Sporadic duodenal polyps: classification, investigation, and management.

Sporadic duodenal polyps are uncommon, being found in up to 5% of patients referred for upper gastrointestinal endoscopy. They are often discovered incidentally and are usually asymptomatic. The histological subtype of polyps cannot always be determined on endoscopic appearance alone, and biopsy is advocated. The need for further imaging, endoscopic procedures, surgical resection, and surveillance is determined by the histological features, neoplastic potential and associated symptoms. This review describes the different subtypes of sporadic duodenal polyp: adenomas, hamartomas, gastric metaplasia, inflammatory fibroids, lipomas, leiomyomas, carcinoids, stromal tumors, solitary Peutz-Jeghers polyps, lymphomas, and other rare benign and malignant lesions. It describes the epidemiology, clinical presentation, investigation, management options, and screening and surveillance strategies for each, based on current evidence.

Omission after admission: failure in prescribed medications being given to inpatients.

Prescribing errors are a recognised problem on admission to acute medical wards which may be detrimental to patient care. The authors had anecdotal evidence that prescribed medicines do not always reach patients and the aim of this audit was to quantify this problem. Admission prescription charts on two separate occasions were studied in detail and all drugs prescribed but not given in the first 48 hours were recorded along with the reason given for omission. In total, 271 patient charts were analysed. Of these, 20% of prescriptions affecting 17% of patients did not reach patients. The two dominant reasons for medications not being given to patients were that the medication was not available on the ward (38% of omissions) or that the patient was nil by mouth (32% of omissions). In 10% of cases the patient refused the medication, in 19% no reason for omission was given and in only a minority (0.3%) was the patient off the ward. This audit demonstrates that even when medications are prescribed they are not always given. This may lead to increased morbidity and length of stay. Strategies need to be put in place to reduce this problem. The current system that permits omission of medications with inadequate justification must be revised.

Experience of 5-aminosalicylate nephrotoxicity in the United Kingdom.

AIM: To study 5-aminosalicylate nephrotoxicity in patients with inflammatory bowel disease in the UK. METHODS: A detailed postal questionnaire was sent to all 1298 names in the British Society of Gastroenterology database and 290 consultant members of the Renal Association. The British Society of Gastroenterology reported new cases monthly, the Renal Association 6 monthly. Results were expressed as estimated glomerular filtration rate. RESULTS: Retrospective study: cases--British Society of Gastroenterology:Renal Association 202:87, aged 15-76 years. Median peak (range) creatinine (British Society of Gastroenterology:Renal Association) - 300:301 (78-1200) micromol/L. Prospective study - 59 cases, median age 52 years (M:F ratio: 47:12). Median pre-treatment estimated glomerular filtration rate: 76.9 (123.9-39), at diagnosis 28.4 (80.5-3.6, creatinine range: 92-1361 micromol/L), recovery 46.8 [111.2-end stage renal failure] mL/min/1.73 m2. Recovery of renal function was significantly improved for patients treated for < 12 months [n = 10, median recovery estimated glomerular filtration rate 70.5 (92-26.9) vs. > 12 months 38.4 (111.2-end stage renal failure) mL/min/1.73 m2, P = 0.028]. CONCLUSIONS: Regular monitoring of renal function may allow earlier detection of nephrotoxicity, particularly during the first year of therapy. Based on an inflammatory bowel disease prevalence in the United Kingdom of 412 x 10(5) with about 50% on treatment, we estimate that the incidence of clinical nephrotoxicity in patients taking 5-aminosalicylate therapy is approximately one in 4000 patients/year.

Oral methotrexate in ulcerative colitis.

BACKGROUND: We performed an audit of methotrexate for ulcerative colitis, because efficacy is unclear. Aim : To investigate the role of methotrexate in the management of ulcerative colitis. METHODS: Patients with ulcerative colitis treated with oral methotrexate at the inflammatory bowel disease clinics of Oxford and Wycombe General Hospital, UK, were evaluated. Efficacy was defined by remission (complete steroid withdrawal for >3 months) and response (good, partial or nil, proportionate reduction of steroids). RESULTS: There were 50 patients (42 ulcerative colitis alone; eight had rheumatoid arthritis associated with ulcerative colitis and were analysed separately). Indications for methotrexate in ulcerative colitis alone were azathioprine intolerance (31 of 42) and lack of benefit from azathioprine (11 of 42). The mean dose of methotrexate in ulcerative colitis alone was 19.9 mg/week for a median of 30 weeks (range: 7-395). Remission occurred in 42%. The response was good in 54% and partial in 18%. Side-effects occurred in 23%; 10% stopped treatment because of side-effects. Of those treated with methotrexate because of treatment failure with azathioprine, three of 11 achieved remission, but four came to colectomy within 90 days of starting methotrexate. The colitis remained in remission in seven of eight of those with RA treated with methotrexate and ulcerative colitis (mean dose 15.0 mg/week). CONCLUSION: Oral methotrexate (approximately 20 mg/week) is well-tolerated and moderately effective in steroid-dependent or steroid-refractory patients with ulcerative colitis.

Contrasting liver function test patterns in obstructive jaundice due to biliary strictures [corrected] and stones.

BACKGROUND: Obstructive jaundice is believed to be characterized by abnormalities of alkaline phosphatase (ALP), rather than aspartate transaminase (AST). AIM: To compare liver function tests (LFTs) in obstructive jaundice due to malignant strictures with those of jaundice due to gallstones. METHODS: LFTs were measured immediately before endoscopic retrograde cholangio-pancreatography (ERCP) in 207 jaundiced patients. Group 1 (n = 69) had malignant strictures, group 2 (n = 97) had common bile duct stone(s), and group 3 (n = 41) appeared to have recently passed a stone. LFTs in groups 2 and 3 were also analysed at maximal liver enzyme derangement, maximum hyperbilirubinaemia and during acute pain episodes. RESULTS: Group 1 had higher median bilirubin, AST and ALP levels than groups 2 or 3 (p < 0.001). In group 1, median rise in ALP exceeded that in AST (4.3 x normal upper limit (NUL) vs. 2.6 x NUL, p < 0.01), but in groups 2 and 3, AST and ALP were similarly elevated (both approximately 2 x NUL). At the time of maximum enzyme derangement in groups 2 and 3, median AST elevation (4.4 x NUL, 185 IU/l) exceeded that for ALP (2.4 x NUL, 276 U/l), (p < 0.001), and this was also true at peak hyperbilirubinaemia in these groups (AST 3.6 x NUL, ALP 2.4 x NUL, p < 0.01. Similarly, severe pain episodes in groups 2 and 3 were accompanied by greater elevations in bilirubin and AST, but not ALP, compared with levels at ERCP. DISCUSSION: The conventional wisdom that ALP rises more than AST in obstructive jaundice holds true where the jaundice is due to strictures, but in obstructive stone disease, the rise in AST may equal that in ALP, or even exceed it during maximum jaundice and during painful episodes. Clinicians should consider the possibility of extrahepatic biliary obstruction, even when AST is the predominantly elevated enzyme.

Review article: adrenergic control of motor and secretory function in the gastrointestinal tract.

The role that the sympathetic nervous system plays in modulating physiological processes in the gastrointestinal tract is becoming clearer. It is now known that motor, secretomotor and vasomotor activity are all modulated independently by the system. Adrenoreceptor stimulation appears to reduce intestinal contraction (except at sphincters), both via alpha-receptors which inhibit neurotransmitter release and also by a direct beta-receptor mediated action on smooth muscle. There is also evidence for tonic activity in the beta-adrenergic pathway, since beta-antagonists tend to increase contraction pressures. In animals alpha-receptor-mediated pathways modulate fluid and electrolyte absorption, and alpha-adrenergic agonists enhance net absorption and reduce net secretion. In man there is also evidence for a beta-adrenergic pathway which controls secretomotor function. Carbohydrate absorption appears to be dependent on activity in a beta-adrenergic pathway, although this may be an indirect effect of changes in motor function. The time course of changes of both secretomotor and motor activity, induced by modulating sympathetic or adrenergic input, differ from the vascular changes indicating that the effects occur independently of each other. The gastrointestinal response to stressors is mediated, in part at least, by the sympathetic nervous system. Differences between individuals are likely to prove important. Since the sympathetic nervous system regulates gastrointestinal function both in the basal state and under stressful conditions, it will have effects on pathophysiological responses. Modification of such responses is likely to ameliorate symptoms, as has already been found for alpha-2-adrenergic agonists which have an antidiarrhoeal action.

Are patients' sedation preferences at gastroscopy influenced by preceding patients' decisions?

BACKGROUND: When patients choose sedation or no sedation for gastroscopy, it is unknown whether the decision and experience of preceding patients on the same endoscopy list influence such decisions. AIM: To address this question in an endoscopy unit, where pre- and postprocedure patients are free to communicate. METHODS: The order and sedation decisions of 503 out-patients attending diagnostic gastroscopy lists were analysed. One hundred patients completed a preprocedural questionnaire about sedation preferences. RESULTS: Three hundred and fifteen (63%) patients chose no sedation. Men were more likely to be unsedated, 170 (72%), than women 158 (59%) (chi(2) = 9.1, P < 0.01). Age did not influence decisions. If the first patient on an endoscopy list requested sedation, 36% of subsequent patients were also sedated. This was similar to 38% of subsequently sedated patients on lists where the first patient was unsedated. Similar proportions of subsequent patients requested sedation when comparing lists where the first two patients were both sedated or both unsedated and when comparing lists where the first three patients were all sedated or all unsedated. Ninety per cent of the patients completing preprocedural questionnaires had made sedation choices before arrival; the remaining undecided patients had unsedated endoscopies. CONCLUSIONS: Patients' sedation decisions are not influenced by preceding patients' decisions. Most patients attending for out-patient gastroscopy have already decided about sedation.

The effect of beta-adrenoreceptor agonists and antagonists on fructose absorption in man.

To explore the effect of beta-adrenoreceptor stimulation and blockade on the extraction of monosaccharide from the upper gut, we first established the malabsorption threshold in 26 normal volunteers using a series of test meals containing varying proportions of fructose and glucose. Incomplete small intestinal extraction and consequent arrival of carbohydrate into the caecum was identified by a rise in exhaled breath hydrogen concentration. The malabsorption threshold varied between individuals from 30 to 80 g fructose (median 40 g) but was reproducible within individuals, with 90% agreement of repeat studies. The malabsorption threshold for an individual was unrelated to body height (tau = 0.007, P > 0.05) or weight (tau = 0.003, P > 0.05) but correlated closely with time to onset of the breath hydrogen rise of a standard meal (tau = 0.70, P < 0.001). Administration of the beta-adrenoreceptor antagonist propranolol (160 mg) reduced the quantity of fructose required to exceed the malabsorption threshold from 45, 30-60 (median and range) to 40, 30-50 g (P = 0.03); administration of the beta-adrenoreceptor agonist isoprenaline (0.015 micrograms.kg/min) increased the quantity of fructose required to exceed the malabsorption threshold by 10 g (55 (50-90) g; P < 0.02). The effect of both drugs correlated closely with their transit effect (tau = 0.79, P < 0.01). A beta-adrenoreceptor mediated pathway thus appears to be capable of influencing the extraction of monosaccharide from the small intestine in normal subjects both under resting and stimulated conditions, probably acting via an effect on upper gastrointestinal motility.

Adenomatous colonic polyps are rare in ulcerative colitis.

BACKGROUND: Uncertainty exists as to whether dysplastic polyps in ulcerative colitis should always be managed as dysplasia-associated lesions/masses requiring colectomy, or whether some can be managed by polypectomy. The prevalence of non-inflammatory polyps in ulcerative colitis is unknown. AIM: To compare dysplastic polyp occurrence in patients with ulcerative colitis and in patients without inflammatory bowel disease. METHODS: The clinical, endoscopic and histological records of 150 ulcerative colitis patients (median disease duration, 10 years; 57% with pancolitis) undergoing colonoscopy were scrutinized for any polyp history. Two hundred and five patients undergoing colonoscopy for altered bowel habit, but without features suggestive of polyp presence, were used as a control group. Immunohistochemical staining of flat and polypoid mucosa for p16, beta-catenin, p53 and cyclo-oxygenase-2 was compared in the two groups. RESULTS: Only six (4%) ulcerative colitis patients had ever had dysplastic polyps. Two had single adenomatous polyps proximal to the colitis segment. Of the four patients with dysplastic polyps within colitic mucosa, two were treated endoscopically, but in two the lesions were considered to be dysplasia-associated lesions/masses and colectomy was advised. In contrast, 24 controls had at least one adenomatous polyp (chi(2) = 6.7, P < 0.01). Ten (6.7%) ulcerative colitis patients and 24 (12%) control patients had metaplastic polyps (N.S.). Immunohistochemical staining was not discriminatory. CONCLUSION: Despite the increased cancer risk in long-standing ulcerative colitis, adenomatous polyps arise less frequently in ulcerative colitis patients than in patients without ulcerative colitis.

The effect of alpha-1-adrenoreceptor agonist and antagonist administration on human upper gastrointestinal transit and motility.

To explore the role of alpha-1-adrenoreceptor-mediated pathways on human upper gut motor function in vivo, we studied the effects of the alpha-1-agonist phenylephrine and the alpha-1-antagonist thymoxamine on oro-caecal transit and antroduodenal motor activity. Transit was measured using a standard exhaled-breath hydrogen method, and motility was measured by intraluminal manometry. Oro-caecal transit was unaffected by 80 mg thymoxamine [median 63 min (range 35-164 min) vs. control, 65 min (range 30-155 min), P greater than 0.1]. However, phenylephrine (2.4 micrograms/kg/min) consistently delayed oro-caecal transit time to 103 min (50-215 min), P greater than 0.005. Co-administration of thymoxamine abolished this phenylephrine-induced delay. The mean amplitude of antral postprandial contractions was reduced by phenylephrine from 29 (13-37) to 10 (3-13) mmHg (P less than 0.02). In contrast, neither the pattern nor the mean inter-contraction interval was altered. Responses to phenylephrine in the duodenum were similar to those in the antrum, with reduction in amplitude from 12 (3-18) to 6 (5-13) mmHg without alteration in the pattern or interval between contractions. Nutrient transit through the upper gut can thus be inhibited via activation of an alpha-1-adrenoreceptor-mediated pathway. Failure of alpha-1-antagonist administration to alter oro-caecal transit suggests that this pathway is not tonically active, and it is therefore unlikely to play a major role in nutrient passage under normal circumstances.

Reducing delays in the diagnosis and treatment of Clostridium difficile diarrhoea.

BACKGROUND: The diagnosis of Clostridium difficile diarrhoea is often delayed. AIM: To assess and reduce delays in diagnosis and treatment. DESIGN: Two-part study: retrospective audit then prospective observational. METHODS: The retrospective study audited cases positive for C. difficile culture or toxin A between June 2000 and January 2001. Cases were reviewed regarding demographic characteristics and the timing from onset of symptoms to testing and treatment (n = 27). In the prospective study, efforts were made to increase the awareness of medical staff about C. difficile diarrhoea, and testing for C. difficile toxin A assay was substituted for stool culture and external toxin analysis. Data were prospectively analysed for demographic characteristics and time from onset of symptoms to testing and treatment (n = 24). RESULTS: There were no significant differences in age (76 vs. 78 years), male to female ratio (1:2 vs. 1:4), reason for admission, specialty responsible, or mortality rate (40% vs. 37%) during the presenting admission. Preceding antibiotic use, the combination of antibiotics used and subsequent treatment also did not differ between groups. The time from onset of diarrhoea to sampling was reduced from 4.7 days (range 3-30) to 0.8 days (range 0-5; p

Dissecting intramural haematoma of the oesophagus.

The largest series of patients (n = 10) with dissecting intramural haematoma of the oesophagus is described. The typical features, chest pain with odynophagia or dysphagia and minor haematemesis are usually present but not always elicited at presentation. If elicited, these symptoms should suggest the diagnosis and avoid mistaken attribution to a cardiac origin for the pain. Precipitating factors such as a forced Valsalva manoeuvre cannot be identified in at least half the cases. Early endoscopy is safe, and confirms the diagnosis when an haematoma within the oesophageal wall or the later appearances of a longitudinal ulcer are seen. Dissecting intramural haematoma of the oesophagus has an excellent prognosis when managed conservatively.

Treatment of a symptomatic hepatic cyst by tetracycline hydrochloride instillation sclerosis.

We report the case of an 84-year-old woman with abdominal pain, distension and inferior veno-caval compression due to a large non-parasitic hepatic cyst. She was treated by instillation of tetracycline hydrochloride into the hepatic cyst. Six months after treatment, the patient is asymptomatic, with no reaccumulation of the hepatic cyst. We conclude that symptomatic hepatic cysts may be successfully treated by tetracycline hydrochloride instillation sclerosis.

Dissecting intramural haematoma of the oesophagus.

Dissecting intramural haematoma of the oesophagus is an under-recognized cause of sudden onset chest pain. Diagnosis is aided by the common co-existence of haematemesis, odynophagia, and dysphagia. Oesophagoscopy, barium swallow and cross-sectional radiology are all appropriate modalities of investigation. The latter is useful in excluding aortic dissection from the differential diagnosis. The condition usually follows a benign course with spontaneous healing requiring supportive treatment only. A systematic analysis of all the cases of dissecting intramural haematoma of the oesophagus (DIHO) reported in the worldwide literature reveals that this is essentially a benign condition. Eighty per cent of patients have at least two of the three typical presenting features of chest pain, haematemesis and dysphagia or odynophagia. Forty-nine per cent of cases are associated with sudden pressure changes within the oesophagus (e.g. due to swallowing) or secondary to direct trauma to the oesophagus. A further group appears to arise spontaneously and may be associated with underlying abnormal pressure changes within the oesophagus or a bleeding tendency. Awareness of the condition prevents the pain being mistakenly attributed to a cardiac cause. With conservative management the symptoms usually resolve within 2 weeks of presentation. The only mortality associated with DIHO is due to operative intervention or where there is another underlying life-threatening condition.

Duplex Doppler ultrasound identifies veins suitable for insertion of central feeding catheters.

Central venous access for feeding catheters may prove difficult in patients who have had numerous previous central line insertions or complications. Duplex Doppler ultrasound was used to identify the anatomy and patency of major central veins in 11 patients in whom attempts at obtaining central venous access by an experienced operator had failed at least once and in 40 control subjects. Doppler ultrasound demonstrated the subclavian veins (diameter 12.5 +/- 3.5 mm, mean +/- SE) and internal jugular veins (11 +/- 3.5 mm) in all the control subjects. In the patients, 18 of 44 veins were patent, 11 were small or had low blood flow, and 15 were thrombosed. In 7 patients who required central feeding catheter insertion, a suitable vein was identified and the catheter suitably placed, even in 3 subjects where no central vein was considered normal. Duplex Doppler ultrasonography is a useful technique for identifying veins suitable for the insertion of central venous lines when access has previously proved difficult.

Motor responses of the upper esophageal sphincter and body to intraluminal acid.

1. It is known that contraction of the upper esophageal sphincter (UES) and secondary peristalsis protect the airway and clear the esophagus of refluxed gastric contents. However, the exact nature of the stimulus and the role of acid remain controversial. 2. Secondary peristalsis and UES responses were measured following the intraluminal infusion of 0.1 N hydrochloric acid and equiosmolar NaCl solutions in seven normal volunteers. The protocol consisted of three phases: infusion of increasing volumes (1, 3, 5 and 7 ml per min), infusion of a given volume (7 ml per min) at different stimulation sites and balloon distension. 3. At the proximal esophagus the UES response to both solutions was similar, rising from a basal resting pressure of 30 mmHg to 70 mmHg for both HCl (range 60-85 mmHg) and NaCl (55-85 mmHg). The magnitude of the response decreased as the distance from the UES increased. The level of response decreased to 40 mmHg for both NaCl and HCl (range 30-60 mmHg) at the distal esophagus. These responses were also volume dependent. When the solutions were infused at 7 ml/min into either the proximal or distal esophagus, the sphincter pressure increased with increased volume to 65 mmHg for HCl (range 50-85 mmHg) and 60 mmHg for NaCl (range 50-80 mmHg). Secondary peristalsis was also induced by the two solutions. The level of response again decreased as the distance from the UES increased. This response was also volume dependent. Esophageal distension by a balloon positioned 10 cm below the sphincter induced secondary peristalsis and sphincter response identical to those induced by the infusion of fluid. 4. These results indicate that the principal stimulus for recruitment of the esophageal motor clearance mechanism is intraluminal distension and not necessarily the pressure of intraluminal acid.

Long-term parenteral nutrition: problems with venous access.

Long-term parenteral nutrition requires central venous access, often difficult in patients who have had several central venous catheterizations. Therapy may be complicated by thrombosis and sepsis which may further compromise central access. We report five cases illustrating such difficulties and suggest that these patients be referred early to specialist centres where experienced catheter insertion and management results in a greatly reduced incidence of complications.