Post-coital haemoperitoneum: a downside to intercourse.

We present the case of a 43-year-old multiparous female patient presenting with post-coital haemoperitoneum secondary to a ruptured uterine fibroid. This is a rare case demonstrating the need to elicit full gynaecological history in patients presenting with an acute abdomen.

Nurse endoscopy in a district general hospital.

INTRODUCTION: This study describes the first full year of independent practice by a newly appointed nurse endoscopist in a district general hospital. PATIENTS AND METHODS: Patients underwent either 'one stop' flexible sigmoidoscopy and barium enema or flexible sigmoidoscopy alone. Barium enema results, video photography, clinical follow-up, and histology were used to validate the results of the flexible sigmoidoscopy. One stop clinic: 161 endoscopies were performed, with 104 female patients (65%), and a mean age of 64 years. There was one failed endoscopy due to poor bowel preparation. Abnormalities were identified in 84% of endoscopies. Flexible sigmoidoscopy detected abnormalities not seen on the barium enema in 28 cases, all of which were polyps (18%). Barium enema identified one abnormality within reach of the flexible sigmoidoscope not identified at endoscopy (small polyp in sigmoid; 1%). Elective flexible sigmoidoscopy list: 121 endoscopies were performed, with 65 female patients (54%), and a mean age of 59 years. There were two failed endoscopy procedures, both attributed to poor bowel preparation. Two-thirds of patients had an abnormality on investigation. There were no complications in either group of patients. CONCLUSIONS: The nurse-led endoscopy service has been successfully initiated with a high completion rate for flexible sigmoidoscopies. All significant conditions were identified with 99% sensitivity. Nurse endoscopy is a safe, useful and practical procedure in the setting of this district general hospital.

Implications of a sclerotherapy program for the medical and surgical care of bleeding in portal hypertension.

The results of endoscopic sclerotherapy are promising and, at first sight, this technique offers a relatively simple and widely available method of achieving definitive control and preventing rebleeding from the esophageal varices. While it is an attractive option to operation, there is a small but significant group of patients, both at initial presentation and follow-up examination, in whom sclerotherapy is inappropriate. It remains to be determined whether shunt operation or a gastric vascularization procedure is superior. It must be remembered that surgical intervention may be required for a number of nonvariceal complications which may arise in patients with portal hypertension. Despite the apparent simplicity of endoscopic sclerotherapy, the management of these patients unquestionably requires a team of physicians, surgeons and nurses with back-up facilities from other personnel who are experienced in this problem, if mortality is to be kept to a minimum. The management of bleeding esophageal varices requires considerably more than a simple injection of sclerosant into a varix and a chronic sclerotherapy program imposes a large and inevitably increasing workload on a gastroenterologic unit.

Dilatation of benign oesophageal strictures in the outpatient department.

Maloney's mercury weighted dilators have been used to dilate benign oesophageal strictures in 109 patients in the outpatient department. A total of 524 dilatations have been performed. Following dilatation two patients had a small haematemesis but there have been no oesophageal perforations. Maloney's dilators can be used in the outpatient department effectively to dilate benign oesophageal strictures and the risk of complications is low.

Controlled trial of the Grassi (pH) intraoperative test for completion of proximal gastric vagotomy.

Forty-eight patients undergoing PGV for duodenal ulcer were randomized to Grassi test (24) or no test (24). Operations were performed by surgeons who were Fellows of the Royal College of Surgeons trained in the technique of PGV and every effort was made to complete the vagotomy if the test was positive. Patients were assessed by standard pentagastrin test preoperatively and postoperatively. The two groups were closely matched for age (Grassi 48, non-Grassi 43), sex (Grassi 20 males; non-Grassi, 21 males), preoperative BAO (6.4 +/- 1.2 S.E.M. millimols hydrogen ions per hour and 6.6 +/- 0.9 S.E.M. millimols hydrogen ions per hour) and preoperative PAO (45.5 +/- 2.1 S.E.M. millimols hydrogen ions per hour and 40.5 +/- 2.6 S.E.M. millimols hydrogen ions per hour). Postoperatively, the BAO was 1.2 +/- 0.4 S.E.M. millimols hydrogen ions per hour for the Grassi group and 0.8 +/- 0.2 S.E.M. millimol hydrogen ions per hour. The postoperative PAO (pg) for the Grassi group was 19.1 +/- 0.9 S.E.M. millimols hydrogen ions per hour and for the non-Grassi group, it was 19.5 +/- 1.9 S.E.M. millimols hydrogen ions per hour. The mean reduction in PAO (pg) were 57.0 +/- 4.3 per cent for the Grassi group and 51 +/- 4 per cent for the non-Grassi group, but two patients in the non-Grassi group had a reduction of less than 10 per cent, one of whom has had recurrent symptoms at three months. Eight Grassi and four non-Grassi patients had reductions of greater than 65 per cent. The mean operating was 110.0 +/- 6.8 minutes for the Grassi patients and 87.0 +/- 3.1 for the non-Grassi patients.

Venous distension in the diabetic neuropathic foot (physical sign of arteriovenous shunting).

A new physical sign is described in the feet of a group of diabetic patients with ulcerating neuropathic problems, in which major venous distension of the veins on the dorsum of the foot and lower calf is seen. Elevation of the leg is required to an average height of 32.3 cm to cause collapse of these distended veins. It is suggested that this clinical sign indicates the presence of arteriovenous shunting in such neuropathic legs, and as such is a simple and useful measure of this abnormality.

Surgery for thyrotoxicosis.

Recent reports have suggested the use of radio-iodine for the treatment of all cases of thyrotoxicosis. This paper evaluates the results of 627 patients undergoing subtotal thyroidectomy with a mean follow-up of 5 X 8 years. The most common complications were hypothyroidism (26 X 6 per cent) and recurrent thyrotoxicosis (2 X 6 per cent). Permanent hypocalcaemia occurred in 8 cases (1 X 4 per cent) and one patient developed a permanent, though asymptomatic, unilateral cord palsy (0 X 2 per cent). Ultimately all patients receiving radio-iodine appear to become hypothyroid and there is continued worry about possible thyroid malignancy. Almost 70 per cent of our cases were free of complications and euthyroid and we therefore believe that surgery remains the treatment of choice for thyrotoxicosis. We also discuss the difference in results between Graves disease and toxic multinodular goitre.

Genital oedema in patients treated by continuous ambulatory peritoneal dialysis: an unusual presentation of inguinal hernia.

Four patients receiving continuous ambulatory peritoneal dialysis presented with scrotal or labial oedema but no detectable cough impulse. Two of the patients later developed clinical evidence of inguinal hernia, and in the other two inguinal hernias were found at operation. These cases suggest that genital oedema occurring in a patient receiving continuous ambulatory peritoneal dialysis is a sign of a small inguinal hernia which may not be detectable clinically.

A modified prognostic index based upon nutritional measurements.

This paper describes a formula which, on solution, derives a prognostic index (PI) for predicting surgical complications using an anthropometric measurement and serum protein levels which may be obtained easily and rapidly. The formula was applied to three groups of patients, firstly 106 patients undergoing major surgical resection, secondly to 16 patients admitted for minor surgery to assess a normal range, and thirdly 10 patients undergoing total parenteral nutrition. In patients undergoing major surgical resection the prognostic index was significantly greater in those patients developing complications than in the control group and a good predictor of the risk of complications. The index uses nutritional measurements to predict complications rather than being a measurement of nutritional status and is therefore a poor monitor of the efficacy of nutritional therapy.

Acute abdominal complications of systemic lupus erythematosus.

Four patients with acute abdominal complications of systemic lupus erythematosus requiring laparotomy are presented. The complications consisted of intestinal ischaemia, without perforation, in 3 patients and omental infarction in the fourth. In 2 patients the abdominal emergency was the first manifestation of the collagen disease. Tissue removed from 3 patients showed a marked vasculitis on histological examination. The pathogenesis and management of acute abdominal complications of systemic lupus erythematosus are discussed and the literature reviewed.