Variations in the reporting of endoscopies by different endoscopists.

All gastroscopies and colonoscopies performed in two U.K. teaching hospitals over a period of one year were audited to investigate whether endoscopic reporting of gastroscopies and colonoscopies by different endoscopists is consistent. Endoscopic diagnoses were retrieved from the hospitals' endoscopy databases. The results of 1814 colonoscopies and 2127 gastroscopies were analysed using chi2 (Chi squared). The frequency of reporting common diagnoses was variable and the differences between specialist endoscopists were highly significant, including for important conditions such as peptic ulceration (range 2-10%, p = 0.001) and colonic polyps (16-45%, p < 0.001). There is a large variation in the frequency of the diagnoses reported by different endoscopists. This is unlikely to be explained by casemix or chance. This may have major implications for the health of patients. More emphasis must be placed during training on the correct interpretation of endoscopies.

A questionnaire study to assess long-term outcome in patients with abnormal esophageal manometry.

Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, "nutcracker" esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p < or = 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, "nutcracker" esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

Effect of a gluten-free diet on plasma nitric oxide products in coeliac disease.

BACKGROUND: Inducible nitric oxide synthase is expressed in the small intestine of patients with coeliac disease. This produces increased plasma concentration of nitric oxide end products (NOx), most marked in those ingesting gluten. The time-course of change in NOx with a gluten-free diet (GFD) and its correlation with histology and coeliac serology were studied. METHODS: Fasting plasma NOx was determined by the Greiss reaction in 20 coeliac patients at diagnosis and 2, 4 and 6 months after commencing a GFD. Endomysial and gliadin antibodies were checked at the same time. Duodenal biopsies were taken at diagnosis and at 6 months, and then graded according to the Marsh classification. RESULTS: Plasma NOx fell rapidly following the introduction of a GFD (mean before GFD 95.8 microM to 61.5 microM at 2 months), and further still by 6 months (mean = 37.0 microM). Reductions at 2 and 6 months were statistically significant compared with baseline (P < 0.01 and P < 0.005, respectively: Wilcoxon signed ranks test). Plasma NOx was correlated with histological grade initially (P = 0.03: Kruskal-Wallis) but not after 6 months on a GFD (P = 0.24). Coeliac serology correlated poorly with histology. CONCLUSIONS: Plasma NOx falls rapidly following GFD in coeliac disease and is related to histological grade initially. However, values vary widely between individuals, which may limit its use as a clinical tool.