Mucosal proctectomy and colo-anal anastomosis for distal ulcerative proctocolitis.

Four patients with long-standing symptomatic ulcerative colitis confined to the left colon and rectum were treated by resection, mucosal proctectomy and colo-anal sleeve anastomosis. There was no operative mortality or anastomotic leakage. Follow-up has ranged from 12 to 66 months (mean 52 months). Loose bowel motions with urgency and frequency of defaecation were troublesome postoperative symptoms. Recurrence of the colitis in the neorectum with extension into the proximal colon occurred in all patients within 3 to 11 months (mean 6 months) of operation. This necessitated total proctocolectomy with ileostomy in three patients (mean 18 months postoperatively). In the fourth patient the recurrence is medically controlled without a stoma more than 5 years after operation. This operation is unsuitable for the treatment of segmental ulcerative proctocolitis.

Duodenitis: a clinical, endoscopic and histopathologic study.

In 219 subjects who presented with dyspepsia the findings of serial endoscopies and mucosal biopsies ranged over periods from three to 12 months (48.9 per cent) and three to 36 months (51.1 per cent) were studied. The minimum number of endoscopies per subject was four. One hundred and sixty-three subjects had one or more periods of treatment with cimetidine. One hundred and thirty-five had a pentagastrin-stimulated maximal acid output measurement. At the initial endoscopy 78 subjects had either non-erosive or erosive duodenitis but no ulcer: 48 per cent of these ultimately developed an ulcer. By the final endoscopy three to 36 months after the initial one, 81.8 per cent of the 219 had shown an ulcer crater at one or more endoscopy examinations. Erosive duodenitis on 276 occasions, was more common than non-erosive duodenitis on 187 occasions. Erosive duodenitis is significantly associated with a raised acid secretory capacity. Serial endoscopies reveal a permutation of association between the different degrees of duodenitis and the presence of one or more ulcer crater. The commonest permutations are non-erosive duodenitis or erosive duodenitis or ulcer (30.1 per cent) and erosive duodenitis or ulcer (23.7 per cent). Ulcer without duodenitis at any time was only seen in 8.2 per cent and duodenitis without an ulcer at any time in 18.3 per cent. Treatment with cimetidine resulted in healing of ulcer craters in 68.5 per cent but resolution of the duodenitis was observed in only 28.1 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Intrapleural perforation of peptic ulcer in association with diaphragmatic hernia.

Two patients with perforation of intrathoracic peptic ulcer in association with paraoesophageal hiatus hernia are described. This unusual complication of hiatus hernia should be considered in the differential diagnosis of patients presenting with spontaneous hydropneumothorax.

Early- and late-onset duodenal ulcers in Chinese and Scots.

Two unselected series of 528 Chinese and 539 Scottish patients with duodenal ulcer were compared. In both races, early-onset patients (symptoms began before age 30 years) in contrast to late-onset patients (symptoms began after age 30 years) constituted significantly more males, more patients with positive familial dyspepsia, more acid hypersecretors, and more gastrointestinal bleeding, but, unlike late-onset patients, there was no significant blood group O predominance, and their females did not have an older onset age than males. Among early-onset patients, Scottish patients developed symptoms at a significantly later age and had significantly more acid hypersecretors than Chinese, whereas among late-onset patients the Scots had significantly more patients with positive familial dyspepsia, in whom the frequency of acid hypersecretion was increased. These findings indicate that (i) early and late-onset duodenal ulcers are distinct subgroups, with many features common to both Chinese and Scots despite different ethnic backgrounds, suggesting the occurrence of similar pathophysiological mechanisms in the two races, (ii) for early-onset disease, these mechanisms appear to operate sooner in the Chinese, (iii) in the Scottish patients, familial late-onset duodenal ulcers with acid hypersecretion form a substantial and distinct subgroup.

Clinical spectrum of "solitary ulcer" of the rectum.

A review of 40 patients with "solitary ulcer" of the rectum confirmed by rectal biopsy has provided information about the natural history of this unusual condition. At presentation, symptoms usually were the passage of blood and mucus per rectum, alteration in bowel habits, and anorectal pain. Solitary or multiple ulcers were found within 13 cm of the anal margin in 27 patients and were usually sited anteriorly; in 13 patients macroscopic ulceration was absent, though the histopathology of the rectal biopsy specimens was otherwise similar. Rectal mucosal prolapse was found in 25 of 29 patients examined specifically for this. Thirty-one patients were followed-up for a mean period of 4.8 yr (range 1-15 yr). In 22 patients, rectal ulceration was observed at presentation. In 14 of these patients, ulceration persisted despite treatment. In 9 patients presenting without macroscopic ulceration, rectal ulcers were not observed during follow-up; thus two patient groups were apparent. Neither medical nor local surgical treatment consistently achieved relief of symptoms or healing of the lesion.

Nature of the inflammatory cell infiltrate in duodenitis.

Counts of lamina propria and intraepithelial cells, lymphoid and polymorphonuclear, have been performed on semithin sections of endoscopic biopsies from the duodenum of patients with ulcer-associated duodenitis, with non-specific duodenitis, and from controls. In both types of duodenitis there were significant increases in lamina propria counts of plasma cells, lymphocytes and eosinophils, and in intraepithelial lymphocyte counts, when compared with controls. In control specimens, neutrophil polymorphs were very infrequent but a substantial neutrophil polymorph infiltration of the epithelium and lamina propria was present in both types of duodenitis. In biopsies from areas of duodenitis scanning electron microscopy showed the presence of cells, which are probably neutrophil polymorphs, on the luminal surface of the mucosa. Abnormalities in cell counts were present only in biopsies taken from visually inflamed areas of the duodenal bulb. These values returned to normal after healing of duodenitis with cimetidine. This study highlights the complex nature of the mucosal cellular infiltrate in in duodenitis, particularly the striking increase in polymorphonuclear leucocytes. Histopathological features of ulcer-associated and non-specific duodenitis are identical.

Shrinkage of the gastric antrum following gastroenterostomy.

Radiological and endoscopic shrinkage of the antrum of the stomach may occur in the elderly and following gastroenterostomy. We describe this in 18 subjects, of whom 17 had a gastroenterostomy with or without vagotomy. Shrinkage can appear within two years of operation and is usually associated with a well-functioning stoma. Reflux biliary gastritis occurred in almost all and in nine out of ten tested the acid secretion in response to pentagastrin was virtually nil. Dyspepsia and bile vomiting were frequent indications for endoscopy. No patient had jejunal ulceration. In the majority radiological interpretation was correct.

The factors determining success or failure of cimetidine treatment of peptic ulcer.

Why a substantial proportion of peptic ulcers fails to heal in clinical trials of drugs remains uncertain. We therefore made a prospective study of biological and social factors which might influence healing. 160 patients who were treated with cimetidine for various types of peptic ulceration were grouped into successes or failures by serial endoscopic review. There were 80 patients in each group. Significant differences between the two groups emerged. The mean age and mean age of onset of symptoms were lower in the failure group. The proportion of manual workers and artisans, the frequency of family history of peptic ulcer, the proportion of smokers, alcohol users, analgesic takers, and the frequency of acid hypersecretion were all higher in the failure group. The "degree" of abuse of smoking, alcohol, and analgesics was also greater in the failures than in the successes. The proportional reduction of maximal acid output after a dose of cimetidine was not different between the groups.

Duodenal mucosal architecture in non-specific and ulcer-associated duodenitis.

This study was done to determine the severity and extent of abnormalities of duodenal mucosal architecture in non-specific (non-ulcerative) and ulcer-associated duodenitis. The effect of successful treatment with cimetidine on these changes has also been assessed. A method of microdissection and measurement of villus height, crypt depth, and mitotic figure count per crypt was applied to endoscopic biopsies from the duodenum. Five groups of patients were studied: untreated ulcer-associated duodenitis, untreated non-specific duodenitis, healed ulcer-associated and non-specific duodenitis after cimetidine treatment, and controls. Significant reduction in villus height, increase in crypt length, and increase in mitotic figure count per crypt were all found in both ulcer-associated and severe non-specific duodenitis as compared with controls. These changes were localised to visually inflamed areas and regressed after healing of these lesions with cimetidine. This is the first quantitative comparison of the architectural features between diseased states in the duodenum and control in the same study. Identical morphological changes in the form of crypt hyperplasia and villus atrophy were demonstrated in areas of non-specific and ulcer-associated duodenitis. No evidence could be found from this study that non-specific duodenitis constitutes a different disease from ulcer-associated duodenitis.