Audit of a nurse endoscopist based one stop dyspepsia clinic.

As a response to the UK Health Department's "two week cancer wait" initiative a one stop dyspepsia clinic based on a nurse endoscopist was introduced, and the first 100 cases attending this clinic have been audited. After referral on a purpose designed form, patients were assessed by a gastroenterologist and then investigated at the same visit--where possible and appropriate--by endoscopy or ultrasound scan. All endoscopies were performed by a trained nurse specialist. Of the 100 patients, 84 were gastroscoped the same day and 11 had an ultrasound scan. Inappropriate tests were avoided in 16% of referrals. The commonest endoscopic diagnoses were minor oesophageal or gastroduodenal inflammation (64% of gastroscopies). Only six oesophageal or gastric cancers were found--all at an advanced stage--and three further malignancies were diagnosed. Only a minority (12%) of the patients with "alarm symptoms" had cancer. The waiting time for an appointment rose progressively during the first six months of the clinic. The system was popular with patients as most of them (70%) were dealt with at a single hospital attendance. Basing the endoscopy practice on a trained nurse specialist not only facilitated the creation of the service by maximising the use of scarce resources, but also improved communication and overall management of patients.

Gas gangrene after colonoscopy.

A case of spontaneous clostridial myonecrosis developing shortly after diagnostic colonoscopy is described. The prime underlying factor proved to be an unsuspected colonic cancer, developing in a patient with pre-existing ulcerative colitis and sclerosing cholangitis.

Pulse oximetry monitoring during non-sedated upper gastrointestinal endoscopy.

Fifty consecutive patients judged fit for non-sedated upper gastrointestinal endoscopy were monitored by pulse oximetry before, during and after the procedure. Transient hypoxia developed during intubation in five subjects (10%) but treatment was not required nor was the test halted. Only one patient with pre-existing respiratory problems became hypoxaemic to the extent that oxygen had to be given and the procedure halted. The chance of hypoxia was unrelated to age, sex, smoking, anxiety, or the duration of intubation. Routine pulse oximetry is not necessary for non-sedated gastroscopy but oximetry monitoring may be important in selected cases.

Randomised, double blind comparison of omeprazole and cimetidine in the treatment of symptomatic gastric ulcer.

In a randomised, double blind, parallel group study in patients with symptomatic gastric ulcer (94% greater than or equal to 5 mm diameter), 102 received omeprazole 20 mg om and 87 cimetidine 400 mg bd. After four weeks 73% and 58% (p less than 0.05) respectively had healed (eight weeks: 84% and 75%, ns). After four weeks, a greater proportion (81%) of omeprazole treated patients was symptom free than of those receiving cimetidine (60%; p less than 0.01). Over the first two weeks, patients receiving omeprazole had less day pain, less night pain and took fewer antacids than those receiving cimetidine (all p less than 0.05). The difference between omeprazole and cimetidine was not appreciably affected by age, smoking, size of the ulcer and trial centre. Tolerability was similar in the two treatment groups. In the treatment of symptomatic gastric ulcer, omeprazole relieves the symptoms more quickly than cimetidine and heals a greater proportion of ulcers within four weeks.

Symptom relief and duodenal ulcer healing with omeprazole or cimetidine. Opus (Omeprazole Peptic Ulcer Study) Research Group.

In a double-blind parallel-group study, 98 patients with symptomatic duodenal ulcer received omeprazole 20 mg o.m. and 91 cimetidine 800 mg nocte for 2 or, if then not healed, 4 weeks. After 2 weeks the healing rates on an intention-to-treat basis were: for omeprazole 62% and for cimetidine 33% (P less than 0.001), and at 4 weeks 85% and 61%, respectively (P less than 0.001). The proportions symptom-free at 2 weeks were 83% of the omeprazole and 63% of the cimetidine-group (P less than 0.01) and at 4 weeks 84% and 72% (P = 0.01). Patients receiving omeprazole took fewer antacid tablets than those receiving cimetidine. Patient tolerance of both drugs was similar and good. In the treatment of duodenal ulcer, omeprazole 20 mg o.m. gives faster symptom relief than cimetidine 800 mg nocte, as well as healing a greater proportion of ulcers within 2 and 4 weeks.

Double-blind comparison of olsalazine and sulphasalazine in active ulcerative colitis.

Fifty-six patients with ulcerative colitis of mild to moderate severity were entered into a randomized, double-dummy comparison of sulphasalazine, 3 g/day, with olsalazine, 3 g/day. Patients were assessed clinically, and by sigmoidoscopy and biopsy, on entry and at 5 weeks. Both agents produced a similar reduction in stool frequency and in the passage of blood and mucus. Improvements in sigmoidoscopic and histological appearances of the rectal mucosa were observed to a similar extent in both groups of patients. Two patients treated with olsalazine were withdrawn because of increased diarrhoea attributable to the medication. Two patients given sulphasalazine for the first time developed a skin rash. Other side-effects seen during the trial were mild. In this small short-term study, oral olsalazine appeared to be as effective as sulphasalazine in the treatment of mild to moderate ulcerative colitis.

Crohn's disease and pericarditis.

A patient is described who developed acute pericarditis during a severe first attack of Crohn's disease. The opportunity was taken to measure levels of circulating immune complexes, both during the acute phase of the illness and during convalescence; no significant change in these levels from normal values was found. The Crohn's disease and the associated pericarditis responded to systemic corticosteroid therapy, and no relapse has occurred during 14 months of follow-up.

Crohn's disease and pregnancy.

Infertility and the outcome of pregnancy has been examined in 112 married women with Crohn's disease who were below the age of 45 years. Fifty four patients were available for study. The infertility rate (12%) was similar to that seen in the general population. Patients who had active disease at the time of conception continued to have symptoms and they mostly failed to go into satisfactory remission despite therapy. Furthermore, there was a high rate (35%) of spontaneous abortion in this group. In contrast, patients whose disease was in remission at the time of conception had a normal pregnancy and, in the majority, the Crohn's disease remained quiescent.

Distribution and metabolism in healthy volunteers of disodium azodisalicylate, a potential therapeutic agent for ulcerative colitis.

A series of experiments has been performed in healthy male volunteers to investigate the disposition of orally administered disodium azodisalicylate, a potentially useful drug for the treatment of ulcerative colitis. The drug was given by mouth in doses of up to 2 g a day for six weeks and there were no adverse effects. Serum concentrations of the intact compound were low and the serum half-time was 4-12.8 days, probably because of a combination of a low clearance rate and a high apparent volume of distribution. Less than 5% of the ingested dose was excreted unchanged in the urine. Circulating concentrations of 5-ASA and N-acetyl-5-ASA were low and 30% of the equivalent daily dose was excreted in the urine, predominantly as N-acetyl-5-ASA. In most subjects more than 30% of the equivalent daily dose of 5-ASA was recovered from the faeces, either as 5-ASA itself or as the acetylated derivative. As 5-ASA has been shown to be the active therapeutic moiety of sulphasalazine, disodium azodisalicylate appears to be suitable for therapeutic trial in ulcerative colitis.

Ulcerative colitis and pregnancy.

A survey has been made of pregnancy occurring in patients who were attending the Ulcerative Colitis Clinic at Oxford during the 20-year period, 1960-79 inclusive. There were 256 married women of child-bearing age who attended during this period. Of these, 100 were excluded from the survey for various reasons, such as that they had completed their family before the onset of the ulcerative colitis, had already had an hysterectomy, or had a proctocolectomy before their first pregnancy. Of the remaining 156 patients, nine could not be traced. Full details were obtained from 147 patients, virtually all of whom were interviewed. The fertility of these patients was normal. Of the 147 women, 119 (81%) had conceived and only 10 (6.8%) were involuntarily infertile. The size of family approximated to that found in the general British population. The overall outcome of the pregnancies was similar to that in the general British population. The patients in whom the disease was quiescent at the start of pregnancy fared particularly well. Those with active disease had a somewhat lower chance of producing a normal live baby. The small group of patients in whom the disease was severe had a much lower chance of a normal outcome. Patients in whom the ulcerative colitis was quiescent at the beginning of pregnancy had a good chance of remaining symptom-free throughout the pregnancy and puerperium. Even if the colitis recurred, it was likely to be mild and responsive to medical treatment. By contrast, when the ulcerative colitis was active at the start of pregnancy, most patients continued to have symptoms in spite of medical treatment. Some patients had their first attack of ulcerative colitis during pregnancy or the puerperium. In contrast to previous experience the attacks were generally mild and responded to medical treatment. Medical treatment with corticosteroids or sulphasalazine appeared to have no obvious deleterious effects on the fetus or new-born child.

The effect of topical N-acetyl-5-aminosalicylic acid in ulcerative colitis.

In a double-blind controlled therapeutic trial, retention enemas of N-acetyl-5-aminosalicylic acid (Ac-5-ASA) were compared with dummy enemas in the treatment of active ulcerative colitis. Forty patients were studied, each patient taking one test enema twice a day for 2 weeks. Seventeen of the patients had a mild clinical attack of the disease; the 23 others had sigmoidoscopic evidence of active inflammation although they were in clinical remission. Histological and sigmoidoscopic improvement were significantly commoner in the patients receiving the active treatment than in those taking the dummy preparation. Pronounced histological improvement was only seen in patients taking the Ac-5-ASA enemas. In those patients who had clinical attacks of ulcerative colitis at the start of the study, symptomatic improvement was commoner in the group treated with Ac-5-ASA enemas than in those who received placebo therapy. Ac-5-ASA resembles 5-aminosalicylic acid in its effect on the inflamed mucosa in ulcerative colitis. Further studies into other substituted salicylates may lead to the development of an effective oral agent that does not carry the side effects associated with the sulphapyridine moiety of sulphasalazine.

Campylobacter colitis.

A patient is described in whom a campylobacter enteritis closely resembled ulcerative colitis on clinical, sigmoidoscopic, and histological grounds. Selective stool culture techniques may be necessary to differentiate campylobacter colitis from ulcerative colitis proper.

Comparison of disodium cromoglycate and sulphasalazine as maintenance therapy for ulcerative colitis.

In a trial lasting six months disodium cromoglycate (800 mg daily), sulphasalazine (2 g daily), and these two agents in combination were compared in 120 patients as maintenance treatment for ulcerative colitis. Relapse was defined as recurrence of colitic symptoms accompanied by sigmoidoscopic evidence of inflammation. The patients receiving disodium cromoglycate had a much higher relapse-rate than those taking sulphasalazine and the results with the two agents combined were little different from those with sulphasalazine alone. Disodium cromoglycate in the dose employed is greatly inferior to sulphasalazine as maintenance treatment for the prevention of relapse in ulcerative colitis.

Tissue eosinophils in ulcerative colitis.

A morphometric method has been used to quantitate eosinophils in the rectal lamina propria. The results from examination of paired biopsy specimens indicate that eosinophil distribution is uniform in the rectum. The number of eosinophils in specimens from patients with long-standing ulcerative colitis is significantly greater than that found in control subjects and increases with increasing clinical activity of the disease. In contrast, when biopsies are obtained from patients in a severe first attack of ulcerative colitis, eosinophil counts are not higher than in controls. The possible significance of these findings is discussed.

Further experience in the treatment of severe attacks of ulcerative colitis.

One hundred courses of an intensive intravenous regimen have been used in 87 patients with severe attacks of ulcerative colitis during the past 5 years, 11 of the patients having been treated more than once during separate admissions to hospital. 60% of the attacks responded swiftly to the regimen, and the patients were symptom-free at the end of the 5-day course. In 15% there was improvement but the patients were not entirely symptom-free. In 25% failure to respond resulted in emergency colectomy, the usual operation being proctocolectomy as a single-stage procedure. There were no deaths directly due to ulcerative colitis or to surgical treatment in these patients during the period of the study, the mean period of follow-up being 25 months; but 4 elderly patients died from unrelated causes. These favourable results are better than most published figures. The advantages of the intensive medical regimen are that: (i) many patients quickly go into clinical remission, which is frequently sustained; and (ii) failure to improve can be regarded as a clear-cut indication for emergency surgery.

Amino acid imbalance in cystinuria.

After oral ingestion of a free amino acid mixture by three cystinuric patients, plasma increments of lysine and arginine were lower and those of many other amino acids were significantly higher than those found in control subjects. Similar results were obtained in control subjects after amino acid imbalance had been artificially induced by the omission of cystine, lysine, and arginine from the amino acid mixture. Especially high increments of alanine and proline provided the best evidence of amino acid imbalance caused by a temporary lysine and, to a lesser extent, arginine and cystine deficit. No such amino acid imbalance was found to occur in the cystinuric patients after ingestion of whole protein, indicating that absorption of oligopeptides produced by protein digestion provided a balanced physiological serum amino acid increment. This is considered to explain the lack of any unequivocal nutritional deficit in cystinuric patients despite poor absorption of the essential free amino acid, lysine.