Dietary phosphilipids and sterols protective against peptic ulceration.

The prevalence of duodenal ulceration in regions of developing countries with a stable diet is related to the staple food(s) in that diet. A higher prevalence occurs in areas where the diet is principally milled rice, refined wheat or maize, yams, cassava, sweet potato or green bananas, and a lower prevalence in areas where the staple diet is based on unrefined wheat or maize, soya, certain millets or certain pulses. Experiments using animal peptic ulcer models showed that the lipid fraction in foods from the staple diets of low prevalence areas gave protection against both gastric and duodenal ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs), and also promoted healing of ulceration. The protective activity was found to lie in the phospholipid, sterol and sterol ester fractions of the lipid. Amongst individual phospholipids present in the phospholipid fraction, phosphatidyl ethanolamine (cephalin) and phosphatidyl choline (Lecithin) predominated. The sterol fraction showing activity contained ß-sitosterol, stigmasterol and an unidentified isomer of ß-sitosterol. The evidence shows that dietary phytosterols and phospholipids, both individually and in combination, have a protective effect on gastroduodenal mucosa. These findings may prove to be important in the prevention and management of duodenal and gastric ulceration including ulceration due to NSAIDs.

How labile is gastric infection with H pylori?

It is known that patients infected with H pylori can spontaneously become free from infection, and that the reverse change can occur. The time-scale of these conversions is expressed as percentages per year. Since they have been investigated in terms of serology, the changes are called sero-reversion and sero-conversion respectively. Using serological evidence to investigate these phenomena is open to the criticisms that positive serology can be present in the absence of all other evidence of infection, and that a time-lag of 6-12 mo or longer can occur between eradication of the infection and sero-reversion. Investigations using direct evidence of current infection are sparse. The few that exist suggest that some individuals can seroconvert or sero-revert within six to twelve weeks. If these findings are confirmed, it means that some patients have an ability that is variable in time to resist, or spontaneously recover from, H pylori infection. Evidence suggests that the deciding factor of susceptibility is the level of gastric secretion of acid.

Possible absence of Helicobacter pylori in the early stages of duodenal ulceration.

BACKGROUND: Helicobacter pylori is thought to be a cause of duodenal ulceration, but there is some evidence that it is found less often in early than in later disease. AIM: To assess the presence of H. pylori in patients undergoing endoscopy for dyspepsia, with respect to their duration of symptoms. DESIGN: Retrospective case note review. METHODS: Patients were categorized as having a history greater or less than 6 months, and as H. pylori-positive or -negative, using biopsy rapid urease, culture and PCR tests. RESULTS: Thirty-two duodenal ulcer patients with a history >6 months were all H. pylori-positive according to the PCR test; the five with a shorter history were H. pylori-negative. No patient H. pylori-negative by PCR was positive by the other tests. DISCUSSION: H. pylori was (at least) less commonly present before 6 months. It is possible that H. pylori, although nearly always present after 6 months, is not present at the onset of the disease. Confirmation of this finding would imply that infection with the organism is not the cause of duodenal ulceration, but a factor producing recurrence and chronicity.

Quantification of swallowed saliva in aspirated gastric juice.

OBJECTIVE: The aim of this study was to test a new mathematical model of the electrolyte concentrations in basal gastric secretion and to demonstrate whether this model was better than the old formula. Previous evidence suggests that primary gastric acid secretion has an electrolyte composition of [H+] 145, [Na+] 7, [K+] 17 and [Cl] 170 mmol/l, and that this can be modified by an extragastric component consisting of duodenogastric reflux and swallowed saliva. The only quantitative measurement available to date ignores the swallowed saliva. METHOD: Under basal conditions, gastric juice was aspirated and simultaneous sampling of saliva was performed in 60 adult subjects (33 men, 27 women), aged 23-85. Na+, K+, Cl-, phenol red (marker for pyloric loss) and titratable acidity or alkalinity were measured in aspirated gastric juice, and epidermal growth factor (EGF) was measured in saliva and gastric juice. Estimates of the primary gastric acid secretion were made by two methods: (1) V(G) formula which corrects for the duodenogastric reflux and assumes that there is no swallowed saliva: and (2) V(acid) formula, a novel procedure intended to correct for swallowed saliva as well and based on the known concentrations of electrolytes in saliva secreted at varying rates. RESULTS: The mean EGF concentrations were 3.42 ng/ml in saliva, 3.40 ng/ml in gastric juice. From the relationship of EGF output versus calculated primary acid secretion, the concentration of EGF in the extragastric component could be calculated. The V(G) formula gave a zero value of EGF whilst with V(acid), the calculated concentration of salivary EGF was 3.73 ng/ml and showed close correspondence with the measured EGF concentration in spat saliva. CONCLUSION: It is concluded that the new formula is more accurate, and gives a reasonable measurement for the volume of saliva in aspirated gastric juice.

A technique for safe resection of extensive tumours associated with the extracranial internal carotid artery.

Resection of tumours associated with the extracranial internal carotid artery such as carotid body tumours and paraganglionomas carry a hazard of stroke which might occur from temporary clamping of the artery to obtain better control, or from inadvertent damage to the artery which requires ligation. Some extensive tumours have been deemed unresectable because of their extent. Intracranial extension is a further technical challenge. We describe a technique for safe resection of such tumours employing an outlying Pruitt Inihara shunt. During resection of the tumour the shunt allows safe dissection because the internal carotid artery is rendered relatively bloodless. Further, any damage to the artery can be safely repaired, and indeed if necessary the artery itself can be resected and grafted. We have employed this technique in 3 difficult case of paraganglionoma (1) and carotid body tumour (2) whilst at the same time resecting 8 other simple cases without the need for such a technique.

Gordon-Taylor Lecture, 1980. Sir Gordon Gordon-Taylor: two themes illustrated by the surgery of the parotid salivary gland.

Personal experience in the management of calculi in the parotid duct and of parotid neoplasms is reviewed in the light of the teaching and practice of Sir Gordon Gordon-Taylor.

Primary FRSC (Eng). I. Evaluation of assessment techniques.

In five consecutive Primary Examinations for the Fellowship of the Royal College of Surgeons of England, the scores of candidates in the multiple choice question paper, written paper, and oral interview have been analysed for mutual correlations and for the reproducibility of the written paper score. The conclusions reached were that all these scores correlate with each other, that no score can be left out without reducing the reliability of the examination, that the marking of written papers in a close-marking system is remarkably reproducible, and that the oral score contributes most, the multiple choice question paper the least, to the overall assessment.

A simple clinical approach to quantifying losses from the extracellular and plasma compartments.

It is possible to estimate the category and volume of lost liquid in patients who have become acutely depleted of body fluids by measuring the haematocrit and plasma protein concentration in venous blood samples. Three recent examples of different categories of loss are presented: plasma loss in pancreatitis, extracellular fluid (saline) loss in paralytic ileus, and mixed plasma and extracellular fluid loss in peritonitis complicating acute appendicitis. Goood clinical results were achieved by infusion of appropriate volumes of either plasma or saline so as to restore the haematocrit and plasma protein concentration to their presumptive basal values.

Is the undeniably palpable liver ever 'normal'?

A study of whether the lower border of the normal liver, if it extended below the costal margin, could be reliably identified by clinical examination was undertaken in 42 patients in whom there was no clinical, biochemical or scintographic evidence of liver disease. Two clinical observers independently agreed that in 10 of these patients the liver extended infracostally. However, scintiscanning demonstrated that 30 patients had livers extending below the costal margin and that 2 of the 10 livers clinically identified did not in fact lie infracostally. Thus whilst the normal liver commonly extended below the costal margin, recognition of this extension by clinical methods occurred no more frequently than would be expected by chance. It is concluded that the confident clinical finding of a liver projecting below the costal margin should suggest that the organ is abnormal.

Recognition and treatment of abdominal wall pain.

In some patients with abdominal pain, the source of the pain may be the abdominal wall. A simple test is described which allows these patients to be identified and treated with injections of local anaesthetic and steroid. Twenty-six patients were studied, 20 of whom were available for follow-up. Sixteen of these 20 were symptom free or improved at a median follow-up period of 29 months. Failure to recognize abdominal wall pain may lead to unnecessary investigation.

Broadband telemedicine: teaching on the information superhighway.

The INSURRECT project uses the SuperJANET network to link six sites in the UK for interactive teaching and learning in surgery, an area of higher education where visual information is critical to the learning process. Collaboration between the six universities allows students access to a larger pool of surgical expertise and case studies than any single institution could provide. The project expects to improve the time that medical students can devote to surgery by up to 50%, by providing both supervised and unsupervised access to important visual information and case studies. Finally, the reduction in student numbers in operating theatres should reduce the infection risk to patients. A key component of the project is the central image resource, located in London, but allowing students and surgeons access from anywhere on the network. This paper describes the development of the interactive surgical teaching system and our experience with it during the first 18 months. One subjective observation, noticed after just one term's teaching, was the improved quality of the teaching.

Lessons learned during the INSURRECT project (INteractive SURgical Teaching at REmote CeNtres).

The INSURRECT project began in 1993 as a collaboration between six UK universities in distance teaching of undergraduate surgery. The first year was spent in testing the network and preparing the course material. This was followed by a two-year pilot teaching course. During this phase, 108 teaching sessions were conducted, involving more than 1300 students in all. It was found that successful teaching depended on increasing the amount of audience interaction was much as possible and transmitting high-quality video pictures. Although the time taken to deliver material by interactive video was greater than for conventional lectures, both students and teachers responded favourably to the project.

Effect of two doses of pirenzepine on histamine-stimulated gastric acid secretion in man.

The effect of two dose-schedules of Pirenzepine (25 mg b.d. or 50 mg t.d.s. during 2 1/2 days) on histamine-stimulated gastric acid secretion was tested in eleven healthy volunteers. Gastric secretory responses were calculated as acid output values and as VG-values (VG = gastric secretory volume corrected for duodeno-gastric reflux and pyloric loss). Stimulated acid output per two hours was reduced with Pirenzepine 25 mg b.d. by 12.5% (n.s.), with Pirenzepine 50 mg t.d.s. by 21% (p less than 0.01). Stimulated VG per two hours was reduced with Pirenzepine 25 mg b.d. by 15.8% (p less than 0.01) and with Pirenzepine 50 mg t.d.s. by 24% (p less than 0.01). Pirenzepine reduces histamine-stimulated gastric acid output to a similar degree as other anticholinergic drugs. Reduction seems to be due to true inhibition of acid secretion and not to altered gastric motility.