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.

A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture. Restore Investigator Group.

BACKGROUND/AIMS: Dilatation combined with subsequent pharmacological control of gastroesophageal reflux represents a logical but poorly documented approach to the management of benign esophageal stricture. This large trial (366 patients) aimed to assess whether omeprazole as the most effective available medication for gastroesophageal reflux disease prevents recurrent stricture formation. METHODS: Patients (n = 366) were randomized in a double-blind study to undergo either omeprazole (20 mg once daily; 180 evaluable patients) or ranitidine therapy (150 mg twice daily; 185 evaluable patients) for 1 year after dilatation to 12-18-mm diameter (36-54F gauge). Subsequently, endoscopy and dilatation were performed when clinically indicated and endoscopy on completion. Symptoms were assessed at clinic visits every 3 months and using weekly diary cards. RESULTS: Fewer patients undergoing omeprazole therapy required redilatation compared with those on ranitidine (43 of 143 [30%] vs. 66 of 143 [46%] by 12 months; P < 0.01), and patients in the omeprazole group needed fewer redilatations during the year (0.48 vs. 1.08; P < 0.01). On completion, symptom relief favored omeprazole: 76% of patients in the omeprazole group were free of dysphagia (compared with 64% in the ranitidine group; P < 0.05); 83% were able to accept a normal diet (69%; P < 0.01); and 65% were completely asymptomatic (43%; P < 0.001). CONCLUSIONS: Omeprazole, 20 mg once daily, was more effective than ranitidine, 150 mg twice daily, as prophylaxis against stricture recurrence and in providing symptom relief.

Prevention of rebleeding from oesophageal varices: two-year follow up of a prospective controlled trial of propranolol in addition to sclerotherapy.

A prospective randomised trial comparing propranolol and sclerotherapy to sclerotherapy alone was conducted over a 2-year follow up in a district hospital setting of unselected patients. Rebleeding and survival were analysed. Thirty-nine patients were randomised to propranolol plus sclerotherapy and 34 to sclerotherapy alone. The two groups were clinically comparable. There was no significant difference in the cumulative percent of patients free of rebleeding; 54% of the sclerotherapy group rebled compared to 52% of the group treated with propranolol plus sclerotherapy (Hazard ratio 1.09 (0.54-2.22) and p = 0.81, NS). Two-year actuarial survival was also not significantly different, with 77% of the propanolol plus sclerotherapy group surviving, compared to 74% of sclerotherapy alone (Hazard ratio 1.08 (0.35-2.22) and p = 0.79, NS). The mean time to eradication of varices was not significantly different between the two groups (propranolol plus sclerotherapy 222 days, sclerotherapy alone 243 days), nor did the rate of variceal recurrence differ (72.7 vs 72 days). This study did not show long-term improvement in rebleeding or survival using propranolol in addition to a regular sclerotherapy programme.

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.

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.

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.

A randomized controlled trial of variceal compression as an adjunct to endoscopic variceal sclerosis.

Endoscopic variceal sclerosis is effective at eradicating oesophageal varices and prolonging survival, but early rebleeding before varices have been obliterated remains a problem. A randomized controlled trial was therefore conducted to determine whether more rapid variceal obliteration and hence a lower morbidity and mortality in the first month could be achieved by compressing the varices after the first injection of sclerosant. Forty patients bleeding from previously untreated varices were studied. There was no demonstrable benefit from post-sclerosis variceal compression in terms of early death from rebleeding (compression, 3 of 19; no compression, 3 of 21 in the first month), total number of patients rebleeding (compression, 5 of 19; no compression, 6 of 21 in the first month), or speed of variceal obliteration (percentage of variceal columns obliterated at 1 month: compression, 13%; no compression, 26%). This study shows that post-sclerosis variceal compression by means of the Williams overtube and Sengstaken tamponade does not improve the efficacy of endoscopic variceal sclerosis.

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.

Colonic Crohn's disease and use of oral contraception.

The prevalence of use of oral contraception before the onset of disease was established in 100 consecutive women attending follow up clinics for inflammatory bowel disease. A significant excess of women with Crohn's disease confined to the colon had taken oral contraceptives in the year before developing symptoms (10/16 (63%] compared with women with small-intestinal Crohn's disease (12/49 (24%); p less than 0.02) and women with ulcerative colitis (3/35 (9%); p less than 0.0005). When the patient groups were matched for age and year of onset of disease usage of oral contraception before the onset of disease was still more common among women with isolated colonic Crohn's disease (9/12, 75%) than among those with ulcerative colitis (2/12 (17%); p less than 0.02) and was also more common than would be expected from reported figures for oral contraception in England and Wales (31.4% of women aged under 41; p less than 0.005). A survey of current patient records showed that isolated colonic disease was at least twice as common among women with Crohn's disease (63/218, 29%) compared with men (25/181, 14%; p less than 0.001). These data support the suggestion made previously that oral contraceptives may predispose to a colitis that resembles colonic Crohn's disease.

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.

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.