Prednisolone metasulphobenzoate foam retention enemas suppress the hypothalamo-pituitary-adrenal axis.

BACKGROUND: Corticosteroid enemas represent effective treatment for ulcerative proctitis, but absorption into the systemic circulation may have undesirable metabolic consequences. Prednisolone metasulphobenzoate, a lipophobic corticosteroid derivative, is designed to be absorbed poorly through the recto-sigmoid mucosa, but the effects of foam enema preparations upon the hypothalamo-pituitary-adrenal axis have not been examined. METHODS: Nine patients suffering from active ulcerative proctitis underwent four weeks of therapy with prednisolone metasulphobenzoate foam enemas. The hypothalamo-pituitary-adrenal axis, defined using the modified single-dose metyrapone test, glucose homeostasis and lipid profiles were studied before and after treatment. RESULTS: The hypothalamo-pituitary-adrenal axis was significantly depressed after the treatment period; mean stimulated plasma cortisol concentration fell from 384 +/- 244 (s.d.) to 288 +/- 252 nmol/L, P < 0.02; stimulated mean plasma 11-deoxycortisol concentration fell from 677 +/- 333 to 407 +/- 326 nmol/L, P < 0.01. Mean fasting plasma glucose, insulin, C-peptide, fructosamine and triglyceride concentration were unchanged, whilst the mean serum cholesterol concentrations rose from 5.6 +/- 1.1 to 6.0 +/- 1.2 mmol/L (not significant). CONCLUSION: Prednisolone metasulphobenzoate foam enemas have significant systemic and endocrine metabolic effects, which could assume importance with long-term therapy.

Nitric oxide and gall-bladder motor function.

BACKGROUND: The L-arginine: nitric oxide (NO) pathway has been shown to be important in the regulation of intestinal motility and NO may be the mediator for nonadrenergic noncholinergic (NANC) neurotransmission. AIM: To determine the role of the L-arginine: NO pathway in gall-bladder motor function. METHODS: Strips of fresh bovine and human gall-bladders were stimulated with cholecystokinin (CCK). The effects of glyceryl trinitrate (GTN), sodium nitroprusside and Kreb's solution upon CCK-stimulated muscle contraction were examined. The effect of the NO synthase inhibitor, L-NG-monomethyl-arginine (L-NMMA) upon basal muscle tone was also examined. Ten human gall-bladders were immunohistochemically stained for nitric oxide synthase (NOS) and product 9.5 to identify neurones. Postprandial gall-bladder emptying was measured on separate occasions in six healthy volunteers during systemic intravenous infusion of normal saline; glyceryl trinitrate; sodium nitroprusside (SNP), hydralazine and L-NMMA. RESULTS: In the in vitro study, GTN and SNP significantly reduced the tension of CCK-stimulated muscle contraction whilst Kreb's solution had no effect. L-NMMA increased tonic and phasic muscle contractions. Immunohistochemical staining for NOS was consistently absent in human gall-bladders. In the in vivo study, both GTN and SNP caused significant impairment of gall-bladder emptying; the ejection fraction was only 50% at the end of the study period involving these infusates, this contrasted with ejection fractions in excess of 80% during infusions with hydralazine, saline and L-NMMA. CONCLUSION: Pharmacological doses of NO donors impair postprandial gall-bladder emptying in vivo and relax gall-bladder smooth muscle in vitro. However, negative immunohistochemical staining suggest NOS is unlikely to be the neurotransmitter for NANC innervation regulating gall-bladder motility.

Prevalence, outcome and associated factors of deranged liver function tests in patients on home parenteral nutrition.

INTRODUCTION: The prevalence of deranged liver function tests (LFT) in patients on long-term home parenteral nutrition (HPN) is poorly documented. The aim of our study was to document the prevalence of this complication and possible associated factors. METHOD: Retrospective analysis of case notes of 107 patients on HPN was performed. Deranged LFT was defined as any biochemical parameter of LFT that is 1.5 times above the reference range. RESULTS: There were 39 males and the median age was 51 (range 20-73) years old. Median duration of HPN was 40 (range 6-252) months. Underlying diagnoses were Crohn's disease (40%), ischaemic bowel disease in 28.1% (arterial or venous), post-surgical intestinal adhesion and fistula (16.9%) and others (21.7%). The mean energy intake from HPN was 1003+/-544(SD) kcal/day with 845+/-474 kcal/day from glucose, 157+/-127 kcal/day from fat and mean nitrogen intake was 6.2+/-3.6 g/day. Raised alkaline phosphatase (mean 197+/-143(SD)U/L) was the most common abnormality (40 patients). Two patients had hyperbilirubinaemia; one patient had hereditary spherocytosis and in the other patient, the cause could be attributed to HPN with bilirubin of 54 micromol/l. Fifty-one patients (47.7%) had deranged LFT as judged from raised parameters on LFT. Abnormality in LFT was transient in nine patients. For the other 42 patients (39%), abnormalities in LFT remained stable for median duration of follow-up of 18.5 (range 3-180) months. No patients developed decompensated liver disease. On univariate analysis, length of small bowel of less than 100 cm, a higher total caloric intake from HPN (mean 1117+/-486 kcal against 907+/-576 kcal, P<0.05), and higher daily caloric intake from HPN in relation to calculated daily energy requirement (70+/-32% against 57+/-36%) were noted to be significantly associated with deranged LFT. However, on multivariate analysis, length of small bowel of less than 100 cm was the only significant variable for deranged LFT. CONCLUSION: Our finding showed the prevalence of deranged LFT to be 39% and raised alkaline phosphatase was the most common abnormality. Length of small bowel of less than 100 cm was found to be a significant independent variable for deranged LFT and the reason for this observation could be due to higher parenteral caloric intake. In our experience, LFT abnormalities are associated with a good prognosis as none of the patients developed decompensated liver disease.

Quality of life in patients stented for malignant biliary obstructions.

BACKGROUND/AIMS: Endoscopic stent placement is the standard treatment for patients with extrahepatic malignant biliary strictures (EMBS) who are too frail to undergo surgical resection. Stenting relieves jaundice and pruritus but the effects upon other systemic symptoms and quality of life (QOL) are not known. METHODS: Forty-seven patients (age: 46-89 years) with jaundice due to EMBS completed the European Organisation for Research and Treatment of Cancer QOL questionnaire, EORTC QLQ-C30, and two further questions assessing jaundice and pruritus, at the time of diagnosis and 1 month after endoscopic stenting. Thirty-eight patients successfully completed the study; nine patients succumbed to their illness within a month. RESULTS: No significant difference was found in the baseline QOL measurements and liver function tests between those patients who completed the study and those who were either too weak to answer the questionnaire or died within the first month of stenting. For patients who successfully completed follow-up, liver function tests (apart from serum albumin) improved after stenting. They also reported significant improvement in emotional, cognitive and global health scores (P < 0.01). In addition to the expected improvement in pruritus and jaundice (P < 0.01), anorexia, diarrhoea and sleep pattern were also reported to be improved (P < 0.01). CONCLUSION: Endoscopic stent insertion considerably improves a range of symptoms and enhances quality of life.

Failure of Nd-YAG photocoagulation therapy as treatment for Barrett's oesophagus--a pilot study.

INTRODUCTION: Acid suppression therapy and surgical antireflux procedures have not consistently led to regression of Barrett's epithelium. We reasoned that laser photocoagulation in combination with powerful acid suppression might destroy the metaplastic columnar epithelium and allow the area to be replaced by normal squamous mucosa. PATIENTS AND METHODS: Eight patients with endoscopic and histologically proven Barrett's oesophagus were recruited into the study. Four patients were randomized to receive omeprazole 40 mg daily and four patients received the same medical therapy plus repeated laser photocoagulation administered at 4-6 weekly intervals. Endoscopies were performed on entry and at 6 months. The extent of Barrett's epithelium was assessed and mapped on to a grid system and histological changes were assessed in blinded manner by a single histopathologist. One new quadrant of Barrett's segment was irradiated per treatment. RESULTS: Laser therapy was well tolerated and no complications occurred. After 6 months, the extent of Barrett's epithelium was unchanged in both groups. There was no appearance of squamous islands either endoscopically or microscopically in areas treated with laser. CONCLUSION: Nd-YAG laser is ineffective in ablating Barrett's epithelium.

Idiopathic bile acid malabsorption: long-term outcome.

OBJECTIVE: Idiopathic bile acid malabsorption (IBAM) is a rare cause of diarrhoea. The natural history of this disorder has not previously been reported. The aim of our study was to determine the long-term outcome in a cohort of patients with severe IBAM using a subjective assessment and by measuring the proportion of 75Se-homocholic acid taurine (75SeHCAT) retained 7 days after its ingestion. PATIENTS AND METHODS: Twenty-three patients with IBAM were identified in 1989. All had responded well to treatment with a bile acid chelator (cholestyramine or aluminium hydroxide). Questionnaires relating to current clinical symptoms and prescriptions were sent to these patients and their general practitioners. 75SeHCAT tests were performed for objective assessment. RESULTS: Three patients were lost to follow-up, three had died owing to malignancy and three had been diagnosed as suffering from inflammatory bowel disease. The mean period of follow-up for the remaining fourteen patients was 99.2 (range 48-140) months. Seven of the patients showed an improvement in symptoms and no longer required treatment with cholestyramine. In the remaining seven symptomatic patients, diarrhoea was well controlled by continued treatment with cholestyramine (five patients) or standard anti-diarrhoeal treatment (two patients). All seven symptomatic patients and three asymptomatic patients underwent repeat 7 day 75SeHCAT tests. The test results in the asymptomatic group had all improved so that the retention of the tracer after 7 days was above 5%; all but two patients in the symptomatic group still had values under 5%. However, the small number of patients in both groups precluded statistical analysis. CONCLUSIONS: IBAM is a rare cause of diarrhoea and should be diagnosed only after malignancy and inflammatory bowel disease have been excluded by rigorous investigations. Patients should be followed up as some develop other serious gastrointestinal diseases. Fifty per cent of the patients in our survey have remitted spontaneously and no longer require medication with bile acid chelators or anti-diarrhoeal agents.

Helicobacter pylori infection is unlikely to be transmitted between partners: evidence from genotypic study in partners of infected patients.

INTRODUCTION: We postulated that the oro-oral route of transmission between spouses could be an important route of transmission of Helicobacter pylori. AIMS: To estimate the prevalence of different genotypes of H. pylori as distinguished by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in our local population, and to compare the genotypes of H. pylori isolated from patients and their spouses. METHODS: Gastric biopsies were obtained from 183 dyspeptic patients during endoscopy. PCR for H. pylori was carried out using the uceC gene for amplification, and PCR products were digested further for RFLP analysis using the enzyme MboI. Spouses of H. pylori-positive index cases were screened for the infection using serological testing; if found to be positive serologically, endoscopy and gastric biopsies were performed for genotypic study of the micro-organism. For couples with indistinguishable H. pylori strain on RFLP with restriction endonuclease MboI, the process of RFLP was repeated with digestion of the PCR products using restriction endonuclease HhaI. RESULTS: We established our PCR technique to be 89.5% sensitive and 95.5% specific. Eighty-nine subjects were found to be H. pylori positive by PCR, and eight different genotypic strains were found according to our RFLP analysis. Two genotypes accounted for 80.8% of the cases. Sixteen of 31 spouses tested serologically for H. pylori were positive. All 13 spouses who agreed to undergo endoscopy were PCR positive for H. pylori. Five couples shared indistinguishable H. pylori genotypes, but this strain was also the commonest genotype in our local population, as based on RFLP with restriction endonuclease MboI. Further RFLP on the PCR products on these five couples using restriction endonucleases HhaI showed that the H. pylori isolated from these five couples were of different strains. CONCLUSION: The oro-oral route of transmission between spouses is unlikely to be an important mode for H. pylori infection.

Helicobacter pylori in the mouth--negative isolation from dental plaque and saliva.

OBJECTIVE: To determine the colonization of Helicobacter pylori in dental plaque and saliva of individuals with H. pylori-associated gastritis. PATIENTS AND METHODS: One hundred and twenty adult dyspeptic patients attending for outpatient endoscopy were randomly selected. Saliva, dental plaques and antral biopsies were collected and cultured in Dent's medium. Antral biopsies were also taken for histological confirmation of colonization. RESULTS: Eleven patients were withdrawn owing to poor tolerance of endoscopy. Fifty-two patients (47%) were found to be H. pylori positive on culture from antral biopsies and on antral histology. H. pylori was not isolated from saliva and dental plaques in any of the patients irrespective of their infective status. The H. pylori seropositivity rate was higher in the Japanese (72%) than in the Dutch (33%). CONCLUSION: We failed to isolate H. pylori from saliva and dental plaque in a group of dyspeptic patients with H. pylori-associated gastritis. We believe that our finding strongly suggests that oral to oral route is not an important mode of transmission in the adult population.

Mathematical model for predicting biliary therapeutic endoscopic retrograde pancreatography (ERCP).

INTRODUCTION: Magnetic resonance cholangiopancreatography is as sensitive as endoscopic retrograde pancreatography in the evaluation of biliary tract diseases but does not offer therapeutic options. The aim of the present study was to develop a mathematical model to predict 'therapeutic endoscopic retrograde pancreatography' using clinical variables so that patients with low probability could be more appropriately investigated by magnetic resonance cholangiopancreatography in future. METHODS: Endoscopic retrograde pancreatography cases between January 1996 to December 1997 were retrospectively reviewed (before introduction of magnetic resonance cholangiopancreatography). Clinical, biochemical and radiological variables were analysed and a model was developed using multiple logistic regression. RESULTS: Case notes for 573 patients were successfully reviewed. A total of 330 patients underwent therapeutic endoscopic retrograde pancreatography (sphincterotomy or stent insertion). Clinical indications of obstructive jaundice and cholangitis, ultrasonographic findings of dilated common bile duct, and raised liver function tests (two or more elevated parameters) were each found to be predictive for 'therapeutic' endoscopic retrograde pancreatography. Using these variables, the mathematical model in the present study has specificity of 77% and sensitivity of 75% at the probability level of 50% or higher. This model has been tested in a separate group of endoscopic retrograde pancreatography cases carried out in 1998 and was found to have sensitivity 77.6%, specificity 80.3%, positive predictive value 68.5% and negative predictive value 86.6%. CONCLUSIONS: The model reported in the present study can help clinicians to identify cases for therapeutic endoscopic retrograde pancreatography and diagnostic magnetic resonance cholangiopancreatography.

Audit of investigations in patients with iron deficiency anaemia.

BACKGROUND: Patients with iron deficiency anaemia (IDA) are commonly referred to the gastroenterologists for exclusion of gastrointestinal (GI) pathologies. The British Society of Gastroenterology (BSG) has published a guideline for management of IDA. As recommended by this guideline, all patients should have examinations of both upper and lower GI tract with the exception of pre-menopausal women younger than 45 years old. The primary aim of this audit was to determine how thoroughly patients referred to our unit at the Singapore General Hospital had been investigated. The secondary aim was to determine the yield rate of gastroscopy and lower gastrointestinal investigations (colonoscopy or barium enema) in our patients. METHODS: We reviewed the case notes of patients who underwent gastroscopy for indication of anaemia between the period from April to December 1999. We classified iron deficiency anaemia as having haemoglobin of lower than reference range with either low ferritin level or iron/ TIBC ratio of less than 10%. RESULTS: Of a total of 326 patients reviewed, 172 patients (65 men, 109 women) met the inclusion criteria of IDA. The median age for the group was 59 (Range 16 to 88) years old and there were 107 (62.2%) women. There were 31 female patients younger than 45 years old (group A) and 141 patients in group B which included all the males and females older than 45 years old. Due to the method of data retrieval, all of the patients in group A fulfilled the standard set by the BSG guideline in that they all underwent gastroscopy. In this group, few gastrointestinal pathologies were found (one patient with peptic ulcer and two patients with colonic cancer). In terms of finding potential gastrointestinal causes of IDA, the yield rate of gastroscopy and colonoscopy were 3.2% and 13.6% respectively. In group B, 96 patients (68%) underwent upper and lower gastrointestinal investigations. Evaluation with gastroscopy showed peptic ulcer disease in 31 patients (21.7%) and gastric cancer in 9 patients (6.3%). Only 96 patients (68.1%) in group B had lower gastrointestinal investigations. Twenty-six patients were found to have gastrointestinal disorders (12 patients with colon cancer, 10 colonic polyps, one Crohn's disease, one colonic tuberculosis and two haemorrhoids). The yield rate of gastroscopy and colonoscopy were 31.2% and 25% respectively. CONCLUSION: In this study of patients with confirmed IDA, we found much higher incidence of gastrointestinal disorders in the group of male and postmenopausal women than in the group with premenopausal women. Furthermore, over 30% of patients in this group did not undergo lower gastrointestinal tract investigations as recommended by the BSG guideline. We also found two cases of colonic cancer in the latter group. We would recommend bidirectional endoscopy for postmenopausal women and men with IDA. For premenopausal women, we would recommend similar approach unless there are clinical pointers to dietary iron deficiency or menorrhagia.

Survey of dyspepsia management in community.

INTRODUCTION: Dyspepsia is a common complaint and represents an important health problem in the community. The aim of the study was to survey the diagnostic approach and management of dyspepsia and Helicobacter pylori (H. pylori) infection by primary care physicians. METHODS: Questionnaires were given to 70 medical officers (MO) working in government polyclinics and 70 general practitioners (GP) in private practice. RESULTS: Questionnaires were returned from 68 MO's (response rate 97%) and 61 GP's (response rate 87%). Only 20% of MO and 50% of GP prescribed H. pylori eradication therapy. Of those who have prescribed eradication therapy, 70% would confirm H. pylori infection before therapy (50% for gastroscopy, 19% for Urea Breath test, 25% for laboratory based serology, 6% for office based serology test kits). 85% would prescribe triple therapy against 15% for dual therapy. Proton pump inhibitor (PPI) is the acid suppression agent most commonly prescribed (77%) in regimens of eradication therapy; the remaining would prescribe either bismuth subcitrate or H2 antagonists. Only 8% of respondents would confirm eradication after therapy. CONCLUSION: Less than half of the primary care physicians surveyed prescribed H. pylori eradication therapy. The main reason given for not prescribing therapy was lack of facility for testing the infection. Of those who prescribed eradication therapy, majority would order the correct and reliable investigations to confirm the infection. Most of them would prescribe triple therapy which is the recommended eradication regimens.

One week triple therapy for Helicobacter pylori associated duodenal ulcer disease.

INTRODUCTION: Eradication of Helicobacter pylori (H. pylori) cures and prevents the relapse of duodenal ulceration. Different treatment regimes for the eradication of H. pylori have been used and the most successful eradication regimens have been one week treatments with a proton pump inhibitor and two antibiotics. AIM OF STUDY: To examine the eradication rate of H. pylori with a one week regimen consisting of OCT (Omeprazole 20 mg BD, Clarithromycin 250 mg BD, Tinidazole 500 mg BD). This treatment regimen has been used for H. pylori eradication in our department since the end of 1996. METHODS: Patients diagnosed to have duodenal ulcer in 1997 were retrospectively reviewed. Infection with H. pylori must be documented either by gastric biopsy or by a positive CLO test. Eradication of H. pylori was confirmed by negative 14C urea breath test or by histology at least four weeks after cessation of therapy. RESULTS: The review was performed on 251 patients. There were 177 males, 74 females. The median age was 51 (18-77) years. H. pylori infection was confirmed by CLO test in 170 patients and by histology in 72 patients. Thirty patients did not undergo further investigation after therapy to confirm the eradication. Of the remaining 221 patients, H. pylori was successfully eradicated in 198 patients (89.6%) as confirmed by 14C urea breath test (190 patients) or repeat gastroscopy and gastric biopsy (31 patients). There were no serious adverse events documented. CONCLUSIONS: Our retrospective study showed that the one week regimen used in our department is effective for the eradication of H. pylon in nearly 90% of infected cases.

Efficacy of a nitroimidazole containing tripletherapy regime in Singapore.

BACKGROUND: There has been a gradual increase in the proportion of Singapore patients with metronidazole resistant strains of Helicobacter pylori. We studied the efficacy of a nitroimidazole containing regime in eradicating H. pylori. METHODS: Consecutive treatment naive patients with peptic ulcer disease and culture proven H. pylori were recruited. From each patient, two antral biopsies were taken for rapid urease test and two for histology. Two biopsies each from the gastric antrum and corpus were taken for H. pylori culture. Antibiotic sensitivity to amoxycillin, metronidazole, clarithromycin and tetracycline were tested using the disc diffusion method. Patients were treated with lansoprazole 30 mg bd, tinidazole 500 mg bd and clarithromycin 500 mg bd for seven days. Successful eradication was defined as either negative urea breath tests 4 and 12 weeks after treatment, or negative histology and culture at least four weeks after the end of treatment. RESULTS: A total of 64 patients were culture positive (51 males, 13 females). Forty-two patients had duodenal ulcers (DU), 17 gastric ulcers (GU), and 5 DU and GU. Metronidazole resistance was detected in 16 patients (25%). Three of the 16 patients (19%) had a mixed population of resistant and sensitive strains of H. pylori. None of the H. pylori isolates were resistant to amoxycillin, tetracycline or clarithromycin. Overall, eradication was achieved in 51/64 patients (80%). Eradication rate was 88% (42/48) among those with metronidazole sensitive strains, and 56% (9/16) among those with metronidazole resistant strains (p < 0.02). CONCLUSION: A high proportion of our patients with metronidazole resistant strains of H. pylori failed eradication therapy when a nitroimidazole containing regime was used. It may not be appropriate to use a nitroimidazole containing without prior knowledge of the antibiotic sensitivity pattern of the H. pylori isolate.

Gastrointestinal manifestations of systemic lupus erythematosus.

Gastrointestinal symptoms are common in patients with systemic lupus erythematosus (SLE) and can be due to primary gastrointestinal disorders, complications of therapy or SLE itself. In this case report, we describe three different presentations and causes of gastrointestinal complaints in patients with SLE. Diagnostic and management problems are discussed.

Percutaneous endoscopic gastrostomy--indications and outcome of our experience at the Singapore General Hospital.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is widely used for patients with dysphagia from neurological causes and head and neck malignancy. We examined the indications, complication rates and long term outcome of PEG inserted in our department. METHODS: We performed a study of PEG inserted in our department between January 1995 to March 2000. Consecutive patients with PEG inserted during this period were identified from our database that contained demographic data, primary and secondary underlying medical conditions, and immediate complications after the procedure. Casenotes were reviewed and caregivers (relatives or staff at nursing homes) were contacted for information on long term outcome at the time of this study between April 2000. Data was collected in standard form designed for this study. RESULTS: 181 cases of PEG insertion were performed during the study period. 174 patients were successfully followed up and reviewed. The median age was 70.5 (range 24 to 93) years old and there were 111 males. Indications for PEG insertion were: cerebrovascular diseases (60.4%), Parkinson's disease and other neuromuscular disorders (10.9%), nasopharyngeal carcinoma and other upper gastrointestinal malignancies (24.7%), and head injury (4%). Superficial wound infection (22.4%) and granuloma formation (31%) were common minor complications. Major complications were infrequent: peritonitis (2.3%) and gastrointestinal bleeding (0.6%). The mortality rates were 11.5% and 28.2% at one and six months respectively. Only one death from peritonitis was directly attributed to the procedure, most deaths were due to underlying co-morbidities with pneumonia being the most common cause. The proportion of the first PEG tubes removed or replaced were 12.2% and 35.5% at one and six months respectively. Thirty tubes were replaced due to blockage at median interval of 9.6 months. 9.7% of PEG tubes functioned longer than 24 months. CONCLUSIONS: Our results confirm the safety of PEG tubes in elderly patients with multiple co-morbidities. Major complications of the procedure were infrequent but produced grave consequences in these elderly patients with multiple co-morbidities. As such, patients considered for PEG feeding should have reasonable prognosis and the procedure is inappropriate for patients with rapidly progressive and incurable diseases.

Appropriateness of the use of parenteral nutrition in a local tertiary-care hospital.

INTRODUCTION: Parenteral nutrition (PN) is an important supportive therapy for critically ill patients who have non-functioning gut. However, it is an expensive therapy and carries significant complications. The objective of our audit was to determine the appropriateness of prescription of PN in our hospital, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) 2002 guidelines. In our hospital, the prescription of PN is managed by the Nutrition Support Team. MATERIALS AND METHODS: A retrospective review of adult patients prescribed with PN in 2001 was undertaken. Data on patient demographics, underlying diagnoses, indications, duration and routes administration were collected. The use of PN was classified as "appropriate", "inappropriate" or "indeterminate" by the authors based on the above guidelines. RESULTS: 145 patients were prescribed PN in 2002. We were able to review the case notes for 137 patients. One patient received PN on 2 separate admissions. Of the 138 courses of PN (in 137 patients) reviewed, there were 88 males with the median age of 61 years (range, 16 to 91 years). 81.2% were surgical patients and of the remaining patients, 10.1% had haematological malignancies. The 2 most common indications were postoperative ileus (37.0%) and post-surgical complications (14.5%). The median duration of PN prescription was 9 days (range, 1 to 175 days). 109 (78.3%) courses of PN were classified as "appropriate", 22 (15.9%) courses as "inappropriate" and 7 (5.8%) courses as "indeterminate". Patients from the postoperative ileus group contributed to 10 (45.5%) patients with "inappropriate" indications; the main reason was premature initiation of PN. Of the patients considered to show "inappropriate" indications, 15 courses (68.1%) were prescribed for less than 7 days. PN was discontinued in 78% of courses due to satisfactory resumption of oral or enteral intake. The mean duration of PN use for patients with "inappropriate" indication was significantly shorter than for patients with "appropriate" indication (7.7 +/- 5.3 days versus 15.8 +/- 20.0 days, P = 0.002). 99.3% of PN courses were given via the central routes (with central vein cannulation or PICC). These lines were specifically inserted for PN in 60.14% of the cases. CONCLUSION: Our audit showed that 15.9% of PN prescriptions were inappropriate according to the ASPEN guidelines. This was largely attributed to premature initiation of PN for postoperative ileus. We believe that these PN courses could have been avoided if these patients had been tried on naso-jejunal tube feeding, or oral nutrition with the use of prokinetics during the postoperative period.

Acute myelocytic leukaemia presenting as anergic pulmonary tuberculosis.

This case report describes a patient with anergic pulmonary tuberculosis who presented with pyrexia of unknown origin and vasculitis. He did not exhibit any pulmonary symptoms at his initial presentation and developed acute myelocytic leukaemia, a recognised association, during the subsequent course of his illness.

Dysphagia as a side effect of botulinum toxin injection.

Dysphagia is a known adverse effect of botulinum toxin injection into the cervical region for dystonia. We present an unusual case of dysphagia arising from injection into the orbicularis oculi muscle, which has hitherto not been described. We postulate that her dysphagia was caused by distant side effects of botulinum toxin due to repeated injections. We recommend that clinicians should restrict the frequency of injections to as few life-time doses of the toxin as possible for adequate management of spasm. The practice of re-injecting patients routinely every three months, or at the first return of mild spasms should be discouraged.

Gastrointestinal Cytomegalovirus infection in non-human immunodeficiency virus infected patients.

This is a retrospective study of fourteen patients who had proven Cytomegalovirus (CMV) infection of the gastrointestinal tract with no Human Immunodeficiency virus infection. The median age was 60.5 (Range 28 to 81) years. Eight patients were below (Group 1) and six above sixty five years old (Group 2). Areas of gastro-intestinal involvement were: oesophagus (2), stomach (1), colon (10) and multiple sites (1). Seven patients from Group 1 had received immunosuppressive therapy at the time of presentation and one had diabetes mellitus. We found a high prevalence of co-morbidities such as chronic renal failure and diabetes mellitus in Group 2. At median follow up of 13.9 months, there was a mortality rate of 50%. Only four patients were treated with ganciclovir. Our study concludes that the gastrointestinal CMV diseases in young patients were associated with immunosuppression whereas the older patients had chronic renal failure or diabetes.

Endoscopic biopsy features and diagnostic challenges of adult Crohn's disease at initial presentation.

AIMS: Endoscopic biopsy diagnosis of Crohn's disease (CD) is problematic due to lack of specific microscopic features and patchy involvement. There is no documentation of the pattern and severity of microscopic features of CD at initial presentation in adults or children. We aimed to assess the initial mucosal biopsy features of CD in adults and to identify any specific features to confirm the diagnosis. METHODS: Thirty sets of initial, adult endoscopic biopsies suspected to be CD with subsequent resections, repeat biopsies with long-term follow-up, and/or other confirmatory laboratory results were analysed by three gastrointestinal pathologists, blinded for the final diagnosis for mucosal architectural changes, epithelial abnormalities, chronic and active inflammation and changes of muscularis mucosae and submucosa. There were 25 cases of CD and five cases of non-CD for comparison (3 tuberculosis and 2 right-sided diverticular disease and associated colitis). Cases confirmed as ulcerative colitis were excluded, as diagnostic challenges are already well established. RESULTS: The majority of initial biopsies (96%) of CD were abnormal with active chronic ileocolitis with a very high proportion (80%) showing the classic combination of abnormal mucosal architecture, epithelial abnormalities and active chronic inflammation. The most sensitive feature was lamina proprial chronic inflammation (sensitivity 92.7%). Sensitivity for other features was as follows: active inflammation 87.8%, basal plasmacytosis 82.1%, architectural changes 80.5% and epithelial abnormalities 70.7%. Abnormalities were found in 94% of ileal and 76% of colonic biopsies. No feature was specific as all tuberculosis and diverticular disease cases showed the classic combination. Granulomata were seen in 10 of 41 CD, in all five tuberculosis and in no diverticular disease biopsies. Small, tight, well defined granulomata characterised CD over large coalesced ganulomata of tuberculosis. Paneth cell and pseudopyloric metaplasia was seen only in CD (2/25). CONCLUSIONS: Initial endoscopic biopsies of adult CD are significantly abnormal and a majority shows active chronic ileocolitis. The features are sufficiently important to suspect CD at initial presentation in the appropriate clinical setting. Tuberculosis and diverticular disease associated colitis are two important mimics to consider in addition to ulcerative colitis.