Enprostil, a prostaglandin E2 analogue, in the treatment of duodenal ulcer; a multicentre comparison with cimetidine.

In a multicentre trial, 120 patients with endoscopically diagnosed duodenal ulcer were randomly allocated to treatment with either 35 micrograms enprostil b.d. or 400 mg cimetidine b.d. for up to 6 weeks on a double-blind basis. After 6 weeks, 82% (42/51) of enprostil-treated patients and 92% (44/48) of cimetidine-treated patients were healed. Corresponding healing figures on an intention-to-treat basis were 70% and 76%. No significant differences were detected between treatments with respect to healing rates or symptom control at any time. Side-effects were reported by 14 patients taking enprostil and 17 patients taking cimetidine; none were serious but they resulted in withdrawal of one and two patients respectively. Enprostil was found to be similar in efficacy and tolerance to cimetidine.

Comparison of 40 mg famotidine nightly and 150 mg ranitidine b.d.: ulcer healing and symptom relief in benign gastric ulcer.

Two hundred and eight patients with benign gastric ulcers seen on endoscopy were recruited by 13 hospitals in the United Kingdom and Ireland into this double-blind study. Patients were assigned by pre-randomized schedule to 8 weeks of treatment with either 40 mg famotidine at night or 150 mg ranitidine b.d. Repeat endoscopy confirmed complete ulcer healing in 62 of 77 evaluable patients in the famotidine group (81%) and 58 of 71 in the ranitidine group (82%). The treatments were equally effective in promptly relieving day and night pain. Adverse events were uncommon; dizziness and headaches were the most frequently reported in both groups. In conclusion, night-time famotidine is as effective as twice daily ranitidine in healing benign gastric ulcers and provides similarly rapid symptomatic relief.

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.

Gastroscopy and gastric photography with the Olympus GTF-A.

One hundred patients were examined with the Olympus GTF-A fibregastroscope and gastrocamera. The entire stomach was seen in most cases; the technique permitting this is described in detail. The examination was most rewarding in patients with gastric haemorrhage and when radiology was equivocal. Advantages and disadvantages of the instrument are discussed.

The prognosis and risk of missing malignant disease in patients with unexplained and functional diarrhoea.

One hundred and sixty-three patients who had been diagnosed as suffering from diarrhoea without an organic cause were followed up to assess the risk of missing malignant disease. Three patients with carcinoma, two involving the stomach and one the colon had escaped diagnosis and the reasons for this are given. Prognosis in the others was usually good.

Effect of ranitidine and cimetidine on gastric ulcer healing and recurrence.

Fifty-eight patients with endoscopically confirmed benign gastric ulceration were randomly allocated to treatment with 150 mg ranitidine twice daily, placebo matching ranitidine twice daily, or 200 mg cimetidine three times daily and 400 mg at night. Patients were endoscoped at monthly intervals for up to 3 months, the endoscopist being unaware of the treatment. Significantly more ulcers (p less than 0.05) had healed after 2 months of ranitidine (14 of 18, 78%) and cimetidine (17 of 20, 85%) than with placebo (9 of 20, 45%; p less than 0.05) and after 3 months of ranitidine (15 of 18, 88%) and cimetidine (18 of 20, 90%) than with placebo (11 of 20, 55%; p less than 0.05). Forty-eight patients with healed ulcers were randomly allocated in a double-blind prophylactic study to receive 150 mg ranitidine at night or matching placebo. After 6 months recurrent ulcers were found in 2 of 24 (8%) of patients receiving ranitidine and 10 of 24 (42%) of patients receiving placebo (p less than 0.05). These data indicate that H2-receptor antagonists are significantly better than placebo in healing gastric ulceration and that ranitidine and cimetidine are equally effective. Ranitidine is significantly superior to placebo in preventing gastric ulcer recurrence.

Clinical picture of peptic ulceration diagnosed endoscopically.

Clinical features and laboratory data are presented for 100 patients with benign gastric ulceration and 150 patients with duodenal ulceration confirmed endoscopically in a district general hospital unit. Abdominal pain was the commonest indication for endoscopy, but one third of examinations were performed for acute gastrointestinal haemorrhage. Although the patients were selected by referral for endoscopy their clinical presentation, age, and sex distribution were similar to those reported in previous general surveys. There were no clinical features which clearly distinguished gastric from duodenal ulceration. However, of those with gastric ulceration younger patients more often had distal ulcers and presented with pain, while elderly subjects tended to have high lesser curve involvement and presented with haemorrhage. Moreover, all females presenting with haemorrhage were aged over 50 years, while 6% of males bleeding from gastric ulceration and 40% of males bleeding from duodenal ulceration were under this age. Anaemia when present, except in two premenopausal females, indicated either a recent acute gastrointestinal haemorrhage or a coexistent second diagnosis.

Gastrointestinal endoscopy services--a review of the 70s with predictions for the 80s.

Information obtained from 3 questionnaires circulated to British gastrointestinal endoscopists has been used to trace the development of endoscopy services during the 1970s. Oesophagogastro-duodenoscopy became available in most hospitals; colonoscopy services were slower to develop and endoscopic retrograde cholangio-pancreatography was performed in under 50% of hospitals. Various therapeutic techniques followed the diagnostic procedures and by the end of the decade constituted one of the major areas of growth. The impact of gastrointestinal endoscopy on other disciplines, diagnostic radiology, surgery, pathology and general practice is reviewed. Organizational aspects of endoscopy services with emphasis on staff, premises, instrumentation and finance are discussed. Analysis of the trends during the 70s has allowed some predictions of the likely developments in the 1980s.

The reasons for failure of endoscopic retrograde cholangio-pancreatography in patients with jaundice.

The results of 100 attempts at endoscopic retrograde cholangio-pancreatography (ERCP) performed in patients with jaundice have been reviewed. The examination provided a diagnosis in 75% of cases. The reason for failure to cannulate the correct duct was obstruction at the lower end of the common bile duct in 15 patients and distortion of the duodenum in seven. There was no cause for the failure in only two patients. Even with a perfect technique it will not always be possible to obtain an endoscopic cholangiogram. However, as the commonest cause of failure is obstruction, transhepatic cholangiography should usually succeed when ERCP fails.

A unique apudoma producing the glucagonoma and gastrinoma syndromes.

A patient is described who presented with a 10 year history of intermittent peptic ulcer symptoms and a 3 year history of an undiagnosed skin rash. Investigations indicated raised plasma levels of gastrin, glucagon and pancreatic polypeptide. A single tumour was localised to the pancreas and resected. The tumour had the typical histology of an apudoma, and contained cells which stained for gastrin, glucagon, pancreatic polypeptide and neurotensin.

Vitamin C in the human stomach: relation to gastric pH, gastroduodenal disease, and possible sources.

Fasting gastric juice pH and concentrations of vitamin C in gastric aspirate and plasma were measured in 73 patients undergoing endoscopy. Vitamin C concentrations were significantly lower in those with hypochlorhydria (pH greater than 4; n = 23) compared with those with pH less than or equal to 4 (p less than 0.005) and there was a significant correlation between gastric juice and plasma concentrations (p = 0.002). Patients with normal endoscopic findings had significantly higher intragastric concentrations of vitamin C than those with gastric cancer (p less than 0.001), pernicious anaemia (p less than 0.005), gastric ulcer (p less than 0.01), duodenal ulcer (p less than 0.05), or after gastric surgery (p less than 0.01). There was a strong trend (0.05 less than p less than 0.1) towards lower intragastric concentrations of vitamin C in patients with chronic atrophic gastritis. In vitro, vitamin C concentrations remained stable in acidic but fell significantly over 24 hours in alkaline gastric aspirate. Gastric secretory studies in five volunteers showed that vitamin C concentrations increased significantly after intramuscular pentagastrin. These findings suggest that the low fasting levels of vitamin C in hypochlorhydric gastric juice may be caused by chemical instability and that vitamin C may be secreted by the human stomach.

Duodenal inhibition of gastric secretion by osmotic agents in normal subjects and patients with duodenal ulcer.

Gastric secretion in man is inhibited by the presence in the duodenum of hyperosmolar and hypoosmolar solutions. Both acid and pepsin outputs are affected. There is no change in hydrogen, sodium, or potassium ion concentration in the gastric juice. Pepsin concentration, however, is reduced by all inhibitory stimuli. Inhibition is thought to act directly upon parietal and chief cells, and a possible basis for this mechanism is discussed. The response is similar in control subjects and duodenal ulcer patients; there is in particular no evidence of impaired inhibition in the ulcer group. An anomalous feature is the relatively small inhibition of acid output after hypertonic saline in control subjects compared with the duodenal ulcer patients.

Transient cerebral ischaemic attacks--management and prognosis.

Fifty patients who had recently had a transient ischaemic attack took part in a double-blind cross-over trial of sulphinpyrazone 200 mg 4 times daily against placebo. Each treatment was given for 4 months. The incidence of recurrences was much greater in the initial 4 months but there was no difference between the 2 treatments. A follow-up of 39 of the patients showed that 2 years later 90% of those who had not had a recurrence during the 8 months had suffered no further neurological events whereas of those who did have a recurrence during the study only 47% had no further neurological events.

Adenocarcinoma of the upper small bowel complicating coeliac disease.

Adenocarcinoma of the small intestine complicating coeliac disease is uncommon. Only 14 cases have been reported, and in only one of these was a jejunal biopsy carried out more than eight months before the diagnosis of malignancy. We describe four more patients with this association, all with long histories of coeliac disease, confirmed in three by jejunal biopsy over five years before the diagnosis of malignancy. Important presenting features of carcinoma were abdominal pain, anaemia, occult gastrointestinal bleeding, abdominal mass, and intestinal obstruction, and these were the main indications for operation. After resection of the tumour survival may be prolonged, as evidenced by one of our cases who remains well eight years after surgery.