Controlled trial of endoscopic injection treatment for bleeding from peptic ulcers with visible vessels.

Controlled trials have shown that bleeding peptic ulcers can be successfully treated by endoscopy and injection of adrenaline, with or without sclerosant. However, these trials have been done in major research centres, and endoscopic treatment of upper gastrointestinal bleeding has not yet become routine in general hospitals. We have done a prospective, randomised, controlled trial of injection treatment for bleeding peptic ulcers in a district general hospital. Between April, 1989, and June, 1991, all patients with acute upper gastrointestinal bleeding (n = 555) underwent endoscopy by an experienced endoscopist within 24 h of admission. 98 patients were found to have an ulcer with a visible vessel, of whom 93 were randomised to injection (n = 48) or standard treatment alone (n = 45). Injection treatment consisted of 1-2 ml of 1 in 10,000 adrenaline injected at four to six sites around the ulcer. Adrenaline and 5% ethanolamine oleate (1-2 ml) were then injected directly into the vessel. The medical team managing the patient was unaware of the endoscopic treatment given. The two groups were similar for age, initial haemoglobin concentration, shock, and ulcer site. Rebleeding (injected 8 [16.7%] vs control 21 [46.7%], p = 0.011) was significantly reduced in treated patients. The treated group also had lower mortality (4 [8.3%] vs 9 [20%]), requirement for surgery (4 [8.3%] vs 8 [17.8%]), and mean blood-transfusion requirement (5 vs 7.5 units). Endoscopic injection treatment in our patients significantly reduced rebleeding rate and may have other benefits. This cheap and widely applicable treatment can be used routinely in the management of patients with bleeding peptic ulcers who are at high risk of rebleeding.

Comparison of endoscopic forceps biopsies and capsule biopsies in determining disaccharidase activity in the duodenum.

Endoscopic biopsy is an accepted technique for obtaining samples of small bowel mucosa for histological examination. In this study a comparison between endoscopic forceps biopsies and capsule biopsies in estimating disaccharidase enzyme activity in the small bowel was evaluated. Disaccharidase levels on 168 consecutive small bowel biopsies obtained by either endoscopic biopsy or capsule biopsy were reviewed retrospectively. There was no significant difference in enzyme activity in samples collected by either method. Another 18 patients had simultaneous endoscopic and capsule biopsies from the second part of the duodenum. Again, there was no difference in enzyme activity between samples collected by either technique at the same level in the duodenum. The disaccharidase activity in forceps biopsies taken from the second part of the duodenum is equivalent to those obtained by capsule biopsy.

Defenestration of hepatic sinusoids as a cause of hyperlipoproteinaemia in alcoholics.

The hepatic sinusoidal endothelium separates sinusoidal blood from hepatocytes; changes in the porosity of this endothelium may affect the passage of chylomicrons into hepatocytes and influence lipid metabolism. Chronic exposure to ethanol reduces the porosity of the endothelium; this mechanism may underlie the hyperlipoproteinaemia observed in some people who drink heavily.

Dientamoeba fragilis: a bowel pathogen?

Although many patients infected with Dientamoeba fragilis suffer gastrointestinal symptoms, controversy still surrounds the pathogenic role of this intestinal protozoan. We describe three patients infected with D fragilis who had gastrointestinal symptoms. In the first patient symptoms resolved with therapy before the protozoan was eradicated from the stool, however in the second, symptoms persisted unabated despite clearing of the organism. In the third patient, symptoms resolution was associated with effective treatment. We discuss the life cycle, diagnosis and treatment of this organism and its role as a pathogen.