Preparation, premedication, and surveillance.

The main criteria for assessing conscious sedation (perhaps now more correctly termed "moderate sedation/analgesia") continue to be patient satisfaction and comfort, short duration, amnesia, and above all, patient safety. The problems reviewed last year - including the increasing pressure on endoscopy units to perform yet more procedures, reduce costs, and achieve shorter patient turn-around times - certainly have not gone away. Studies reviewed this year suggest that although many endoscopic procedures, such as oesophagogastroduodenoscopy (OGD), colonoscopy, and endoscopic ultrasonography (EUS) can indeed be performed without intravenous sedation, many patients still prefer to be sedated. Further papers on the possible role of ultrathin endoscopes in unsedated OGD are reviewed here. A study in Italy comparing virtual computed-tomographic (CT) colonography and conventional colonoscopy suggests that unsedated colonoscopy is unlikely to meet with wide acceptance. Audits of colonoscopy in both the United States and the United Kingdom suggest that there is still a long way to go before caecal intubation rates of more than 90 % are regularly attained. The evidence suggests that some endoscopists are using larger doses of a midazolam and pethidine combination than are generally recommended (particularly in elderly patients), and sedation-related deaths are still occurring. Impressively large clinical studies, particularly those from Switzerland, on the use of propofol administered by nonanaesthetists are leading to reconsideration of the earlier view that propofol should only be used by anaesthetists. If propofol is to be used more widely and become an agent administered by endoscopists (or nursing staff), then considerable improvements in the standard of airways management will be needed. Several new studies relating to bowel-cleansing agents and the use of a carbohydrate/electrolyte "cholera mixture" to prevent the associated intravascular volume contraction have been published. Warm water is a cheap and effective way of reducing colonic spasm during colonoscopy, and intraluminal peppermint oil is a good antispasmodic in the stomach as well as the colon. Sedation should still be regarded as one part of an overall "endoscopy package". Finally, more attention needs to be given to patients' complaints regarding what are often considered by endoscopists to be "trivial complications" if the patients are to have a positive experience of their examination that will lead to them being prepared to come back a second time.

Premedication, preparation, and surveillance.

The vigorous debate over whom to sedate, when to sedate, and how to sedate shows no sign of running out of steam. There is a general consensus that patients should be more involved in the decision-making process for the sedation "menu". A move away from the take-it-or-leave-it attitude of all or nothing to an "à la carte" choice is to be encouraged. A new textbook and several further guidelines have appeared. The particular problems associated with sedating the elderly are briefly presented. The pros and cons of using local pharyngeal anaesthesia are discussed. Enthusiasm for the use of intravenous propofol is gathering momentum, despite continuing worries about its safety in the hands of the nonanaesthetist. For many endoscopists, the combination of a benzodiazepine plus (or minus) an opioid with which they are most familiar is still the best compromise in terms of efficacy, cost, and safety. Fatal drug-induced cardiopulmonary complications continue to occur, despite a general trend toward using smaller doses of sedation than we did 5 - 10 years ago. Monitoring techniques that are at present considered as research tools may one day become commonplace. These include: the use of an electroencephalography parameter known as bispectral analysis; transcutaneous CO(2) measurement; and a modified continuous capnographic waveform trace to monitor ventilatory effort. Bispectral analysis may be of use in monitoring central nervous system depression and helping to distinguish between conscious sedation and deep sedation. If the measurement of CO(2) levels, either transcutaneously or in breath samples, was as easy and inexpensive as measuring SpO(2) with a pulse oximeter, then undoubtedly such technology would enhance the early detection of sedative-induced hypoventilation and apnoea. Further evidence regarding droperidol's possible role in conscious sedation is presented. Pain during colonoscopy remains a problem, and the possible role for intraluminal injection of peppermint oil, as well as the value of variable-stiffness colonoscopes, in reducing the need for intravenous sedation is discussed. Case reports of hyponatraemic encephalopathy and hypocalcaemic tetany as complications of oral bowel preparation are presented, as is the challenge associated with adequate bowel preparation in diabetic patients.

Experience with 'triple' anti-Helicobacter pylori eradication therapy: side effects and the importance of testing the pre-treatment bacterial isolate for metronidazole resistance.

At the 1990 World Congresses of Gastroenterology, the Working Party on Helicobacter pylori (H. pylori) recommended that, in suitable patients, the bacterium should be eradicated using a therapeutic regimen comprising a bismuth salt, tetracycline and metronidazole for two weeks. We have treated 40 patients infected with H. pylori with 'triple' therapy consisting of 120 mg tripotassium dicitrato bismuthate q.d.s., 500 mg tetracycline q.d.s. and 400 mg metronidazole t.d.s. for two weeks. The success rate, in terms of bacterial eradication, was 19/21 (90.5%) in patients with metronidazole-sensitive organisms, compared with only 6/19 (31.6%) in patients whose H. pylori were resistant to metronidazole (P less than 0.01). Side effects, particularly diarrhoea and vomiting/nausea, were common: 23/40 patients reported such symptoms during the 14-day course of therapy. Fifteen of these 23 patients completed the entire 14-day course, although suffering from significant side effects, while the remaining eight patients had to discontinue the treatment because side effects became intolerable. If a form of triple therapy is going to be widely used to eradicate H. pylori infection, the regimen will have to be simpler, shorter, produce fewer side effects and be more effective in patients with metronidazole-resistant bacteria.

Helicobacter pylori infection treated with a tripotassium dicitrato bismuthate and metronidazole combination.

Seventy-two patients with H. pylori infection in their antral mucosa took part in the study. Forty-three received metronidazole 400 mg t.d.s. for two weeks, plus De-Nol tabs 2 b.d. for four weeks, and the remaining 29 patients received metronidazole 400 mg t.d.s. for two weeks plus De-Nol liquid 5 ml q.d.s. for four weeks. Seven of 57 H. pylori isolates were found to have pre-treatment metronidazole resistance. Success, in terms of eradication of H. pylori, was assessed using a one-month post-treatment 14C urea breath test. Successful eradication of H. pylori was achieved in 72% and 79%, respectively, of the metronidazole/De-Nol tablet and metronidazole/De-Nol liquid groups. These figures increased to 87% and 84%, respectively, if the patients whose organisms were known to be metronidazole-sensitive were considered in isolation. H. pylori was successfully eradicated in only one of seven patients with a metronidazole-resistant organism.

Skeletal applications of videofluoroscopy.

The use of skeletal videofluoroscopy is spreading as new applications emerge for coupling the fluoroscope with the video cassette recorder to obtain detailed information on moving anatomy. This review compiles the findings of an extensive literature search and summarizes the current state of videofluoroscopy knowledge. It traces the development of this imaging tool, beginning with cineradiography and its early investigations into cervical spine motion in the 1950s. Videofluoroscopy is presently used to evaluate the entire spine and other areas of the skeletal system, as well as diverse systems throughout the body. Because it is the only imaging technique capable of visualizing actual joint motion in real time, it provides details on movement mechanics not available through other methods. Along with presenting current applications of videofluoroscopy, this review points to future research needs.

Stones in the common bile duct: experience with medical dissolution therapy.

Thirty-one patients with radiolucent common bile duct stones received medical treatment. Nineteen had Rowachol, a terpene preparation, eight (42%) achieving complete stone disappearance within 3 to 48 months. Fifteen (including 3 of the above) took Rowachol with bile acid (chenodeoxycholic in 11, ursodeoxycholic in 4) for 3 to 60 months: 11 (73%) achieved complete dissolution within 18 months. Persistent symptoms and complications settled on conservative management: 8 (25%) patients required admission (2 biliary colic, 1 obstructive jaundice, 4 cholangitis, 1 pancreatitis). One patient died of a myocardial infarction during recovery from pancreatitis; the other continued treatment, 2 achieving complete dissolution/disappearance. Oral dissolution therapy with Rowachol and bile acids should be considered when endoscopic sphincterotomy or surgery is not feasible, but careful attention to potential complications is required while stones persist.

Delayed release peppermint oil capsules (Colpermin) for the spastic colon syndrome: a pharmacokinetic study.

Excretion of menthol (as glucuronide) from orally ingested peppermint oil contained in Colpermin was compared with oil contained in two soft gelatine capsules. Total 24 h urinary excretion of menthol was similar in the two formulations in healthy volunteers, but peak menthol excretion levels were lower and excretion delayed with Colpermin. Menthol excretion was reduced in ileostomy patients who took Colpermin and moderate amounts of unmetabolised menthol were recovered from the ileostomy effluent. This is consistent with Colpermin being a delayed-release form of peppermint oil.

Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation.

Thirty patients with radiolucent stones in a radiologically functioning gall bladder were treated for up to two years with a combination of Rowachol (one capsule twice daily), a mixture of cyclic monoterpenes, and chenodeoxycholic acid (7.0-10.5 mg/kg/day). The patients were not selected for body weight or size of stones. All complete dissolutions diagnosed by oral cholecystography were confirmed or refuted by ultrasound examination. Control of symptoms was excellent, only one patient withdrawing from the study because of persistent biliary pain. No evidence of hepatotoxicity was detected biochemically, and diarrhoea due to chenodeoxycholic acid was minimal at this dose. Stones disappeared completely in 11 patients (37%) within one year and in 15 (50%) within two years. These results compared favourably with those obtained with similar doses of chenodeoxycholic acid alone, in particular those of the National Co-operative Gallstone Study (complete dissolution in 13.5% of patients at two years). Treatment with a combination of medium dose chenodeoxycholic acid with Rowachol for radiolucent gall stones is economical, effective, and likely to minimise persistent symptoms and adverse effects of treatment.

Elevation of serum high density lipoprotein cholesterol by rowachol, a proprietary mixture of six pure monoterpenes.

Rowachol, a proprietary choleretic containing 6 pure monoterpenes markedly elevates serum HDL cholesterol (SHDL-C) concentrations in man. The concentration of SHDL-C showed a progressive increase in 16 patients treated with 6-9 capsules of Rowachol daily for periods of 2-28 weeks. There was no accompanying significant change in the concentrations of serum total cholesterol or triglyceride. In view of the significant inverse relationship between SHDL-C concentration and the risk of developing ischaemic heart disease, it is suggested that Rowachol and possibly other terpenes merit further investigation as possible therapeutic agents in the prevention and treatment of atheroma.

Rowachol--a possible treatment for cholesterol gallstones.

It has been claimed that Rowachol, a proprietary choleretic, is occasionally successful in the treatment of gallstones. In gallstone patients we have examined its effect on the lipid composition of (1) samples of fasting gall bladder bile obtained at the time of cholecystectomy, and (2) T-tube bile on the tenth post-operative day. In a dose of two capsules, three times a day for only 48 hours, Rowachol significantly lowered the cholesterol solubility of both gall bladder (P less than 0.001) and T-tube bile (P less than 0.05). Rowachol in a dose of one capsule three times a day for 48 hours did not alter bile composition, while four capsules four times a day for a similar period caused a significant (P less than 0.05) deterioration in biliary lipid composition. The possible mechanisms of action of Rowachol and their therapeutic implications are discussed.