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Thirty-seven patients suffering an attack of acute distal ulcerative colitis of mild or moderate severity were randomized in a double-blind, double-dummy fashion to receive either 800 mg oral mesalazine four times daily (18 patients) or steroid enemas twice daily (19 patients) for 4 weeks. Both treatments were well tolerated with no adverse effects. Three patients in each group were withdrawn because of clinical deterioration but both treatments produced significant clinical improvement with decreases in stool frequency and scores for urgency, bleeding and tenesmus. There were no significant differences between the treatments although there was a slight trend in favour of the enemas for reduction in rectal bleeding. Activity of the colitis as graded at sigmoidoscopy also decreased significantly with both treatments and there were corresponding improvements in histological parameters of inflammatory activity assessed with the aid of a computerized morphometric system. Little correlation was seen between clinical, sigmoidoscopic and histological changes.

Background and aims: Nutritional supplements are widely administered in hospitals and can benefit clinical outcome. The aim here was to determine the effect of routine post-operative nutritional supplementation on the nutritional status and clinical outcome of adult orthopaedic patients. Methods: A prospective controlled study was conducted on two adult orthopaedic wards. Patients in the study group were prescribed two nutritional supplements/day post-operatively. Nutritional and biochemical indices and incidence of clinical complications were observed. Results: Of 181 patients studied, 14 in the supplemented group and 34 in the control (P=0.005) developed major complications. There were 22 occurrences of major complications in the supplemented group and 55 in the control (P=0.0002). There was no significant difference in the number of minor complications between the two groups (P=0.2). There was no statistical difference in changes in nutritional parameters or in albumin or CRP between the two groups. There were significantly greater reductions in transferrin (P=0.002) and in haemoglobin (P=0.002) in the control group at week 1. The median costs of hospital stay were £2068 in the supplemented group and £2199 in the control. The median cost of additional treatments was £30.16 in the supplemented group and £46.23 in the control. Conclusion: A significant reduction in major complications and in number and costs of additional treatments was seen in the supplemented group.

Morphometric measurements were performed on rectal biopsy specimens from 10 normal control subjects and 33 patients with a relapse of distal ulcerative colitis before and after treatment for four weeks in a double blind controlled trial with oral eudragit S coated 5 amino salicylic acid (n = 12) or rectal prednisolone enemas (n = 15). Measurements were assessed using a computer aided measuring system and a counting technique. When untreated patients were compared with the control group there were significant decreases in the area and height of the surface epithelium, in the area of crypt epithelium, and in the ratios of goblet cells to epithelial cells and of surface epithelium to lamina propria. The vascular and lamina propria areas and the number of intraepithelial polymorphs were increased. Treatment with 5 amino salicylic acid and corticosteroids resulted in similar morphological improvements: there was an increase in the area and height of the surface epithelium and the ratios of surface epithelium to lamina propria and of surface to crypt cell height. The ratio of goblet cells to epithelial cells also increased after treatment, while the numbers of polymorphs in the surface and crypt epithelium and lumen decreased. In conclusion, computerised morphometry is valuable for the assessment of the treatment of patients with ulcerative colitis and that in the doses used both treatments were of similar efficacy.

Objectives To determine the number of patients referred for enteroscopy in a district general hospital (DGH), the indication, enteroscopic +/− histological diagnosis, and to compare findings with other series from tertiary referral centres or outside the UK. Design Retrospective case series over a 2-year period. Results In the 2-year period, 52 patients were referred for enteroscopy. All except one underwent enteroscopy. The mean age of the patients was 60 years (range 31–84 years). The main indications for enteroscopy were obscure gastrointestinal haemorrhage in 31 (61%) patients (19 with acute and 12 with chronic bleeding) and 7 (14%) patients with arteriovenous malformations (AVMs) on initial oesophagogastroduodenoscopy (OGD). Other indications included clinical deterioration in known coeliac disease in four (8%) patients and abnormal small-bowel follow-through in five (10%) patients. More than half (51%) of the enteroscopies were reported as abnormal, but 10 (38%) had pathology in the stomach or first part of the duodenum (D1) not diagnosed on initial OGD. Diagnoses of two T-cell lymphomas and one of pre-lymphomatous monoclonal T-cell proliferation were made in the refractory coeliac disease group. Conclusions Indications (obscure gastrointestinal bleeding), most frequent findings (small-bowel AVMs), and ‘missed’ lesions within reach of a gastroscope (20%) were in keeping with other series. Enteroscopy is a useful tool in investigating patients with refractory coeliac disease. Its value in investigating patients with abnormal small-bowel radiology was not confirmed. The current need for push enteroscopy in a DGH is small (approximately 1 per 8000 population per year), but it would take only small changes in referral practice to escalate. Criteria for enteroscopy should be developed and refined with improving knowledge of the diagnostic yield for each indication and clinical outcome.

Background: Studies have shown clinical benefits of nutritional supplementation in orthopaedic and elderly patients in both under and well nourished groups. However, patient compliance with the supplementation has not been reported. Aim: To assess level of patient compliance with nutritional supplementation when prescribed postoperatively to unselected orthopaedic patients as part of a large controlled trial researching the clinical benefits of non-targeted nutritional supplementation. Methods: Patients in the intervention group were prescribed two oral supplements each day of their hospital stay, in addition to usual meals. Information describing the supplements was given by the dietitian. Supplements were issued on drug rounds and the proportion of each drink consumed was recorded and collated. Patients could choose to change the type of drink or to discontinue the supplements completely at any time. Twenty-four hour food intake was analysed for a random sub-sample of 48 patients. Results: Eighty-four patients (27 men, 57 women; mean age, 72 years) were prescribed supplements. Median length of stay was 14.4 days. Supplements were taken for a mean of 6.7 days. Median compliance was 14.9%. Despite this, median energy intake in the study group was 1523 kcal/day and 1289 kcal/day in the control ( P = 0.0214). Conclusion: Compliance with non-targeted, postoperative nutritional supplementation is poor in unselected orthopaedic patients but even low levels of supplementation significantly increase energy intake.

Chronic ischemia of the small bowel is classically described as presenting with abdominal pain associated with eating (intestinal angina). Here we describe the cases of two patients with chronic small bowel ischemia who presented atypically with painless watery diarrhea and weight loss. These cases suggest that the clinical spectrum of chronic small bowel ischemia may be wider than previously appreciated. Chronic ischemia of the small bowel should be included in the differential diagnosis for painless watery diarrhea in the context of weight loss.

Background: It is rare (0.05-0.5%) for clinically significant gastrointestinal haemorrhage to occur as a result of a mucosal biopsy at endoscopy. There are no data on the risk of bleeding specifically in anticoagulated patients. However in a prospective audit1 the one death from haemorrhage (in 13,036 diagnostic procedures) occurred in a patient with abnormal clotting. Aims: This survey was undertaken to determine regional practice with regard to management of patients on warfarin who required endoscopy. Methods: 122 questionnaires were sent to endoscopists (physicians and surgeons) in 16 hospitals across the Northern Region of England. Results:We received 100 replies (83%): 66 from consultants, 26 from training grades. The average experience as an endoscopist was 13.5years. 77% of endoscopists routinely stopped warfarin before a procedure. Usually the warfarin was stopped 3 days prior to the procedure (range 2-7 days). When asked, "If a patient is on warfarin at the time of gastroscopy /colonoscopy and a mucosal biopsy is indicated… ", 49% stated they would never take a biopsy, 38% stated that they would, and for the remainder there were various provisos. In the experience of the endoscopists (totalling 1255 years!) 30% had never taken a biopsy from a patient on warfarin. Of those 70 endoscopists who had taken at least one biopsy from a warfarinised patient; 19% admitted it was non-intentional, and 34% stated it was not always intentional. 8 endoscopists were personally aware of complications occurring as a result of taking those biopsies. Rectal bleeding was the most common but unfortunately one patient had severe bleeding, admission to ITU and died, and another had a fatal upper GI bleed. It is not clear if these instances refer to the same patient. Conclusions: The risk anticoagulation poses to bleeding after endoscopic biopsy is not quantified. It is perhaps unsurprising therefore that practice is so diverse in the Northern Region of England. Most endoscopists aim to stop warfarin before a procedure, but the time off warfarin shows considerable variation. An almost equal division of opinion exists as to whether or not a biopsy should be taken if indicated when the patient is warfarinised. As at least one biopsy resulted in fatal bleeding, this survey emphasises the need for a review of practice and complications. Then a more informed risk-benefit assessment may be made as to whether or not biopsy is indicated. Reference: 1.Quine MA, Bell GD et al. Prospective audit of upper GI endoscopy in 2 regions of England: safety, staffing and sedation methods. Gut 1995; 36:462-467.

Introduction: Push enteroscopy is a comparatively new endoscopy technique not routinely available in the UK.We have offered push enteroscopy to patients attending our hospital for 2 years. North Tyneside General Hospital serves a mixed urban population of approximately 200,000 people. In general it does not receive tertiary referrals, although the enteroscopy service has attracted some referrals from other hospitals outside our catchement area. Aims: To determine during a two year period the number of patients referred for enteroscopy from our own population and from further afield, the indication for referral, the diagnoses made and alterations to patient management. Methods: The medical notes of all 52 patients referred for enteroscopy during this period were reviewed. All except one underwent enteroscopy. 26 patients were referred from within the hospital and 26 from outside. Results: 26 referrals were made from our 200,000 population over a 2 year period. This suggests that there is a need for approximately 6-7 push enteroscopies per 100,000 people per year in our population. The indications for enteroscopy were: Obscure GI haemorrhage (n=32 with 19 acute and 13 chronic cases) Arteriovenous malformations (AVM's) on initial endoscopy (n=7) Unexplained clinical deterioration in known coeliac disease (n=4) Abnormal small bowel follow through (n=5) Other; weight loss, diarrhoea +/- abdominal pain (n=4). Of the 51 patients undergoing enteroscopy, less than half (49%) were normal. Of the 26 abnormal enteroscopies, 7 had pathology in the stomach or first part of the duodenum (D1) that had not been diagnosed on initial OGD. Three had known AVM's in the stomach or D1 only but none distally. There were 9 patients with small bowel AVM's distal to D1 sufficient to explain their presentation and all were treated at enteroscopy. Important and unexpected diagnoses made were three cases of T cell lymphoma, two cases of coeliac disease, one of collagenous enteritis and one of jejunal adenocarcinoma. Conclusions: As in previous series, obscure GI bleeding, both acute and chronic, was the main indication for push enteroscopy and small bowel AVM's were the most frequent finding. Push enteroscopy led to alterations in management in 51% of the cases and, as previously reported, missed abnormal findings within reach of OGD were frequent (14%). Although the need for push enteroscopy appears to be small, it would only take small changes in referral practice to increase this need significantly.

Editor,—Lim and colleagues recently presented three cases of diversion colitis which seemed to act as a trigger for instream ulcerative colitis ( Gut 1999; 44 :279–282). We would like to present a fourth case which has recently come to our attention and which adds to the literature. In 1994, a 75 year old woman presented with a five year history of faecal soiling and urinary incontinence. A former smoker of 50 years, the patient had had a traumatic forceps delivery …

Summary Twenty unselected patients with proven systemic sclerosis had cultures of jejunal juice, and glucose/hydrogen breath tests for small intestinal bacterial overgrowth. Seven had counts of over I06 organisms/ml, higher than was ever found in a control group. Four of these seven had a positive breath test. Small intestinal bacterial overgrowth appears to be relatively common in systemic sclerosis, affecting approximately one-third of unselected patients.

Seventeen patients with proven systemic sclerosis had a peroral jejunal biopsy performed. Four biopsies were regarded as showing abnormalities, which were mostly confined to the deeper structures, although in two there was a minimal degree of villous atrophy without epithelial cell changes. Passive intestinal permeability, as assessed by the cellobiose/mannitol test, was normal in all patients. In contrast, seven patients had a low xylose test result, which in five of them could be accounted for by impaired renal function, small intestinal bacterial contamination, or altered gastrointestinal transit. These results indicate that passive intestinal permeability is unaltered in systemic sclerosis, and that malabsorption, when it occurs, is caused by other factors.

1 The effects of single doses (25 g and 50 g) oral ethanol on the disposition of acetanilide (50 mg/kg metabolic active mass) has been studied in normal subjects, and in patients with chronic non-alcoholic liver disease. 2 In normal subjects, ethanol produced a dose-dependent increase in acetanilide half-life, and a decrease in acetenilide clearance. There was a significant correlation (rs = 0.71, P less than 0.01) between the 90 min blood ethanol concentration and the reduction in acetanilide clearance. 3 In patients with liver disease, ethanol produced a similar proportional change in acetanilide half-life and clearance, but these were less consistent. Moreover, liver disease itself was associated with an increase in acetenilide half-life, and a reduction in clearance. 4 It is concluded that single oral doses of ethanol, comparable to those consumed during social drinking, may inhibit some forms of microsomal oxidation and thus have important clinical implications.

Lundh tests of pancreatic exocrine function were performed on twenty unselected patients with systemic sclerosis. Three patients had very low levels of tryptic activity in their intestinal juice and only nine had results which were unequivocally normal. Eight patients had biochemical steatorrhoea, but in six this was associated with intestinal bacterial overgrowth and a seventh had primary biliary cirrhosis. The remaining patient had no cause for steatorrhoea other than the marked pancreatic insufficiency which had been demonstrated. Although pancreatic damage may contribute to malabsorption in systemic sclerosis, it appears to be less important than other factors such as intestinal bacterial overgrowth.

Passive intestinal permeability has been investigated in rats infected by the nematode, Nippostrongylus brasiliensis, by the simultaneous administration of two probe molecules. Experiments using a closed intestinal loop show that there is a significantly increased absorption of lactulose and decreased absorption of mannitol in rats at the 10th to 11th day of infection. Experiments using serial oral administration techniques show that these changes start during the second week of the infection with a return towards normal values by the end of the third week. The results are similar to those found in human coeliac disease and add weight to previous studies which have stressed the similarity in the two disease processes.

Intestinal permeability has been studied in 21 patients with coeliac disease in relapse and after gluten withdrawal using an oral test of intestinal permeability based on the simultaneous oral administration of two probe molecules. The increased absorption of the larger molecule (cellobiose) and the decreased absorption of the smaller (mannitol) found in untreated coeliac disease both returned to normal within five months of starting treatment, the abnormality in cellobiose absorption correcting more rapidly than that of mannitol. After exposure to a single oral dose of gluten, the intestinal permeability of six patients with treated coeliac disease became transiently abnormal with an increased absorption of cellobiose, returning to normal within one week. The possible structural and functional implications of these findings are discussed. The cellobiose/mannitol ratio appears to be of value in assessing the response to gluten withdrawal in coeliac disease, and also in monitoring patients who are already established on a gluten free diet by detecting dietary lapses and 'non-responding coeliac disease'. It may also offer an alternative to jejunal biopsy in patients subjected to gluten challenge.

In disease states of the small intestine--for example, gluten-sensitive enteropathy--there is an increased permeability to large molecules. This increased permeability extends to polar molecules of intermediate size such as disaccharides, whereas small polar molecules are malabsorbed. A recently-developed oral test, based on the simultaneous administration of two test substances, cellobiose (a disaccharide) and mannitol (a small polar molecule) has been used to investigate permeability in a variety of gastrointestinal diseases, the result of the test being expressed as the ratio (cellobiose/mannitol) of the five hour urinary recoveries of the two probe molecules. Results for patients with pancreatic insufficiency, intestinal bacterial overgrowth, primary hypolactasia, ileocolic or colonic Crohn's disease, and ulcerative colitis were comparable with those in normal controls, whereas in 23 out of 24 untreated coeliacs, and five out of eight patients with Crohn's disease involving the more proximal small bowel, the cellobiose/mannitol ratio was clearly abnormal. A study of its application as a screening procedure for coeliac disease showed that the test was both sensitive and accurate, with fewer false-positive and false-negative results than other recognised screening tests--namely, the xylose test, reticulin antibodies, and blood folate estimations.

Summary Three cases of biopsy-proven coeliac disease are presented. In each case the predominant clinical and laboratory features suggested liver disease, bowel symptoms were a minor part of the presentation and the diagnosis of coeliac disease was not reached for approximately 6 months. Liver biopsy in one case showed marked fatty change, in the other cases only mild hepatitic changes. A gluten-free diet produced resolution of symptoms and, in the patient with steatosis, normalization of liver function tests. Hepatic abnormalities have been reported in coeliac disease and the significance of these is discussed but such abnormalities are usually minor and do not obscure the underlying diagnosis. We feel that these cases serve as a salutary reminder of the protean manifestations of coeliac disease.

Many patients with suspected colonic disease undergo rigid sigmoidoscopy, barium enema examination, and ultimately total colonoscopy, but the need for preliminary radiology has not been formally assessed. A total of 168 patients requiring large bowel investigation were therefore randomised to undergo either rigid sigmoidoscopy plus double contrast barium enema examination or total colonoscopy. Disease was found in 56 patients, including 14 with a carcinoma, 11 with polyps, and 16 with inflammatory bowel disease, the remainder having diverticular disease alone. Of the 89 patients allocated to double contrast barium enema examination, nine required a subsequent colonoscopy for suspected tumour or polyps, three because of incomplete radiological examination, and 12 for rectal bleeding for which no cause was found at the radiological examination. In 16 patients this yielded further information or altered treatment. Of the 79 patients undergoing total colonoscopy, only six required subsequent radiology. As both procedures were well tolerated with no major complications total colonoscopy may be the preferred initial investigation where facilities allow.

A young woman with ulcerative colitis developed pneumonia, which responded to corticosteroids. Histological examination showed this to be bronchiolitis obliterans organising pneumonia.

Over a four-year period 40 patients of local origin, with primary hepatocellular carcinoma were seen at a regional referral centre. Twenty-nine patients had histological evidence of underlying cirrhosis and these patients were predominantly male (25/29) and elderly (mean age 66 years). Serological evidence of hepatitis B virus (HBV) infection was found in 11 (38 per cent) of the cirrhotic group. Of the 25 males with cirrhosis, 13 (52 per cent) were known to have seen military service in the tropics and of these eight had serum HBV markers. The non-cirrhotic group was younger (mean age 55 years) and the sex distribution was nearly equal (six male, five female). Two patients (19 per cent) had hepatitis B markers including one of the two men in this group who had served in the tropics. One patient with no serum HBV markers had integrated HIBV-DNA sequences in the cellular DNA of her tumour. These observations confirm the association of primary hepatocellular carcinoma with hepatitis B virus and suggest that a significant proportion of patients of United Kingdom origin acquired their susceptibility as a result of military service in the tropics. There is presumably a substantial cohort of ex-service men at risk of developing primary hepatocellular carcinoma.

A double-blind, randomized trial was undertaken to compare the clinical, endoscopic and histological response to 6-weeks' treatment with hydrotalcite/dimethicone suspension or magnesium hydroxide/aluminum hydroxide suspension in 36 patients with symptomatic gastritis. Significantly more patients (P less than 0.05) showed symptomatic improvement in the antacid-treated group than in the hydrotalcite/dimethicone-treated group and more had a reduction in histological inflammatory scores (P less than 0.01), although there was little correlation between histology and symptoms. There was no evidence from this study that the bile acid binding and anti-foaming properties of hydrotalcite/dimethicone suspension were of any benefit in the treatment of patients with symptomatic gastritis.

A simple, non-invasive technique has been established for the simultaneous measurement of stomach emptying and the small bowel transit of a liquid meal. The rate of gastric emptying (T1/2) was measured in 21 normal subjects by using a gamma camera and computer to observe emptying of 200 ml of water to which 200 muCi 99Tcm - diethylene tetramene pentacetic acid chelate was added. By adding lactulose to the drink and measuring breath hydrogen (H2) concentration, small bowel transit time (Ta) was simultaneously estimated. There was no significant correlation (r = 0.26, P greater than 0.2) between T1/2 and Ta or between T1/2 and the shape of the breath H2 evolution curve. However, the shape of the breath H2 curve did seem to be affected by Ta. The technique should prove useful for the study of gastrointestinal motility in disease states.

1. Experiments were performed to study the absorption of two simultaneously administered polar probes of different molecular size from closed intestinal loops in rats subjected to various mucosal structural lesions. 2. Absorption of mannitol (molecular radius approximately 0.40 nm) was significantly decreased in rats with villous atrophy and crypt hypoplasia induced by the cytostatic agent methotrexate. The absorption of lactulose (radius approximately 0.54 nm) was also decreased, in contrast to the increased absorption which was found in an earlier study when villous atrophy with crypt hyperplasia was induced by infection by a nematode. The effect of local damage to villous tips, produced by the intraluminal presence of a detergent, was to increase significantly the absorption of lactulose. 3. In conjunction with the findings of earlier studies, these results support the hypothesis that there are at least two routes for the permeation of polar molecules. Small molecules such as mannitol probably pass through numerous cellular pores with a maximum radius lying between 0.40 and 0.54 nm and absorption is closely related to mucosal surface area. Larger molecules such as lactulose are probably restricted to less numerous extracellular pathways and absorption may be related to cell shedding or other areas of mucosal damage.

We investigated the effects of advanced age, hospitalization and poor nutrition on passive and active carbohydrate absorption using the probe molecules lactulose and mannitol (passive absorption), and 3-O-methylglucose (active absorption). We studied five groups of subjects; healthy controls aged 20-30 years, 40-50 years and over 65 years, respectively, together with long-stay patients and elderly in-patients being investigated for malnutrition. Each subject undertook two separate studies ingesting a drink containing 5 g lactulose, 2 g mannitol and 2.5 mg 3-O-methylglucose (3-O-MG), on one occasion in isotonic solution and in the second study in hypertonic solution, following overnight fast. Urinary recovery of all three probe molecules declined significantly with age (P less than 0.02) and was reduced in malnourished elderly subjects compared to healthy elderly controls (P less than 0.05). Correction of urinary recoveries for renal function on the basis of creatinine clearance abolished significant differences between groups. Thus passive absorption of carbohydrate is not impaired with advanced age in healthy elderly subjects or long-stay hospital patients. The ratio of the percentage recovery of 3-O-MG to the percentage recovery of mannitol was significantly reduced in the healthy elderly subjects compared to middle-aged and young controls in the hypertonic study; similar changes did not occur in the long-stay and malnourished elderly patients, interpretation of this finding is thus difficult. If confirmed, this impairment would suggest a possible defect in active sugar transport in the elderly.

Summary A 44-year-old man developed severe pruritus with jaundice which subsequently proved fatal. Liver histology showed intense cholestasis, but at post-morten the bile ducts were patent and there was no cirrhosis, the findings being consistent with a cholestatic drug reaction. The most likely precipitant was the benzodiazepine triazolam, and surveillance is indicated for any further reactions to this recently marketed hypnotic.

Summary Two patients with epithelioid haemangioendotheliomata of the liver are described. Both presented with abdominal pain and malaise, with hepatomegaly and a variable degree of hepatocellular dysfunction. Diagnosis was delayed in both cases, each patient undergoing a protracted series of investigations including repeated liver biopsies. The major obstacles to early diagnosis were a lack of clinical awareness of the condition and difficulties in interpretation of the liver histology: the widespread sclerosis in the tumour tissue is easily mistaken for a post-necrotic or cirrhotic process. The key to the diagnosis is the demonstration of cells containing Factor-VIII-related antigen confirming the endothelial origin of the tumour. One patient died within three months of presentation and the other after 18 months. The tumour may, therefore, be more aggressive than earlier reports seem to suggest. It seems likely that the tumour is being under-diagnosed and although no specific therapy has been shown to be of value, a greater awareness of the condition, resulting in a more prompt diagnosis, should save patients from undergoing unnecessary investigation.

The effects of acute ethanol challenge on serum glycoprotein concentrations in man were studied. Serum levels of haptoglobin, alpha-2-macroglobulin and pre-albumin were measured fasting and 6 hr after oral ethanol 0.75 g/kg body weight in 8 healthy controls, 13 patients with alcoholic liver disease and 13 with non-alcoholic-related liver damage, both patient groups being further subdivided into those with and without cirrhosis. Basal levels of haptoglobin were significantly higher in non-cirrhotic alcoholics than controls and pre-albumin levels were lower in non-alcohol-related cirrhotic liver disease. In response to ethanol challenge, no consistent change was observed in any group, nor was there any significant difference between groups. There was, however, a significant correlation (r = 0.53, P less than 0.005) between the percentage changes in haptoglobin and alpha-2-macroglobulin. In 16 subjects (2 controls, 8 alcoholics and 6 non-alcoholics) blood levels of ethanol and acetaldehyde were measured serially: there was no relationship between the peak or mean concentration and the glycoprotein response. This study does not substantiate other reports which claimed to be able to predict the severity and reversibility of alcoholic liver disease on the basis of the serum glycoprotein response to ethanol: ethanol challenge with measurement of serum glycoproteins cannot substitute for proper histological assessment.

Summary Four patients are described with serologically proven hepatitis A (HAV) infection. In each patient there was a bimodal course to the illness — clinically and biochemically — with complete remission between the two phases of the illness. Other possible causes except NANB for a second hepatitic illness were excluded.

Exotic gastrointestinal infections continue to increase as world travel expands. Many are debilitating and some are life-threatening. A heightened awareness of their significance and symptomatology could help to prevent unnecessary suffering or death.Diarrhea affects approximately 330,000 travelers from industrialized nations each year. Diarrhea is a reflection of inadequate hygiene or waste disposal in the countries visited, usually developing countries. The greatest incidence occurs in 20-29 years olds who take the most dietary risks. Some foods that pose the greatest risk in descending order include raw oysters, steak tartare, ice cubes, washed vegetables, cold milk, puddings, and sandwiches with mixed fillings. 40% of all travelers have a self limiting and rarely grave diarrheal illness caused by local enterotoxigenic Escherichia coli (ETEC). Following an incubation period of 5-9 days, symptoms appear (cramps, fever, and 10 or more diarrheal episodes/day). 5% are infected with Giardia lamblia and 4% with Entamoeba histolytica. Giardiasis occurs worldwide and is characterized by grumbling diarrhea, cramps, and flatulence. E. histolytica causes a severe illness characterized by colitis with bloody stools, anorexia, malaise, sweats, weight loss, and epigastric pain. Only 10-100 Shigella bacteria are required by cause shigellosis. Symptoms include blood and mucus in the diarrhea and malaise. A traveler who ingests food with 100,000 Salmonella bacteria in it most likely will fall ill 48 hours after eating the contaminated food. Typhoid and paratyphoid fevers have an incubation period of about 12 days and may be fatal. Initial symptoms consists of headache, malaise, fever, and pain and 2 weeks later bloody diarrhea appears. Additional common diarrheal illnesses include cholera, post infectious tropical malabsorption, and those caused by Vibrio parahaemolyticus and Campylobacter species. Another disease common in areas of poor hygiene is poliomyelitis with fever, sore throat, and headache present in mild forms. If the virus invades the central nervous system, however, paralysis occurs.

Within 1 year six elderly patients (aged 80-89 years) were admitted because of non-specific deterioration in mental or physical well-being. In no instance was hepatobiliary disease suspected at the time of hospital admission. One patient presented with intermittent confusion only. The other five were referred with "falls" or having "gone off legs", with malaise, confusion, or incontinence. All had raised alkaline phosphatase levels of 159-1230 IU/l, which led to investigation of the biliary tree. At endoscopic retrograde cholangiopancreatography all were shown to have biliary disease (three common duct stones, one gallbladder calculus, one an abscess, and one a widely dilated common bileduct ). With appropriate treatment (endoscopic sphincterotomy for two, surgery for two, and antibiotics alone for two), all showed a gratifying return of mobility and mental function. Biliary disease is a treatable cause of chronic ill health in the elderly and should be excluded, even in the absence of "classical" symptoms, when there is abnormal liver function.

The hepatotoxic effects of conventional drugs are well recognised, but herbal medicines are often assumed to be harmless and are advertised as such. The error of this assumption has recently received attention in the press,' but we think that doctors are not sufficiently aware of the potential toxicity of herbal medicines. We report on four women, three from Edinburgh and one from Tyneside, who sustained liver damage after taking herbal medicines for relieving stress. All had been in good health previously; none could recollect having been in contact with jaundice or hepatitis; none had travelled abroad, or had abused drugs parenterally or otherwise, or had been given blood or blood products; and none took alcohol in excess.

Five patients with hepatorenal syndrome were treated with the orally active angiotensin-converting enzyme inhibitor captopril (25 or 50 mg 6 hourly) for up to 48 hours. Only one patient showed a significant increase in urinary sodium concentration (from less than 10 to 70 mmol/liter), but without associated diuresis; renal function continued to deteriorate in all patients with persistent oliguria and rising serum creatinine. The outcome was uniformly fatal. These results suggest that in the hepatorenal syndrome, captopril in standard dosage is without benefit, and provide further evidence that the changes in the renin-angiotensin system are probably secondary to reduced renal perfusion from some other cause.

Over a four-year period 40 patients of local origin, with primary hepatocellular carcinoma were seen at a regional referral centre. Twenty-nine patients had histological evidence of underlying cirrhosis and these patients were predominantly male (25/29) and elderly (mean age 66 years). Serological evidence of hepatitis B virus (HBV) infection was found in 11 (38 per cent) of the cirrhotic group. Of the 25 males with cirrhosis, 13 (52 per cent) were known to have seen military service in the tropics and of these eight had serum HBV markers. The non-cirrhotic group was younger (mean age 55 years) and the sex distribution was nearly equal (six male, five female). Two patients (19 per cent) had hepatitis B markers including one of the two men in this group who had served in the tropics. One patient with no serum HBV markers had integrated HBV-DNA sequences in the cellular DNA of her tumour. These observations confirm the association of primary hepatocellular carcinoma with hepatitis B virus and suggest that a significant proportion of patients of United Kingdom origin acquired their susceptibility as a result of military service in the tropics. There is presumably a substantial cohort of ex-service men at risk of developing primary hepatocellular carcinoma.

Both saliva and jejunal aspirate were cultured from 22 patients with suspected small bowel bacterial overgrowth and from eight controls. Large numbers of organisms (greater than 10(6)/ml) were recovered from the jejunal aspirate of 16 subjects, in five of whom the same organisms were present in similar relative proportions in the saliva, suggesting contamination of the sample with saliva, while in 11 the jejunal organisms differed from those in saliva. In eight of these the jejunal flora was a typical 'faecal' flora usually associated with small bowel bacterial overgrowth but, in three, the jejunal floral was superficially similar to that of saliva. Distinct subpopulations of bacteria, typically Gram-positive non-sporing rods, were, however, evident in the jejunum of these patients, and were also recovered, in smaller numbers, from the jejunum of controls, suggesting that they form a distinct jejunal microflora. Culture of saliva in addition to jejunal aspirate may be useful in the recognition of contamination of the proximal small bowel with saliva, and in the diagnosis of small bowel bacterial overgrowth.

SUMMARY The buccal mucosa in both coeliac disease and dermatitis herpetiformis behaves in the same manner as the skin with regard to immunofluorescence. The simple technique of buccal punch biopsy can be used to give further confirmation of the diagnosis of dermatitis herpetiformis and, especially in patients with an equivocal diagnosis, may prove easier than carrying out repeated skin biopsies.