Acute biliary pancreatitis.

The development of acute pancreatitis occurs in 4-8% of patients with symptomatic gallstones. Individuals predisposed to acute pancreatitis tend to have small gallstones (with or without larger gallstones), a wide cystic duct and a common channel between the biliary and pancreatic ducts. The importance of this relationship is demonstrated by the ability of urgent endoscopic sphincterotomy (ES) to improve the outcome of a predicted severe attack and to virtually abolish recurrent attacks in patients who are unable to undergo cholecystectomy. Cholesterolosis is an established cause of acute pancreatitis, occurring in up to 29% of cases with cholesterolosis. Biliary crystals are an important marker of microlithiasis or a propensity to form further gallstones following their passage into the duodenum following an attack. A combination of ultrasonography and a serum liver transaminase of > 60 IU/I (< 48 hr o an attack) are necessary to provide optimum sensitivity and specificity for gallstones as a prompt for the use of ERCP and ES in severe cases. Biliary sludge as a cause of acute pancreatitis is not proven. 25-30% of patients will develop complications with a mortality of around 8%. Urgent diagnosis of gallstones and treatment by ES can result in substantial improvement in outcome.

Ulcerative colitis in the anal canal of patients undergoing restorative proctocolectomy.

The development of stapling instruments has obviated the need to perform anal mucosectomy for ulcerative colitis, but the potential exists for continued inflammation and, perhaps, malignant change. We reviewed the pathology specimens of patients who had had restorative proctocolectomy, to determine the incidence and severity of inflammation in the anal mucosa.

Superoxide production by Crohn's disease neutrophils.

Neutrophil superoxide anion production was measured in healthy subjects and in patients with quiescent and active Crohn's disease using superoxide dismutase inhibitable cytochrome C reduction. Three stimuli were used: phorbol 12-myristate 13-acetate (PMA1), phorbol 20-oxo-20-deoxy 12-myristate 13-acetate (PMA2), and Candida albicans in serum. Normal neutrophils produced significantly more superoxide anion than Crohn's disease neutrophils with both PMA1 (mean (SD) 9.6 (2.2) v 8.6 (1.8) nmol/10(6) cells/5 minutes, p = 0.04) and PMA2 (1.8 (0.8) v 0.8 (0.77) nmol/10(6) cells/5 minutes, p = 0.00004). With C albicans in serum, normal and Crohn's disease neutrophils produced similar amounts of superoxide anion (4.4 (1.5) v 4.3 (1.7) nmol/10(6) cells/30 minutes, not significant). Results were independent of disease activity. Superoxide anion production by PMA-stimulated Crohn's disease neutrophils is significantly lower than by normal neutrophils.

Long-term changes in body composition after pancreatoduodenectomy.

Body protein and fat stores were measured in four long-term survivors both before Whipple's procedure for malignancy at the ampulla of Vater and at a mean of 40 months (range 20-64 months) later. The results were compared with predicted well values. At follow-up patients also underwent dietary assessment and measurement of faecal fat losses. A dietary intake of mean (s.d) of 2690 (733) kcal per day and 85 (21) g protein per day met the patients' requirements. There was notable steatorrhoea (faecal fat 28 (21) g per day) but faecal protein losses were normal. Before surgery, body-weight was significantly lower than well-weight (P less than 0.0005), three patients having body fat stores lower than predicted well values. After surgery, body-weight and protein stores did not change significantly but fat stores fell in each patient (P less than 0.04). A curative Whipple's procedure prevents further weight loss in ampullary malignancy but weight gain does not occur because of steatorrhoea, perhaps a result of the accompanying truncal vagotomy.

Candidacidal activity of Crohn's disease neutrophils.

The ability of normal and Crohn's disease neutrophils to kill Candida albicans has been studied using neutrophils isolated from peripheral blood and suspended in phosphate buffered saline at 5 x 10(6) cells per ml. C albicans was grown to a stationary phase in broth culture and suspended in phosphate buffered saline at 10(7) organisms/ml. Neutrophils and Candida were then incubated together at 37 degrees C in a shaking water bath in the presence of fresh serum. At 30 and 60 minutes samples were withdrawn, neutrophils lysed, and Candida survival assessed by colony counting. Results were compared with control suspensions of Candida incubated with serum alone. After 30 and 60 minutes in the presence of autologous serum normal neutrophils had killed significantly more Candida than Crohn's disease neutrophils (mean (SD) 61.0 (16.7)% v 40.5 (16.2)% at 30 minutes, p less than 0.0001; 83.2 (7)% v 70.8) 16)% at 60 minutes, p less than 0.005). The results did not alter significantly when normal neutrophils were incubated with Candida in the presence of Crohn's disease serum instead of normal serum. When Crohn's disease neutrophils were incubated with Candida in the presence of normal serum instead of autologous serum there was some improvement in candidacidal ability at 30 minutes (48.9 (20.6)% v 40.5 (16.2)%, p less than 0.03) but not at 60 minutes. Phagocytosis, measured using a radiometric assay, was normal. Neutrophils from patients with Crohn's disease have an impaired ability to kill this granuloma provoking organism. It is not due to serum inhibitors or defective phagocytosis.

Neutrophil motility in Crohn's disease.

Neutrophil motility in normal subjects and Crohn's disease patients was assessed using both double and single filter assay systems with n-formylmethionylleucylphenylalanine (FMLP) as the attractant, and in a single filter assay with Candida albicans in 10% serum as the attractant. Assays were performed in triplicate and included controls to eliminate the effect of random (non-stimulated) locomotion. After incubation at 37 degrees C, filters were fixed and stained and the numbers of neutrophils per filter field counted under the microscope. Stimulated migration was calculated by subtracting random from total migration. Compared to normal neutrophils, 56% more Crohn's disease neutrophils migrated towards FMLP in the double filter system (p = 0.01). With the single filter technique using FMLP as the attractant 58% more Crohn's disease neutrophils migrated (p = 0.002). With the single filter technique using C. albicans as the attractant 47% more Crohn's disease neutrophils migrated (p = 0.02). Neutrophil motility in patients with Crohn's disease is enhanced and results were not related to disease activity.

Failure of nutritional recovery after total gastrectomy.

Malnutrition is reported to be an inevitable consequence of total gastrectomy, although there are few data to support this contention. Six patients of median age 63 years underwent total gastrectomy for malignancy. At follow-up (median 45 months, range 25-60 months) each patient was clinically tumour-free and underwent dietary assessment, faecal fat and nitrogen measurement and routine haematological testing. Protein and fat stores, measured by neutron activation analysis and the tritiated water dilution technique, were compared with the same measurements made before operation and with predicted values. Mean (s.d.) dietary intake (2224(381) kcal day-1 and 81(15)g protein day-1) met the patients' estimated requirements. Mean(s.d.) serum albumin and faecal nitrogen values were normal but there was notable steatorrhoea (21(17) g day-1). Body composition measurements revealed profound deficiencies of body-weight (P less than 0.02), protein (P less than 0.01) and fat (P less than 0.02) before operation which were not corrected by an apparently curative total gastrectomy (P less than 0.05), although further deterioration was prevented.

Results of 50 ileoanal J pouch operations.

Fifty ileo-anal J pouches were constructed in 26 males and 24 females for ulcerative colitis (n = 45) and familial adenomatous polyposis (n = 5). Two-thirds had proctocolectomy and pouch formation as a one-stage procedure. Thirty patients had a handsewn pouch and anastomosis and 20 were stapled. Forty-five patients had their defunctioning ileostomy closed for at least 2 months, of whom three have not been recently reviewed. One pouch was defunctioned for ischaemic stricture. The median time between pouch construction and ileostomy closure was 15 weeks and the time between closure and assessment ranged from 2 to 50 months (median 18 months). Median stool frequency was six per 24h in both the handsewn and stapled groups. Faecal incontinence occurred in 20% of patients with a handsewn anastomosis but in no patient with a stapled anastomosis (P less than 0.02). Soiling was also more common in the former group. Some 76% of patients noted an improvement in pouch function with time. In all, 67% of males and 78% of females reported unchanged or increased sexual activity since pouch surgery. Pouchitis has occurred in 20% of patients; 10% have had complications related to the pouch or anastomosis; 10% related to the ileostomy; and 6% have had small bowel obstruction. There have been no deaths. Overall, 88% of patients have had a good result, but none of the five patients with a poor result will revert to an ileostomy.

Malakoplakia of the bladder.

Malakoplakia is a disease which most commonly affects the bladder. It is probably more common than is realised because the appearance of the lesions is variable and the diagnosis can be difficult to make histologically. It should be considered in patients with recurring Escherichia coli infections and is also associated with immunosuppression and carcinoma. Three patients with malakoplakia of the bladder are reported: two had recurrent Esch. coli urinary tract infections and one had widespread urological malignancy. The pathogenesis is discussed and a simple treatment regime, which was rapidly successful in the patient who received it, is recommended.

Hepatic artery aneurysm.

We describe a 58 year old woman who had an aneurysm involving the common hepatic artery, the right and left hepatic arteries and the cystic artery which had ruptured into the liver. It was successfully treated by proximal ligation. The features and management of hepatic artery aneurysm are discussed.

Transitional cell carcinoma in an ileal conduit.

Following cystectomy for transitional cell carcinoma a 63 year old woman developed recurrent tumours in the upper urinary tract and ileal conduit, suggesting that malignant transitional cells can auto-implant in ileal epithelium. This phenomenon has not been previously reported. We illustrate the value of retrograde urogram via an ileal conduit following cystectomy for cancer.