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Summary Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

The purpose of this prospective study was to determine the clinicopathological significance of necrotic areas demonstrated by rapid-bolus contrast-enhanced computed tomography (CT) in patients with biochemically predicted severe pancreatitis. Although CT necrosis occurred significantly more frequently in patients with clinically severe (ten of 12) compared with mild (seven of 20) pancreatitis (P < 0.025), seven of 17 (41 per cent) patients with CT necrosis developed clinically mild pancreatitis and six of ten (60 per cent) patients with clinically severe pancreatitis and CT necrosis recovered with conservative management. The site and extent of CT necrosis did not correlate with disease severity. Fine-needle aspiration cytology, operative and post-mortem findings and endoscopic retrograde cholangiopancreatography examinations all strongly suggested that CT necrosis represents true pancreatic necrosis. We conclude that the finding of CT necrosis is not in itself an indication for operative intervention, but that rapid-bolus contrast-enhanced dynamic CT greatly facilitates the planning and execution of surgical therapy.

Summary Twenty-five patients with squamous cell carcinoma (SCC) of the anus have presented over an 8 year period; 18 were female. Six of 9 patients aged under 50 years were female. Five of these women had been treated for a previous cervical malignancy (2 invasive) and 4 practised anal intercourse; human papillomavirus (HPV) type 16 DNAs were isolated from their arcival anal/cervical paraffin sections. Signals were confined to the nuclei of the invasive anal SCC cells and the transformation zone of the cervix. HPV 6, 11 and 18 DNAs were not identified. Young women with cervical intraepithelial (CIN) III or invasive cervical SCC found in association with HPV infection are at risk of developing anal SCC (P

A 63 year old Asian woman who presented with three week's abdominal pain was found to have a hard right iliac fossa mass and rectal ulceration. Profuse rectal bleeding necessitated a laparotomy. An inflammatory paracaecal mass with fistulae involving appendix, small bowel, and bladder was excised with exteriorisation of the bowel ends. Microscopy showed invasive amoebae. Re-anastomosis was successfully done after treatment with metronidazole and diloxanide. There are no previous reports of a paracaecal amoeboma with fistulae to either the appendix, or urinary bladder.

The gastric secretory response to insulin changes in many patients between ;immediate' tests, within two weeks of vagotomy, and ;delayed' tests, done at least six months later. Patients who develop recurrent duodenal ulceration after vagotomy and pyloroplasty show highly significant increases in peak and rise in concentration and output of acid. Those who do not have recurrent dyspepsia show varied individual changes in the test results, but for the group as a whole there is no increase in the peak response and only a slight increase in the rise in acid concentration and output. These findings are interpreted as evidence for vagal recovery, either from neuropraxia or by collateral nerve sprouting, as a major factor in the production of recurrent ulceration. Indeed, it appears to be as important as the functional state of the vagi at the end of the operation. Consequently, only the delayed insulin tests can be of any value in the prediction or diagnosis of recurrence.

A series of 144 patients with acute cholecystitis included 32 who were jaundiced. Seventy-three per cent of the jaundiced group had stones in the common bile-duct, compared with only 6.5 per cent of nonjaundiced patients. Jaundice in acute cholecystitis is, therefore, a strong indication for exploration of the common bile-duct. This applies not only to elective but also to emergency or early operation.

Following sclerotherapy of varicose veins, 158 limbs of 154 patients were randomized to be bandaged with either crepe or Coban for 6 weeks each, or with Coban for 3 days only. Objective assessment of vein eradication and subjective evaluation of symptoms 3 months after completion of treatment showed no clear differences between these regimens. Significantly more discomfort was experienced with Coban than crepe when used for 6 weeks. It is suggested that, following sclerotherapy, 3 days is an adequate period of bandaging when using Coban. Such a policy would considerably reduce the inconvenience to patients during treatment.

Ingrowing of the nail of the hallux has been ascribed to an abnormality of the shape of the nail; our prospective study was planned to test this association. Twenty-three consecutive patients and 23 age-matched controls were assessed by caliper measurement and standard photographs, before a first operation for ingrowing toenail. We found no differences in shape between the toenails of the patients and those of the controls, both groups showing great variation. Our results suggest that the ingrowth is not commonly associated with an abnormal shape of the nail.

It has previously been shown that insulin tests of gastric secretion carried out within 2 weeks of vagotomy and pyloroplasty give no indication of the patient's liability to recurrent duodenal ulceration. Delayed insulin tests (done 6 or more months postoperatively) have been compared in 100 patients without and 50 patients with recurrence after operation for duodenal ulceration. Complete discrimination between the groups was not achieved but the incidence of recurrence was related to the magnitude of the acid response. As no dividing line could be established to separate tests into positive and negative results, it is preferable that the actual figures for the gastric acid response to insulin be quoted. It is suggested that the peak acid concentration should be selected for this purpose. Separate estimates of the probability of recurrence associated with various levels of peak acid concentration have been made for routine insulin tests and for tests performed in patients with clinical evidence suggestive of recurrent ulceration.

A method has been developed in which the simultaneous administration of 51Cr-labelled red bloodcells and 125I-labelled albumin in the dog has been used to compare the flow rates and transit times of erythrocytes and of plasma in three circulatory beds–the hindlimb, the kidney, and the small intestine. Blood-flow rates calculated from either isotope agreed well and were significantly greater than simultaneous direct measurements and electromagnetic flowmeter readings. This difference was due to in complete recovery of the isotope from the venous cannula, recovery ranging from 23 to 96 per cent. When the isotope-flow results were corrected for these losses they did not differ significantly from direct measurements though they were still greater than the electromagnetic flowmeter readings. The mean transit time for erythrocytes was, on average, 6–8 per cent shorter than that for plasma. There was no significant difference in this percentage for the three vascular beds studied or between a control period and haemorrhagic shock. Thus, in this shock preparation red-cell ‘sludging’ cannot have been extensive. The rationale for the use of low-molecular-weight dextran as a specific ‘antisludging’ agent in shock is, therefore, not supported.