Idiopathic retroperitoneal haematoma.

A case of asymptomatic idiopathic retroperitoneal haematoma presenting as an abdominal tumour, is described. A review of English literature has not revealed any description of this condition.

Mutagenicity in gastric juice.

Mutagenicity has been measured in the gastric juice of 228 patients using the Ames bacteriological test system; while mutagenicity in control and duodenal ulcer patients did not differ from saline controls, mutagenicity was significantly increased compared with controls in patients suffering gastric ulcer (p less than 0.002), carcinoma (p less than 0.002), and in patients after gastric resection (p less than 0.01). A transient rise in mutagenicity was seen following H2 antagonist ingestion (p less than 0.002). Increased levels of mutagenicity were found to correlate closely with gastric juice pH and bacterial count. Histidine concentrations in gastric juice did not explain the mutagenicity results.

Intragastric N-nitrosation is unlikely to be responsible for gastric carcinoma developing after operations for duodenal ulcer.

Three groups of patients studied after operations which had cured their duodenal ulcer were compared with a control group (no operation, n = 8). The surgical procedures included: proximal gastric vagotomy (n = 7), truncal vagotomy and pyloroplasty (n = 7), truncal vagotomy and antrectomy (n = 8). Samples of gastric juice were aspirated half hourly or hourly over 24 hours for measurement of pH, counts of all identified bacteria, nitrite and total N-nitrosocompounds. Although the pH over 24 hours was significantly higher after proximal gastric vagotomy (p less than 0.05) and truncal vagotomy and antrectomy (p less than 0.001) than controls, there was no difference between truncal vagotomy and pyloroplasty and controls. Counts of nitrate reducing bacteria over 24 hours were also significantly higher after truncal vagotomy and antrectomy than controls (p less than 0.1) but no differences were observed between the other groups. Only after truncal vagotomy and antrectomy was nitrite over 24 hours significantly increased compared with controls (p less than 0.01). Despite these higher values after truncal vagotomy and antrectomy, there was no significant difference in total N-nitrosocompounds between any of the four groups. Whereas bacterial counts and nitrite increased with pH, no correlation was found between total N-nitrosocompounds and pH. These results provide no evidence that exposure to total N-nitrosocompounds is increased after operations for duodenal ulcer.

Cimetidine and the potential risk of postoperative sepsis.

The gastric microflora of patients receiving cimetidine for duodenal ulceration has been investigated and the results compared with those from a group of untreated patients. Cimetidine-induced hypochlorhydria allows bacterial proliferation in the stomach; 75 per cent of aspirates from 44 fasting patients taking cimetidine 1 g daily were found to contain bacteria 2--4 h after the last dose. Of 41 patients taking cimetidine 400 mg at night, 34 per cent still had bacteria in their aspirates 12--13 h later. Patients treated with cimetidine are likely to be at an increased risk of postoperative sepsis. The drug should either be withdrawn before gastric surgery is undertaken or patients with gastric contents of pH 4 or above should receive antibiotic cover.

The microflora of the postoperative stomach.

The microflora and pH have been assessed in gastric aspirates from 163 patients after gastric surgery and have been compared with 51 patients with gastro-oesophageal carcinoma, 152 unoperated patients with peptic ulceration, 72 of whom were receiving cimetidine, 3 patients with pernicious anaemia and 27 normal subjects. The total viable bacterial count was closely related to the pH of the aspirate and was independent of the cause of the hypochlorhydria; 90 per cent of aspirates of pH 1--2 were sterile, while 94 per cent of those of pH 4--8 contained bacteria. Escherichia coli was found significantly more frequently in the postoperative and cancer groups, and Clostridium spp. were significantly more common in patients with carcinoma. Elevated gastric juice nitrite concentrations were significantly more common in aspirates of pH 4--8 and this correlated well with the presence of nitrate-reducing bacteria. The pH of an aspirate is a good indicator of the presence of bacteria and may be useful in selecting patients requiring postoperative prophylactic antibiotic cover. Hypochlorhydric patients are exposed to increased concentrations of nitrite and there may be an increased risk of gastric cancer induced by N-nitrosocompounds.

Toxic megacolon in ulcerative colitis: a continuing challenge.

The incidence, predisposing factors, management and outcome of toxic megacolon (TM) has been reviewed in 65 cases of severe ulcerative colitis (UC) and compared in 2 successive 6-year periods before and after January, 1973. Nineteen episodes of TM occurred in 18 patients. Despite a conscious aim towards earlier surgery in recent years this was not achieved, and despite more intensive medical therapy the incidence of TM was unchanged. Emergency operative mortality in UC fell from 36% to 21% but the mortality of TM remained at 30%. The chief cause of death was colonic perforation. Mortality was associated with increased age, longer pre-operative hospital stay and lower levels of serum albumin. These findings reemphasize the need for earlier surgery if TM is to be prevented, but such a policy must result in some unnecessary emergency colectomies.

Cimetidine is unlikely to increase formation of intragastric N-nitroso-compounds in patients taking a normal diet.

Studies in fasting subjects have suggested that cimetidine therapy might lead to nocturnal hypochlorhydria, allowing bacterial overgrowth and the production of intragastric carcinogens. This hypothesis was investigated in normal subjects taking full-dose and maintenance cimetidine with food. Nocturnal hypochlorhydria wa rarely found and the incidence of bacterial overgrowth was correspondingly low; gastric-juice nitrite concentrations were rarely raised. These findings suggest that long term treatment with cimetidine is unlikely to promote gastric cancer as a result of bacterial metabolic activity.

Spontaneous common bile duct structure: an illustrated case report.

An illustrated case of spontaneous extrahepatic biliary stricture is presented and the differential diagnosis is considered. A lesion of this sort does not appear to have been described previously.

Reoperation for recurrent peptic ulceration.

Thirty-eight patients undergoing reoperation for recurrent peptic ulceration have been reviewed after at least 3 years. All were considered to be in Visick grade IV before reoperation. There were no operative deaths. Thirty-three of the patients ended with both a vagotomy and antral resection. After reoperation 17 patients (45 per cent) remained in Visick grades III and IV. Eight patients have had further operations and, after 47 procedures in 38 patients, 14 (37 per cent) were still in Visick grades III and IV. Vagotomy and antrectomy has a high non-ulcer mobidity rate and we conclude that other methods of treatment for recurrent ulceration require evaluation.