Effect of Berkefeld filtration on the binding activity of human gastric juice.

The intrinsic factor content of Berkefeld-filtered human gastric juice has been studied. This appears to vary with the pH at which filtration is carried out and also between individual filters. Significant losses of intrinsic factor may result from filtration and complete loss when filtration is carried out at a low pH. The most suitable pH for filtration appears to be in the range pH 7 to 8.

Chronic active hepatitis: a sixteen year survey at a district general hospital.

Over a period of 16 years (1971-87) all cases of chronic active hepatitis (CAH) diagnosed following liver biopsy have been reviewed to assess incidence, aetiology, outcome and response to treatment. North Tees District serves a population of 210,000 and 26 cases were identified (20 female) age range 9-73 years (median 56 years). Incidence remained constant at 1:100,000/year. Twenty cases (77%) had an immune aetiology. Other aetiologies were hepatitis B virus (HBV) infection, alpha-1AT deficiency, non-A non-B hepatitis and a complex multisystem disease. The median follow-up period was 50 months. There were 7 deaths, three unrelated to liver disease. Survival analysis gives an 86% 5-year survival and 56% 10-year survival. Twenty four patients were treated with steroids (and 6 additionally with azathioprine); 15 (63%) were steroid responsive and 9 were non-responsive. In five patients steroids were successfully discontinued but in 10 patients severe symptomatic relapse occurred on steroid reduction below 7.5-10 mg/day. Steroid non-responders were not typical CAH, 5 with predominantly a rise in alkaline phosphatase, one multisystem disease and one HBV positive. Steroid discontinuation was only possible in one third of the patients responding. Eighteen subjects (69%) were cirrhotic at initial biopsy; 9 had follow-up biopsies, 6 were unchanged but three had progressed to cirrhosis despite apparent steroid responsiveness.

Pneumatic dilatation in the management of achalasia: experience of 45 cases.

A 15-year experience of the management of achalasia is described. Forty-five patients were managed by pneumatic dilatation after sedation with intravenous diazepam. The mean period of observation was 47.1 months. Eighty-six per cent of patients had either no symptoms or only minor symptoms following the procedure. Perforation occurred in four patients (8.8 per cent) and one of these required surgical intervention. The others were managed conservatively. Four cases (8.8 per cent) developed reflux. One patient died of myocardial infarction. Eighty-four per cent of patients needed one dilatation only and no patient required cardiomyotomy. The method is simple and rapid and most patients were discharged within 24 h of the procedure.

Bacterial endocarditis after Hurst bougienage in a patient with a benign oesophageal stricture.

A case of bacterial endocarditis which proved fatal in a 65-year-old edentulous male Caucasian with rheumatic valvular heart disease is reported. This occurred following dilatation of a benign oesophageal stricture with a Hurst mercury bougie. Transient low grade bacteraemia following upper gastrointestinal intubation is well documented but we are not aware of any published reports on bacterial endocarditis following this procedure and the possible implications of this case are discussed.

Management of achalasia of the cardia by forced pneumatic dilatation.

Eighteen patients with achalasia of the cardia diagnosed by radiography, endoscopy, and manometry were subjected to forced pneumatic dilatation under fluoroscopic control. The procedure was uneventful in all but one patient who developed a pneumomediastinum which resolved on conservative management. A satisfactory result was obtained in 16 patients (89%), 10 patients remaining asymptomatic and six patients having mild symptoms only in follow-up periods of up to 10 years. Only two patients have unsatisfactory results, one having developed a peptic stricture and one having a fibrosed incompetent lower oesophageal stricture with moderate reflux. The success rate of forced dilatation is similar to that of cardiomyotomy but, as it is a relatively minor procedure with a low incidence of complications and a short hospital stay, we conclude that there is an important place for forced pneumatic dilatation in the first line management of achalasia of the cardia.

Evidence for a change in neurotransmitter affecting oesophageal motility in Parkinson's disease.

In a study of oesophageal motility in 20 patients with Parkinson's disease, intravenous atropine produced marked disruption of co-ordination in response to swallows, when compared with control subjects. This suggests that cholinergic rather than dopaminergic mechanisms are more important in the control of swallowing in patients with Parkinsonism. No conclusive evidence of peripheral dopamine depletion or autonomic neuropathy was found, although minor changes suggestive of the former were found in severely affected patients.

The incidence and prevalence of inflammatory bowel disease in North Tees Health District.

The experience with inflammatory bowel disease in a stable, defined population in northeast England is described. In this population, the incidence of inflammatory bowel disease was higher than expected. In particular, a high incidence of colorectal and anal Crohn's disease was found. The literature is reviewed in order to identify some of the factors responsible for this unusual prevalence of inflammatory bowel disease in the study population. No explanation for our unexpected findings can be advanced.

The insertion of oesophagogastric tubes in malignant oesophageal strictures: endoscopy or surgery?

Oesophagogastric tubes were inserted into 16 patients with malignant strictures of the distal oesophagus by a method employing the flexible fibreoptic endoscope, and these patients were compared with 28 patients in the same hospital whose tubes were inserted by surgical methods. Four patients (25 per cent) in the endoscopic group died in the immediate post-insertion period as a result of the procedure, compared with 13 patients (45 per cent) in the surgical group. Of the remainder, the majority were mobilized and taking diet on the day following the procedure, and the morbidity associated with the surgical method was not seen in the endoscopic group. It is concluded that the endoscopic insertion of oesophagogastric tubes has advantages over surgical insertion in the palliation of malignant oesophageal strictures.

The incidence of bacteremia after outpatient Hurst bougienage in the management of benign esophageal stricture.

Transient bacteremia occurs in a variety of gastrointestinal procedures. Of 13 patients with a benign esophageal stricture treated as out-patients by the passage of Hurst mercury bougies only one developed transient bacteremia which occurred five minutes after dilation. We do not therefore recommend routine antibiotic prophylaxis for patients undergoing this type of management. Attention should be given to the manner in which dilators are cleaned and stored.

High bile duct cancer: incidence and pattern of investigation in the General Hospital setting.

Between 1 April 1977 and 30 November 1979, 16 cases of high bile duct carcinoma presented at North Tees District Hospital, giving an incidence of one per 40000 population per annum for Teesside. Results of this prospective study emphasize the potential accuracy of preoperative assessment using techniques which should be available in a district general hospital. Ultrasound revealed the site of obstruction in every patient in whom it was used (n = 13), and often indicated a neoplastic aetiology (n = 10). Percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiography (ERC) correctly demonstrated the site of obstruction in each patient and suggested a primary bile duct carcinoma in 12 patients. Although intraoperative cholangiography gave additional information in some patients, it was not sufficiently reliable to dispense with either PTC or ERC. Histological proof of a primary bile duct carcinoma was obtained in 15 patients. In the 10 patients without obvious metastatic disease frozen section analysis was positive in 7, but was negative in 3 patients with multiple strictures where malignant cells were relatively infrequent and were found in the perineural lymphatics on paraffin sections. In this difficult group of patients the approach described eliminates the possibility of a false negative laparotomy, enables careful planning of the necessary surgical technique and also the consideration of nonoperative management.

Massive subcutaneous emphysema following colonoscopy.

A case of massive subcutaneous emphysema following colonoscopic polypectomy is reported. The incidence of colonic perforation following colonoscopy is 0.1% and may be intraperitoneal or retroperitoneal. Intraperitoneal perforation is usually immediately apparent and likely to require urgent surgical exploration. The development of subcutaneous emphysema or a pneumoscrotum suggests a retroperitoneal perforation and in the majority of cases management is conservative. Contrast studies are often unhelpful but plain x-rays may help to distinguish between intraperitoneal and retroperitoneal perforations.

Treatment policy for the management of carcinoma of the oesophagus.

The management of 120 consecutive patients with carcinoma of the oesophagus, treated in a district general hospital over a 10-year period is reviewed. The treatment options were by endoscopic methods, radiotherapy, surgery or a combination of these. Adenocarcinoma was the most frequent histological type (51 per cent) and 41 per cent of patients had squamous carcinoma. In addition to survival the quality of swallowing and the incidence of late complications following the treatment options was assessed. Primary surgery was carried out in 21 cases (operability rate 17.5 per cent) and 81 per cent of these cases were resectable. The overall operative mortality rate was 14.3 per cent (6 per cent in resected cases) and the 5-year survival rate was 9.5 per cent. After primary radiotherapy only 5 per cent of patients survived 2 years. The majority of patients were treated by endoscopic intubation with an overall mortality of 16.6 per cent and a mean survival of 5.5 months. Patients treated surgically experienced the best symptomatic relief and had the lowest incidence of late complications, when compared with those treated differently. However the overall results of surgery were poor and there remains the need to compare the results of surgery and radiotherapy in similar groups of patients.

The MRCP (UK) examination from the patient's point of view.

Each year approximately 3,200 volunteer patients attend the examinations of the Royal College of Physicians in England and Wales. A confidential postal questionnaire concerning patients' experiences and satisfaction was administered to those attending North Tees General Hospital in June 1992 with a 90% response rate. The majority of patients derive some enjoyment from the experience and do not mind being repeatedly examined, some even up to eight times per session; but they do feel neglected if examined only once per session. Twenty-two per cent of first time attenders would have liked to have had more information about the proceedings beforehand.

Endoscopy in the elderly.

The endoscopic experience involving the study of 114 patients in the geriatric age group (65-89 years) in a district general hospital is described. The cases examined were mainly patients with dyspepsia, gastrointestinal blood loss, suspected upper alimentary tract carcinoma or those who had undergone gastric surgery. The procedure was well tolerated and safe. Useful information was obtained in the majority of patients (93 per cent). When the endoscopic and radiological findings were compared the endoscopist and radiologist were in agreement in 55 per cent of the cases examined by both techniques. In the others endoscopy played an essential role in establishing the presence of radiologically undetected or undetectable disease, and in confirming or excluding radiologically doubtful disease.

Endoscopic evaluation of dysphagia in the elderly.

A survey of 100 consecutive endoscopies on elderly patients with suspected obstructive dysphagia is reported. Seventy-eight patients had positive findings and one to three lesions were reported in these cases. Benign stricture of the oesophagus was the commonest finding, and led to active treatment (dilation) in most cases either with Hurst bougies or Eder dilators. Fifteen patients had upper gastro-intestinal malignancy (12 oesophagus, three stomach). All of those with oesophageal carcinoma received some form of active treatment, either in the form of radiotherapy, surgery, dilation or Celestin tube insertion. Six patients with negative endoscopies had diagnoses established by other means and in 14 no cause was identified, but in four of these symptoms settled after endoscopy. The duration of dysphagia was not particularly helpful clinically. Two thirds of 'endoscopically normal' patients had short histories with dysphagia for less than 1 year, as did half of the patients with benign stricture. Most patients who were found to be malignant had experienced dysphagia for only a short time although one patient had a 4-year history! Upper gastro-intestinal endoscopy is a safe and valuable procedure in elderly patients with dysphagia and often leads to positive therapeutic intervention even in quite frail subjects.

Teeside coronary survey--fatality and comparative severity of patients treated at home, in the hospital ward, and in the coronary care unit after myocardial infarction.

An epidemiological survey of myocardial infarction in Teesside County Borough was completed between April 1972 and April 1973. Cases were notified and divided into those who had suffered a 'definite', 'possible', or 'not' myocardial infarction. Severity factors were measured in the 'definite' cases and the distribution of the various factors studied among home, ward, and coronary care unit treated cases. Increasing severity was found to be related to increased fatality. The fatality of patients treated at home was less than that of those treated in the ward or the coronary care unit. Those who survived to be treated at home were not less severe than those who survived in a comparable group to be treated in hospital using the objective criteria described in the assessment of severity. It is emphasised that the results must be interpreted with caution as other essentially subjective criteria not so easily measurable, but which might have been of considerable influence in the assessment of severity, were not measured in this study.

Teesside coronary survey: an epidemiological study of acute attacks of myocardial infarction.

A 12-month epidemiological survey of attacks of acute myocardial infarction was carried out in a large urban population. The incidence and mortality at all ages and in both sexes were examined. Altogether, 1938 attacks were diagnosed--an overall incidence of 4-89 per 1000 population. The 28-day fatality rate was 50-5%. A third of the patients were treated at home and these patients had a lower fatality rate than those in hospital, a difference that could not be attributed to age, sex, or severity of attack. Half of the deaths that were witnessed occurred suddenly and a further 21% occurred within the next two hours. The median time to patients coming under care was about three hours. As used at present, coronary care units are unlikely to improve fatality rates. Future advances in treatment must take place outside hospital and will require re-education of the public and the general practitioner.