Education and training in gastroenterology. Report from the OMGE symposia at the International Congress of Gastroenterology, Lisbon, Portugal, September 1984, and at the 8th World Congress of Gastroenterology, São Paulo, Brazil, September 1986.

Gastroenterology is recognized as a speciality in most countries, especially in Europe and North America. The requirements for being acknowledged as a specialist vary from 1 1/2 to 4 years of training and education in gastroenterology in addition to 1-6 years of training and education in internal medicine/surgery. The requirement of theoretical education varying from 40 to 300 h is practiced in some countries only. In some countries training in endoscopy is separated from gastroenterology. A formal examination and post-specialization training program is required in only some of the countries answering the questionnaire. The number of centres per million inhabitants recognized for training and education also varied greatly. The number of specialists per million inhabitants was 3.6 to 15. In the Middle and Far East the organisation of gastroenterology was much inferior to that in Europe and North America because of insufficient education and organization programs and lack of economic support to perform them. The answers from the gastroenterological associations and personal reporters agreed on the following: A speciality in medical and surgical gastroenterology should be established in all countries around the world. Programs for training and education should be agreed upon in recognized teaching and training institutions of gastroenterology, probably of 3 years' duration in combination with a speciality in internal medicine. A gastroenterologist will in most cases be dealing with other diseases as well. The number of specialists per million inhabitants may be estimated to 10, the exact number not being possible to determine at present. In most countries the post-specialization programs were not required but were offered, a problem that has to be clarified.(ABSTRACT TRUNCATED AT 250 WORDS)

The OMGE multinational inflammatory bowel disease survey 1976-1986. A further report on 3175 cases.

This presentation describes the progress during 1982-1986 of the OMGE Multinational Survey of patients with inflammatory bowel disease. After a brief description of the study design and protocol, the status of the survey in 1986 is presented. In all, 40 centres contributed 3175 cases at that time, data collection being meticulous via previously designed proformata. Diagnostic criteria are next discussed. Little change between 1976 and 1986 is noted, with wide congruence of diagnostic thought, now codified into a simple (and recommended) OMGE diagnostic scoring system. Patients seen prior to 1978 were reviewed in 1986. Where attempted, a follow-up of over 86% was achieved, usually more than 4 years after the original presentation involving no less than 5215 'patient-years' of observed follow-up. Following these overall considerations, details of four subprojects are annexed, each of which was presented as a 'free paper' at the 8th World Congress and concerning, respectively, the changing natural history of IBD, risks of perforation and toxic megacolon in the 1980s, IBD in elderly patients, and features associated with recurrence in Crohn's disease.

The natural history of inflammatory bowel disease: has there been a change in the last 20 years?

This presentation reviews the course and outcome of disease in 2657 cases of inflammatory bowel disease (IBD) registered into the OMGE multinational survey and considers whether there are differences between the natural history of IBD observed in this series and that observed in earlier large-scale series. It is concluded that several such differences exist. The current mortality from ulcerative colitis (4% in 10 years) is similar to that from Crohn's disease and quite different from that recorded in earlier series (over 20% in 10 years). This may be because the disease itself has changed (the proportion of patient-years with severe attack has fallen from 14.6% in the 1960s to under 10% in the present series). It may also be because of increasing use of maintenance sulphasalazine (since the attack rate per year is significantly lower than patients on maintenance therapy). Finally, cancer is now equally common in Crohn's disease and ulcerative colitis patients; whilst perforation is more common in Crohn's disease (possibly because ulcerative colitis patients now tend to come to surgery earlier).

Perforation of the intestine in inflammatory bowel disease. An OMGE survey.

This presentation assesses the incidence of perforation of the intestine in patients with inflammatory bowel disease by reviewing the incidence of this complication in a total of 3175 patients from the OMGE inflammatory bowel disease multi-national survey. Amongst 1928 patients with ulcerative colitis, perforation was noted in only 5 (0.3%), which is much lower than in previous series (from 1% to 2%). By contrast, 19 of 1247 patients with Crohn's disease had perforated (1.5%). The survey thus suggests that the incidence of perforation in ulcerative colitis has fallen in the last 2 decades, probably as a result of the widespread implementation of early surgery. The risk of perforation of Crohn's disease remains quite high.

Inflammatory bowel disease in the elderly patient.

Studies of inflammatory bowel disease (IBD) undertaken in the 1960s reported a highly unfavourable course and prognosis in patients over the age of 60 years. However, recent surveys have suggested that the pattern of IBD in the elderly patient is similar to the overall pattern of disease in other age groups. We have, therefore, reviewed data relating to 2657 patients from the OMGE series with particular reference to the pattern of disease in 244 patients (9.1% of the total group) aged over 60 years at the time of registration into the survey. The course and outcome of disease in these 244 patients were similar to other age groups in terms of response to therapy, major complications, and rate of recourse to surgery. However, the death rate in the elderly (2.4%) was higher than that in younger patients (0.8%). We concur with recent studies that the course of IBD is now more favourable in elderly patients than hitherto suspected. The cause is probably multifactorial, involving both a change in therapy and a change in the natural history of the disease.

Factors affecting recurrence after surgery for Crohn's disease.

The prospect of recurrence following surgery for Crohn's disease (CD) poses an important and difficult problem in routine clinical practice. Out of the 1247 CD patients registered in the OMGE multinational inflammatory bowel disease survey, a high proportion came to surgery. A detailed study has been undertaken of 154 patients (77 who did recur matched with 77 who did not recur) who had undergone surgery for CD. An assessment was made which established a 'risk factor' (RF) for each item of patient information. Findings indicated the risk of recurrence to be higher in patients under 20 years both at onset of disease (RF, 2.2:1) and at time of their operation (RF, 2.7:1) and in patients with distal colonic Crohn's disease (RF, 1.8:1). Histopathologic findings, number of previous operations, and symptomatic status prior to operation did not appear to affect the subsequent risk of recurrence. The margin of clearance at operation appeared to affect further recurrence. Amongst patients with 10cm or more margin of clearance (i.e. histopathologically normal bowel) only 21% recurred during follow-up, versus 50% in those with a smaller margin of clearance.

Treatment of reflux oesophagitis with a carbenoxolone/antacid/alginate preparation. A double-blind controlled trial.

Twenty-nine patients were treated with a carbenoxolone/antacid/alginate preparation (Pyrogastrone) and 30 with antacid/alginate alone four times each day for 8 weeks, in a double-blind study, to ascertain the value of carbenoxolone in the treatment of patients with endoscopically confirmed reflux oesophagitis. Symptom review every 2 weeks and endoscopic findings every 4 weeks were converted to a 6-point grading system to facilitate statistical comparison, using a stochastic model for predicting the rate of change in grades during treatment. Carbenoxolone-treated patients showed an 82% improvement in symptom grades over 8 weeks and improved 50% faster (P less than 0.01) than did control patients, who showed a 63% improvement. Endoscopic improvement was not significantly different in the first 4 weeks, although healing was better maintained in carbenoxolone-treated patients during the second 4 weeks (P less than 0.05). At the low doses used (5 X 20 mg daily) no significant side effects of carbenoxolone were encountered. Pyrogastrone should be considered as a therapeutic alternative in patients who fail to respond to routine management with antacids.

The antisecretory effects of RP 40 749 in patients with previous duodenal ulcer.

Thirteen male patients with a history of duodenal ulcer were given 150 mg RP 40 749 or placebo tablets at bedtime in a double-blind crossover study. The medication was given for two periods of 10 days with an 11-day wash-out period between. pH and pepsin concentrations were determined each hour in aspirates of gastric juice for 24 h on day 1, 10, 22, 31, and a 2-h collection of gastric juice was examined in the middle of the treatment and wash-out periods. At defined hours blood samples were examined for gastrin, somatostatin, and pancreatic polypeptide (PP) by radioimmunological methods, and concentrations of RP 40 749 were determined in blood and gastric juice. Meals were served at fixed hours on days 1, 10, 22, and 31. After treatment with RP 40 749 a highly significant elevation of pH was found after the 1st day compared with placebo, most pronounced during night hours. The pepsin activity was slightly elevated. The serum concentrations of gastrin were increased and those of somatostatin and PP decreased during the first 3-4 h after medication, with a subsequent normalization. No side effects were observed.

Introductory remarks on Crohn's disease. Observations from the OMGE studies.

The first report of Crohn's disease (Cd) or regional enterocolitis may be that of Combe and Saunders from 1806. The first nicely described series of cases with this disease was given by Crohn, Ginzburg and Oppenheimer in 1932. Since then numerous studies have given details of Cd from centres and defined areas. The OMGE-studies give information about the presentation, severity and treatment of Cd and ulcerative colitis (uc) around the world. In a total series of 987 cases with Cd and 1,670 with uc, it was found that the accuracy of the clinical diagnosis was 86 per cent and after adding specialized examinations as endoscopy with biopsy etc. the accuracy became 93 per cent. The ratio between uc and Cd varied from 10:1 to 1:4, and the best indices for Cd were in order pulse rate, temperature, systemic complications, severe pain, distention and bowel habits. In about 60 p. cent of Cd drugs were used, salazopyrine was given to 35 per cent and systemic steroids to 23.5 per cent of cases. 25 per cent of Cd came to surgery, the early postoperative mortality being 3.8 per cent. 17 per cent of patients with Cd were at the first treatment symptomfree compared to 30 per cent of those with uc. The overall mortality was 1 per cent. A four years follow-up of 866 patients, showed that the diagnosis had changed in only 0.7 per cent from Cd to uc, and in 2.6 per cent from uc to Cd.(ABSTRACT TRUNCATED AT 250 WORDS)

The distribution of polyps in the large intestine.

The distribution of polyps of the large intestine was investigated. Comparisons were made between results of autopsy studies and a clinical study consisting of 114 consecutively resected polyps. The shift from distal to proximal predominance of adenomas with increasing age from the 50 to the 80 year age group in autopsy studies, was in accordance with the high frequency of adenomas in the distal part of the large intestine in the prospective clinical study, mean 60 years of age. The present clinical study showed a high frequency of adenomas among men, whereas a tendency towards larger polyps and more polyps larger than 10 mm was seen for women. The present examination confirms the reported discrepancy between a high prevalence of adenomas compared to a much lower prevalence of cancer. Thus, the present results emphasize the need for further studies to gain information on risk factors in polyps or individuals predisposed for malignancy of the large intestine.

Occult faecal blood loss determined by a 51Cr method and chemical tests in patients referred for colonoscopy.

In 67 patients referred for colonoscopy the faecal blood loss was determined by a 51Cr method and 7 chemical tests. For patients with negative colonoscopy (no. = 10), colorectal polyps (no. = 24), rectal cancer (no. = 8), or colonic cancer (no. = 12), the median 51Cr-determined faecal blood loss was 0.67, 0.74, 1.26, and 2.18 ml/24 h, respectively. For all chemical tests the results were highly influenced by the upper time limit for a positive reaction. Mixing of faecal specimens before testing proved unimportant. Fecatwin sensitive showed more positive tests in delayed compared with immediate analyses (p less than 0.01). Of cases of colorectal polyps, tetramethylbenzidine (TMB) tests including Hemo-Fec Test could detect half, the benzidine test 2 of 5. Fecatwin sensitive and Hemoccult II 1 of 4, and Fecatwin 1 of 24. Of cases of colorectal cancer, TMB tests, the benzidine test, Fecatwin sensitive, Hemoccult, and Fecatwin could detect about 85%, 85%, 85%, 80%, and 45%, respectively. All chemical tests detected faecal blood loss from colorectal lesions more easily than from gastric lesions.

The O.M.G.E. Multinational Inflammatory Bowel Disease Survey 1976-1982. A further report on 2,657 cases.

This presentation describes the progress during 1978-1982 of the O.M.G.E. Multinational Survey of patients with inflammatory bowel disease. After a brief description of the study design and protocol, and review of results up to 1978, the status of the survey in 1982 is presented. In all, 35 centres contributed 2,657 cases at that time; data collection being meticulous via previously designed proformata. Diagnostic criteria are next discussed. Little change between 1978 and 1982 is noted, with wide variation in the UC/CD ratio for individual centres, but continuing evidence of a congruence of diagnostic thought, now codified into a simple (and recommended) O.M.G.E. Scoring System. Patients seen prior to 1978 were reviewed in 1982. Where attempted, a follow-up of over 90% was achieved, usually more than four years after the original presentation. Interesting data resulted. The stability of diagnosis was high, only 3.4% of patient diagnoses changing between 1978 and 1982. The mortality of Crohn's disease patients, usually unrelated to surgery, was higher than that of ulcerative colitis patents, and the cancer risk identical in the two groups. Most patients were well at review; but--though asymptomatic--were usually on prophylactice therapy, most commonly with salazopyrine. Finally, problems in assessing severity and activity of disease are discussed, and joint studies between O.M.G.W. and the newly formed International Organisation for the Study of I.B.D. described. As regards Crohn's disease, several 'indices of activity' already exist; when tested on a set of 200 O.M.G.E. patients, indices did not correlate well with each other, or with patient prognosis. Further studies are suggested during 1982-1986.

Premedication in upper gastrointestinal endoscopy. A comparison of glucagon and atropine given in combination with diazepam and pethidine.

The effects of four premedication regimes on clinical variables regarded as important in upper gastrointestinal endoscopy were evaluated in a double-blind randomized study. The drug combinations were diazepam/glucagon, diazepam/atropine, pethidine/glucagon, and pethidine/atropine. No significant difference was observed among the combinations of regimes or between diazepam and pethidine or between glucagon and atropine with regard to the variables duration of examination, vomiting, secretion and maximal pyloric opening. Pethidine was more effective than diazepam in reducing salivation and pyloric reflux. Glucagon was more effective than atropine in reducing motility and reflux and was also superior to atropine with regard to diagnostic accuracy. Glucagon caused less subjective discomfort than atropine 2 h and 1 day after the investigation.

Comparative study of cimetidine and trimipramine in the short-term treatment of duodenal and gastric ulcer.

Sixty-nine outpatients with endoscopically confirmed duodenal and prepyloric (DU) or gastric ulcers (GU) completed a 4-week double-blind trial with either cimetidine, 1 g/day, or trimipramine, 50 mg/day. Ulcer healing was assessed by endoscopy at 4 weeks. At the end of the study 14 of 23 patients with DU treated with cimetidine and 13 of 25 treated with trimipramine had healed ulcers. In the patients with GU 7 of 11 ulcers (cimetidine) and 4 of 10 (trimipramine) healed. The differences in healing rates between the two treatment groups were not statistically significant, either in DU and GU groups separately or in the total material. The number of pain attacks per week decreased and the symptoms improved significantly in both treatment groups in DU, GU, and totally. Both drugs were well tolerated, but two patients in each treatment group developed a slight increase in serum transaminases. No serious side effects occurred. The study suggests trimipramine as an alternative drug to the well-established drug cimetidine in the treatment of duodenal and possibly also of gastric ulcer.

hPP and gastrin response to a liquid meal and oral glucose during prolonged severe exercise, caloric deficit, and sleep deprivation.

Sixteen young healthy military cadets were subjected to prolonged severe exercise, caloric supply deficiency, and sleep deprivation during a 5-day ranger training course. Several cadets complained of gastric discomfort. The fasting and postprandial human pancreatic polypeptide (hPP) and gastrin levels induced by a liquid meal (no. = 9) and peroral glucose load (no. = 7) were measured during normal school activities (control) and on the third day during the course. The results showed that the fasting level of hhPP was significantly increased during the course. Both during meal and glucose stimulation the hPP level during the course was significantly higher at most registrations than during control conditions. The fasting level of gastrin was not changed. The maximal level of gastrin during meal stimulation was higher during the course than during the control period. Glucose loading, on the other hand, did not change the gastrin response. The integrated response of hPP and gastrin were not changed during the course either for the liquid meal or for the peroral glucose load.