mellitus,...). Screening interval in sustained virological responders with reduced fibrosis stage may be limited to annual surveillance. Establishing guidelines about consensual strategy to survey sustained virological responders is now necessary especially with high rates of SVR and the extension of treatment indications in era of DAA drugs. Keywords: Hepatocellular Carcinoma (HCC), Screening, Sustained Virological Response (SVR)

TP53 R72P polymorphism modulates DNA methylation in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is characterized by widespread epidemiological and molecular heterogeneity. Previous work showed that in the western part of North Africa, a region of low incidence of HCC, mutations are scarce for this tumor type. As epigenetic changes are considered possible surrogates to mutations in human cancers, we decided, thus, to characterize DNA methylation in HCC from North-African patients.

METHODS

A set of 11 loci was investigated in a series of 45 tumor specimens using methylation-specific and combined-bisulfite restriction assay PCR. Results obtained on clinical samples were subsequently validated in liver cancer cell lines.

RESULTS

DNA methylation at tumor suppressor loci is significantly higher in samples displaying chromosome instability. More importantly, DNA methylation was significantly higher in Arg/Arg when compared to Pro/Pro genotype carriers at codon 72 rs1042522 of TP53 (65% vs 20% methylated loci, p = 0.0006), a polymorphism already known to affect somatic mutation rate in human carcinomas. In vitro experiments in cell lines indicated that enzymes controlling DNA methylation were differentially regulated by codon 72 Arg or Pro isoforms of p53. Furthermore, the Arg72-carrying version of p53 was shown to re-methylate DNA more rapidly than the pro-harboring isoform. Finally, Pro-carrying cell lines were shown to be significantly more resistant to decitabine treatment (two-fold, p = 0.005).

CONCLUSIONS

Our data suggest that Arg72Pro polymorphism in a WT p53 context may act as a primary driver of epigenetic changes in HCC. It suggests, in addition, that rs1042522 genotype may predict sensitivity to epigenetic-targeted therapy. This model of liver tumorigenesis that associates low penetrance genetic predisposition to epigenetic changes emerges from a region of low HCC incidence and it may, therefore, apply essentially to population living in similar areas. Surveys on populations submitted to highly mutagenic conditions as perinatally-acquired chronic hepatitis B or aflatoxin B1 exposure remained to be conducted to validate our observations as a general model.

Can video aids increase the validity of patient consent?

The objective of this study is to identify the value of using video to communicate and share information with patients, and assess the role of video in aiding decision-making and consent in urogynaecological surgery. The patients with the need for urogynaecological surgery who were seen in Weston Hospital from November 2003 to December 2008 were offered a video of the proposed procedure to watch prior to decision-making and consenting. Patients were then sent a questionnaire assessing the role of the video in their understanding of the need for and method of the procedure, and the impact of this on their decision-making. A total of 96 questionnaires were sent out, and 71 forms were returned and analysed. Our study shows that women's understanding of the method and purpose of their operation was significantly increased by using the video.

Variability in the precore and core promoter regions of HBV strains in Morocco: characterization and impact on liver disease progression

Background

Hepatitis B virus (HBV) is one of the most common human pathogens that cause aggressive hepatitis and advanced liver disease (AdLD), including liver cirrhosis and Hepatocellular Carcinoma. The persistence of active HBV replication and liver damage after the loss of hepatitis B e antigen (HBeAg) has been frequently associated with mutations in the pre-core (pre-C) and core promoter (CP) regions of HBV genome that abolish or reduce HBeAg expression. The purpose of this study was to assess the prevalence of pre-C and CP mutations and their impact on the subsequent course of liver disease in Morocco.

Methods/Principal Findings

A cohort of 186 patients with HBeAg-negative chronic HBV infection was studied (81 inactive carriers, 69 with active chronic hepatitis, 36 with AdLD). Pre-C and CP mutations were analyzed by PCR-direct sequencing method. The pre-C stop codon G1896A mutation was the most frequent (83.9%) and was associated with a lower risk of AdLD development (OR, 0.4; 95% CI, 0.15–1.04; p = 0.04). HBV-DNA levels in patients with G1896A were not significantly different from the other patients carrying wild-type strains (p = 0.84). CP mutations C1653T, T1753V, A1762T/G1764A, and C1766T/T1768A were associated with higher HBV-DNA level and increased liver disease severity. Multiple logistic regression analysis showed that older age (≥40 years), male sex, high viral load (>4.3 log₁₀ IU/mL) and CP mutations C1653T, T1753V, A1762T/G1764A, and C1766T/T1768A were independent risk factors for AdLD development. Combination of these mutations was significantly associated with AdLD (OR, 7.52; 95% CI, 4.8–8; p<0.0001).

Conclusions

This study shows for the first time the association of HBV viral load and CP mutations with the severity of liver disease in Moroccan HBV chronic carriers. The examination of CP mutations alone or in combination could be helpful for prediction of the clinical outcome.

Associations of genetic variants in the transcriptional coactivators EP300 and PCAF with hepatocellular carcinoma

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) is a common cause of death by cancer worldwide. In Morocco, HCC is characterized by few mutations and a mild chromosome instability suggesting that epigenetic changes may represent the driving force of tumorigenesis in the region. Recently, three studies looked for an association between EP300 or PCAF polymorphisms and cancer but there is a conspicuous lack of data regarding these histone acetyltransferase (HAT) variants and HCC development. The aim of the current study was to assess the impact of the Ile997Val in EP300 and Asn386Ser in PCAF polymorphisms on the risk of HCC.

MATERIALS AND METHODS

We performed a case-control study comparing 94 cases with HCC and 220 matching controls. Sequencing methods were used to determine the genotype at the Ile997Val and Asn386Ser on EP300 and PCAF.

RESULTS

We found an overall association between genotypes Val/Val in EP300 and HCC risk (OR, 3.03; 95% CI, 1.08-8.47; P=0.028). Population stratifications revealed a trend or significantly higher risks of HCC development for women and HCV-negative patients carrying the EP300 Val/Val genotype (OR, 4.06; 95% CI, 0.71-23.36; P=0.09 and OR, 4.48; 95% CI, 1.04-19.14; P=0.02, respectively). The PCAF Ser/Ser genotype at codon 386 was more frequent in HCC cases than in control group (P=0.03). We observed trends for higher risk of HCC among men and/or HCV-negative patients carrying Ser/Ser genotype when compared with controls (OR, 10.62; 95% CI, 0.50-225.13 and OR, 11.78; 95% CI, 0.47-295.56, respectively).

CONCLUSION

It appears that variants of the transcriptional coactivator genes (EP300 and PCAF) may influence HCC risk in populations with low mutations or chromosomal instability rates. Additional surveys are warranted to confirm this first report.

Acute upper gastro-intestinal bleeding in morocco: what have changed?

Objective. In the present study, we aimed to investigate epidemiological, clinical, and etiological characteristics of acute upper gastro-intestinal bleeding. Materials and Methods. This retrospective study was conducted between January 2003 and December 2008. It concerned all cases of acute upper gastroduodenal bleeding benefited from an urgent gastro-intestinal endoscopy in our department in Morocco. Characteristics of patients were evaluated in terms of age, gender, medical history, presenting symptoms, results of rectal and clinical examinations, and endoscopy findings. Results. 1389 cases were registered. As 66% of the patients were male, 34% were female. Mean age was 49. 12% of patients had a history of previous hemorrhage, and 26% had a history of NSAID and aspirin use. Endoscopy was performed in 96%. The gastroduodenal ulcer was the main etiology in 38%, followed by gastritis and duodenitis in 32.5%. Conclusion. AUGIB is still a frequent pathology, threatening patients' life. NSAID and aspirin are still the major risk factors. Their impact due to peptic ulcer remains stable in our country.

Hepatitis B genotypes/subgenotypes and MHR variants among Moroccan chronic carriers

OBJECTIVES

The aim of this study was to determine the prevalence of Hepatitis B Virus (HBV) genotypes, subgenotypes, HBV surface antigen (HBsAg) subtypes and naturally occurring mutations in Major Hydrophilic region (MHR) of HBsAg among Moroccan patients with chronic HBV infection.

METHODS

The study included 200 patients chronically infected with HBV. The HBV genotypes, subgenotypes, HBsAg subtypes and MHR variants were determined by direct sequencing of the HBV surface (S) gene and phylogenetic analysis.

RESULTS

The S gene was successfully amplified in 134 patients. The mean age was 40.6 ± 12.2 years. Genotype D was predominant (90%, 120/134) and genotype A was less frequent (10%, 14/134). Genotype D strains belonged to subgenotypes D7 (70.8%, 85/120), D1 (25.8%, 31/120) and D2 (0.9%, 1/120). Three strains (2.5%) could not be classified in any subgenotype of genotype D. All genotype A strains belonged to subgenotype A2. HBsAg subtypes found were ayw2 (82.1%, 110/134), adw2 (10.4%, 14/134), ayw3 (3%, 4/134) and ayw4 (3%, 4/134). The global prevalence of MHR variants was 15% (20/134) with substitution P120T/S the most frequent (3.7%, 5/134). The occurrence of MHR variants was significantly associated with advancing age (>40 years) (p = 0.003) and independent of sex, HBeAg status, viral load, genotype, subgenotype and HBsAg subtype.

CONCLUSIONS

This study provides the first description of predominance of HBV subgenotype D7/subtype ayw2 among Moroccan HBV chronic carriers. It also showed a significant prevalence of naturally occurring MHR variants in Morocco.

First multicenter study for risk factors for hepatocellular carcinoma development in North Africa

AIM

To assess the role of the major risk factors for hepatocellular carcinoma (HCC) development in the western part of North Africa.

METHODS

A multicenter case control study was conducted in Tunisia, Morocco and Algeria in collaboration with Pasteur Institutes in these countries. A total of 164 patients with HCC and 250 control subjects without hepatic diseases were included. Prevalences of HBsAg, anti-hepatitis C virus (HCV) and diabetes were assessed. HCV and HBV genotyping were performed for anti-HCV and HBsAg positive patients.

RESULTS

The mean age of patients was 62 ± 10 years old for a 1.5 M:F sex ratio. Sixty percent of HCC patients were positive for anti-HCV and 17.9% for HBsAg. Diabetes was detected in 18% of cases. Odd ratio (OR) and 95% confidence intervals (CI) were 32.0 (15.8 - 65.0), 7.2 (3.2 - 16.1) and 8.0 (3.1 - 20.0) for anti-HCV, HBsAg and diabetes respectively. Multivariate analysis indicated that the three studied factors were independent. 1b HCV genotype and D HBV genotype were predominant in HCC patients. HCV was the only risk factor significantly associated with an excess of cirrhosis (90% vs 68% for all other risk factors collectively, P = 0.00168). Excessive alcohol consumption was reliably established for 19 (17.6%) cases among the 108 HCC patients for whom data is available.

CONCLUSION

HCV and HBV infections and diabetes are the main determinants of HCC development in North Africa. An active surveillance and secondary prevention programs for patients with chronic hepatitis and nutrition-associated metabolic liver diseases are the most important steps to reduce the risk of HCC in the region.

Bioactivity as an options value of sea cucumbers in the Egyptian Red Sea

The utility of a species can be divided into its direct, indirect, and options values. In the marine environment, direct consumptive values predominate and often lead to overexploitation at the expense of significant options values derived through bioprospecting for natural products. We surveyed the waters of the Egyptian Red Sea coast (Gulf of Aqaba [north] and the Red Sea [south]) for species of sea cucumbers and analyzed extracts from species for a range of bioactivities with potential biomedical applications. All habitat types were surveyed within these regions. We found 22 species of sea cucumber of which two, Holothuria fuscogilva and Holothuria flavomaculata, were recorded in Egypt for the first time. Although none of the species identified were unique to the Gulf of Aqaba, 10 species were only found in the Red Sea sector. Bioassay results showed that although no species had antibacterial activity, most extracts exhibited activity against Candida and Leishmania but were most active against a LoVo mammalian carcinoma cell line. Our most significant finding was the intraspecific variation in bioactivity in individuals collected from different habitat types and sectors of the coast. This variation may reflect the effect of environment on secondary metabolite production or may indicate significant genetic diversity between populations within a species. Our results indicate a potentially significant options value to sea cucumbers through bioprospecting. Given the importance of economic development in countries such as Egypt and the perceived low conservation value of invertebrates such as sea cucumbers, the linking of these factors to conservation is vital for the maintenance and sustainable exploitation of these animals.

Obtaining informed consent: observations from community research with refugee and impoverished youth

This paper presents challenges facing researchers in applying basic ethical principles while conducting research with youth in a developing country context. A discussion of the cultural and social challenges to adherence to the elements of informed consent: disclosure, comprehension, capacity, voluntariness and consent is presented. The authors argue that the current institutional review board requirements that guide research reflect values and stem from western contexts that may not be fully applicable to non-western contexts. More dialogue is needed among researchers in developing world contexts on challenges of and possible revisions to requirements that maintain respect for persons, beneficence, autonomy and justice, particularly when working with youth.

Patterns of tobacco use: results from the 2005 Global Youth Tobacco Survey in Lebanon

We report the results of the 2005 Global Youth Tobacco Survey in Lebanon which investigated the self-reported attitudes and behaviours related to tobacco among 3314 Lebanese schoolchildren aged 13-15 years. Current use of any tobacco product was 60.1%; the use of cigarettes was 10% and other tobacco products 59% with male predominance in all areas. About 80% of students lived in homes where others smoked. About 60% of current smokers wanted to quit smoking and 51% of all students had learned about the effects of tobacco in class. Over a quarter (27%) thought that boys who smoke have more friends and 17% believed that smoking makes boys more attractive. The majority of students had been exposed to both anti-smoking media messages and pro-smoking advertisements.

Genomic stability prevails in North-African hepatocellular carcinomas

The molecular pathogenesis of hepatocellular carcinoma, a tumour characterized by a vast clinical heterogeneity, remains unexplored outside Europe and Eastern Asia. We analysed by direct sequencing or loss of heterozygosity assay, the common targets of genomic alterations in 42 hepatocellular carcinomas collected in western North-Africa. Overall, genomic instability was uncommon, allelic losses affecting mostly chromosomes 1p, 4q, 8p and 17p (24-28% of cases). CTNNB1 and TP53 were infrequently mutated (9 and 17% of cases, respectively). Surprisingly, TP53 mutation R249S, diagnostic of aflatoxin B1 exposure, usually frequent in Africa, was exceptional (one case), indicating that in western North-Africa, hepatocellular carcinoma genetics differs markedly from that of the remainder of the continent.

Selection of apoptosis-deficient adenovirus E4orf4 mutants in Saccharomyces cerevisiae

Adenovirus E4orf4 protein has been shown to induce p53-independent, protein phosphatase 2A (PP2A)-dependent apoptosis in transformed cells. Furthermore, E4orf4 also induces toxicity in Saccharomyces cerevisiae in a PP2A-dependent manner (D. Kornitzer and T. Kleinberger, submitted for publication). In this work, we utilized yeast cells to select for nonapoptotic E4orf4 mutants which, in turn, were shown to possess a diminished ability to bind PP2A. The success of this selection system will provide additional apoptosis-relevant mutants for E4orf4 research and strongly supports the relevance of E4orf4-induced toxicity in S. cerevisiae to E4orf4-induced apoptosis in mammalian cells.

[A rare cause of lower digestive tract bleeding: angiodysplasia of the small bowel]

Angiodysplasia of the small bowel is an uncommon condition which causes lower digestive tract bleeding. The aim of this report was to clear up some of the particular problems and to stree the difficulty of diagnosis in low digestive bleeding. We report the case of a 34-year-old patient who had melena for ten years. Explorations performed, mostly endoscopy, had not given the diagnosis. Angiodysplasia was diagnosed on selective angiogram performed during a hemorrhagic episode. The literature emphasizes the difficulty of diagnosis. Selective angiography allows topographic diagnosis and simplifies surgical cure which should be as elective as possible with segmental enterectomy. Different studies on small bowel angiodysplasia have found the disease in both sexes at equivalent frequencies by age. Low digestive hemorrhage is a constant sign. Pathogenesis remains a question of debate: acquired or congenital histology shows an essentially submucosal vessel pastes ectasia. We emphasize the importance of selective angiography for exploring bleeding of the lower digestive tract of unknown cause.

Is the rectum a conduit or storage organ?

The rectum is claimed to be a conduit; as it receives the stools, the rectoanal inhibitory reflex is evoked and defecation occurs. However, in many healthy subjects, stools could be palpated in the rectum by digital rectal examination (DRE) without the subject feeling the desire to defecate. The purpose of this communication is to study whether the rectum is a conduit or a storage organ. The study comprised 48 healthy volunteers (mean age 38.4 +/- 15.8 SD years; 30 men, 18 women). Number of stools per week was recorded and DRE was carried out followed by air enema radiography. The subjects had a normal stool frequency of 7.8 +/- 1.4 per week. Most of them last defecated a mean of 6.2 +/- 3.4 hours prior to the test. Stools were palpated in the lower rectum by DRE in 31/48 subjects and by radiography in 12/16. DRE correlated with radiologic examination in 9/12 subjects; in 3 of them, DRE revealed an empty rectum while radiography showed stools in the upper rectum. The 17 subjects with an empty rectum had their last defecation 5.2 +/- 3.6 hours before DRE, and the 31 subjects with palpable stools 15.6 +/- 12.9 hours. In conclusion, the rectum might be considered not simply as a conduit for stools but also as a storage organ. This occurs when it receives from the sigmoid colon an amount of stools too small to evoke the defecation reflex, or when this reflex is neglected due to unfavorable circumstances of defecation.

[Liver abscess: diagnosis and treatment. Study of a series of 22 cases]

Twenty-two cases of abscess of the liver are reported. Eighteen were due to pyogenic organisms and four to amebas. The diagnosis was established based on clinical and laboratory evaluations and, above all, on ultrasonography with aspiration of the lesion. The causative organism was recovered from the aspirate in 33.3% of cases. Seventeen patients were treated by percutaneous aspiration. Two patients required insertion of a drain because of a biliary fistula. The success rate of percutaneous aspiration with or without drainage was 88.2% in our series. The two patients who had surgery had loculated abscesses with thick pus. In conclusion, the diagnosis and treatment of hepatic abscesses have benefited from advances in imaging techniques; in particular, aspiration or drainage can be performed simply under ultrasonographic guidance.

[The pseudo-tumoral form of hepatic tuberculosis. Five case reports]

The authors report 5 cases of pseudotumoral tuberculosis of the liver. They essentially involved young men from disadvantaged socio-economic backgrounds. Clinically, poor general condition with massive weight loss was constant, while pyrexia and hepatomegaly were sometimes absent. Hepatobiliary ultrasonography revealed hypoechogenic or even anechogenic lesions between 1.5 and 3.5 cm in diameter. Diagnostic confirmation was histological after needle biopsy. The outcome after antibiotic treatment with or without drainage, was recovery, with ultrasonographic normalization of the liver, in all patients, with a mean follow-up of 22 months.