Endoscopic and radiological assessment of recurrent ulceration after peptic ulcer surgery.

One hundred and eighteen patients with dyspepsia after peptic ulcer surgery were assessed by a double contrast barium meal and fibre-optic endoscopy, for the possibility of recurrent ulceration. There was overall endoscopic-radiological agreement in 89%. It is concluded that the two techniques are complementary and that a double contrast barium meal performed and interpreted by an experienced radiologist can demonstrate the presence or absence of a recurrent peptic ulcer with an acceptable degree of accuracy.

Common gastroenterological problems. II.--Sliding hiatus hernia.

A sliding hiatus hernia is a common radiological finding and is not always relevant to the patient's symptoms. The possibility of an alternative explantation for the complaint of retrosternal pain or dyspepsia should always be considered, and when anaemia is present the site of occult blood loss is often lower in the gastrointestinal tract. The majority of patient's with symptomatic gastro-oesophageal reflux can be controlled with medical measures. Surgical intervention in cases of uncomplicated hiatus hernia should be recommended only after careful preoperative assessment and even then a satisfactory result cannot be absolutely guaranteed.

Common gastroenterological problems. III. Chronic benign gastric ulcer.

A gastric ulcer is a lesion which needs to be treated with respect and should be followed to a satisfactory conclusion. The barium meal is still the mainstay of diagnosis but the accuracy of this examination is considerably improved when a double-contrast technique is used. Endoscopy is of value both to check the radiological findings and in particular to obtain biopsy material for histological examination. When the diagnosis has been established surgical intervention may be indicated, but if a course of medical treatment is thought to be justifiable the patient's progress must be closely followed radiologically and surgery reconsidered if there is no convincing evidence of ulcer healing.

Common gastroenterological problems. IV.--Duodenal ulcer.

Duodenal ulcer is a common cause of dyspepsia. The clinical features are non-specific, and suspicion of this lesion requires confirmation with a barium meal, perferably using a double-contrast technique. Duodenoscopy and gastric-acid-secretion studies are helpful in selected cases. Medical treatment is essentially symptomatic but nevertheless remains perfectly acceptable to many ulcer suffers. Surgical intervention is usually necessary in the presence of ulcer complications, but careful assessment is required before recommending operation for a patient with an uncomplicated duodenal ulcer. This decision should be based predominantly on the severity and duration of symptoms.

Common gastroenterological problems. V.-Ulcerative colitis.

Symptoms such as diarrhoea and rectal bleeding are suggestive of ulcerative colitis but this diagnosis should never be made without confirmation by sigmoidoscopy and rectal biopsy and the possibility of infection excluded by stool culture and microscopy. A barium-enema is usually essential to assess the extent of the disease process. Treatment of the initial attack or subsequent relapses should be started as soon as possible and early referral to hospital is indicated, both for diagnostic confirmation and for therapeutic advice. The relapsing nature of the disease necessitates adequate follow-up and it should be possible for the patient to be seen at hospital with the minimum of delay. Most patients with colitis can be managed successfully by medical treatment, but occasionally emergency or elective proctocolectomy is indicated.

Common gastroenterological problems. The irritable bowel syndrome.

The irritable bowel syndrome is one of the commonest conditions seen in gastroenterology clinics. The diagnosis is suggested by the presence of longstanding colonic symptoms without any deterioration in the patient's general condition but depends essentially on the exclusion of any underlying organic disease. Particular care is required before attaching this label to middle-aged and elderly patients presenting with bowel symptoms for the first time. The most important aspects of treatment are firm reassurance, a simple explanation of symptom production and sympathetic follow-up. Drug therapy plays a comparatively minor role although a variety of preparations are helpful in individual cases. Reinvestigation is rarely indicated unless the symptom complex changes or the patient loses weight.

Upper-gastrointestinal endoscopy in perspective.

Three and a half years' experience of an upper-gastrointestinal endoscopy service in a district general hospital is reviewed. It is concluded that the necessity for this investigation is considerably reduced when a positive contribution towards patient management is the main criterion for its use, when there is effective interdisciplinary cooperation, and when a double-contrast barium-meal technique is routinely employed.

Irritable bowel syndrome--a safe diagnosis?

Seventy-seven of 84 surviving patients in whom the irritable bowel syndrome had been diagnosed at least six years previously were reviewed. A different diagnosis was made in only four cases. Forty-four patients remained symptomatic and 29 patients had no further bowel problems. The irritable bowel syndrome is often a chronic, relapsing disorder, and further investigations are not necessary unless symptoms change considerably.

Epsilon-aminocaproic acid therapy in ulcerative colitis.

On the supposition that excessive fibrinolysis at the rectal mucosal level may contribute to the pathogenesis of ulcerative colitis, 11 patients with this condition, in whom rectal bleeding was the predominant feature, were given a course of epsilon-aminocaproic acid therapy. Six patients responded dramatically to this treatment, there was a partial response in two, no effect in two others, and one patient found it necessary to discontinue the treatment after 48 hours because of the severity of side effects.

Gastroenterology: the first 40 years.

Functional gastroenterological disorders were diagnosed in over 50 per cent of patients aged 40 years and under, referred to a district general hospital combined gastroenterology clinic. Peptic ulceration, gastro-oesophageal reflux, biliary tract disease and inflammatory bowel disease accounted for almost 70 per cent of the organic disorders encountered. Malignant disease was rare. The implications for diagnostic investigation in this age group are discussed.

A negative double-contrast barium meal--qualified reassurance.

Four hundred and forty-one consecutive patients referred for endoscopy after a negative double-contrast barium meal were studied to determine the reliability of good quality radiology in excluding significant upper gastrointestinal pathology. Endoscopic abnormalities were detected in 23 patients (5.2%), nine of which were reporting errors. Duodenal ulcer was the commonest lesion missed radiologically, 50% of these patients either having a history of overt upper gastrointestinal bleeding, a family history or impressive symptomatic relief with H2-receptor antagonists. The three patients with radiologically undetected gastric cancer presented with classical symptoms; the radiological demonstration of gastric mucosal atrophy in this clinical context should alert the referring clinician to initiate urgent endoscopy.