Barrett's oesophagus: a clinical study of 52 patients

This paper reports a series of 52 patients with Barrett's (or columnar-lined) oesophagus from one medical unit diagnosed over a six-year period. The commonest associated symptoms were heartburn, regurgitation and dysphagia but 10 patients had no oesophageal symptoms and two had no symptoms at all. Gastrointestinal bleeding (overt or occult) was observed in almost one-third of patients. At diagnosis, 26 patients had oesophagitis, 23 had oesophageal ulceration and 10 had benign oesophageal strictures. An association between oesophageal ulceration and non-steroidal anti-inflammatory drug ingestion was suggested by the data and patients with oesophageal ulceration were significantly older than patients with uncomplicated Barrett's oesophagus. No patient had adenocarcinoma of the oesophagus at diagnosis and neither carcinoma nor dysplasia were seen during a mean period of 16.4 months. However, 17 per cent of patients in the series had malignancies in other sites. Most patients did well on medical treatment and only two were referred for anti-reflux surgery (both for non-healing oesophageal ulcers). Barrett's oesophagus was seen in 10 per cent of patients with gastro-oesophageal reflux at endoscopy. Oesophageal ulceration in patients with Barrett's oesophagus made up 21 per cent of oesophageal ulcers seen and benign oesophageal stricture in patients with Barrett's oesophagus constituted 13 per cent of all benign strictures seen. Barrett's oesophagus is common in our population and despite complications, it can be managed successfully, at least in the short term, by conservative means.

Intestinal permeability in diabetic diarrhoea

Small intestinal permeability to mannitol and lactulose was studied in 12 patients aged 36-70 (mean 56) years with diabetic diarrhoea (DD). Ten uncomplicated diabetics aged 24-56 (mean 37) years and 25 normal subjects aged 22-60 (mean 37) years served as controls. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. Mean lactulose excretion in patients with DD was significantly lower than in normal controls but was not significantly different from the uncomplicated diabetics. Mean lactulose excretion was not significantly different in the three groups. However, lactulose to mannitol excretion ratios (LMER) were significantly higher in patients with DD compared to the controls or the uncomplicated diabetics. LMER in seven patients with DD were outside the normal range. LMER in patients with DD did not correlate with blood urea, small intestinal transit time, faecal fat excretion, small intestinal bacterial overgrowth, duration of diabetes or duration of diarrhoea. Jejunal morphology was normal in all patients with DD. It was concluded that small intestinal permeability was abnormal in some patients with DD and that this might be a factor in the aetiology of the diarrhoea.

Upper gastrointestinal endoscopy in patients aged 80 years or more

A retrospective study of 208 upper gastrointestinal endoscopies (including 56 therapeutic procedures) performed over a 3-year period on 150 patients aged 80 years or more has shown that endoscopy is safe and well tolerated in this age group. Only 10% of first endoscopies were normal. If endoscopies performed for therapy or assessment of peptic ulcer healing are excluded, 79% of endoscopies were considered helpful in revealing the cause of the patients symptoms and/or aiding the patients' management. Endoscopy was particularly helpful in patients with gastrointestinal haemorrhage or dysphagia. Of 63 emergency endoscopies for acute upper gastrointestinal haemorrhage, a source of bleeding was found in 82%. Out-patient diagnostic endoscopy and even out-patient endoscopic oesophageal dilatation was safe in the more robust elderly patient. Patients aged 80 years or more made up 5% of all upper gastrointestinal endoscopies and 10% of all emergency endoscopies performed in our unit. The study emphasizes the important contribution of sophisticated investigative techniques to the care of the elderly.

Clostridium difficile toxin in chronic idiopathic colitis

Clostridium difficile toxin was isolated from the stools of three patients with chronic idiopathic colitis. Two patients were known to have chronic idiopathic colitis before Cl difficile toxin was isolated. The third patient was subsequently found to have ulcerative colitis after presentation with Cl difficile toxin in the stool. Two patients were on sulphasalazine at the time of diagnosis of Cl difficile infection and one had taken sulphasalazine two months previously. Only one patients had antibiotic exposure and that was at least three months before presentation. In each patient, treatment with vancomycin was accompanied by symptomatic improvement and disappearance of the toxin. The underlying colitis remained unaffected. In patients with inflammatory bowel disease in relapse, the presence of Cl difficile toxin should be sought as this may be a factor in the relapse. In any patient presenting with diarrhoea, the presence of Cl difficile toxin may obscure the presence of underlying inflammatory bowel disease.

The delayed diagnosis of coeliac disease

The prevalence of coeliac disease in New Zealand appears to be much lower than in the British Isles suggesting the possibility that coeliac disease is not being diagnosed in this country. This view point is supported by the two patients reported in this paper who had coeliac disease diagnosed after ten years and at least 36 years of symptoms respectively. The importance of diagnosing coeliac disease is stressed, particularly because of the greatly increased risk of developing lymphoma (from which one of the two patients died). The need to investigate all patients with chronic diarrhoea and other gastrointestinal symptoms is stressed.

Small intestinal permeability in normal Sudanese subjects: evidence of tropical enteropathy

Small intestinal permeability to mannitol and lactulose was studied in healthy English and apparently healthy Sudanese subjects to determine whether any differences were apparent. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. The mean excretion of lactulose was significantly higher and the mean excretion of mannitol was significantly lower in the Sudanese than in the English subjects. Lactulose to mannitol excretion ratios were significantly higher in the Sudanese. These data demonstrate abnormal intestinal permeability in the Sudanese subjects and indicate the presence of an asymptomatic enteropathy.

Diarrhoea as a symptom

Diarrhoea is a common symptom in all communities and in both general and hospital practice. Diarrhoeal diseases, particularly of infectious aetiology, are a huge health problem world-wide, causing much morbidity and mortality, especially amongst children. Although the symptom is almost universally understood, the definition of diarrhoea is difficult because of the wide variation in the bowel habits of normal individuals. Diarrhoea is, perhaps, best described as a change in bowel habit from normal with an increase in stool volume and/or fluidity with or without an increase in stool frequency. The disorders causing diarrhoea are many and various, but most episodes of diarrhoea are mild and self-limiting. However, all cases of chronic diarrhoea and all severe cases of acute diarrhoea require investigation after the initial clinical assessment. Investigation must be logical and structured and can be divided into three stages: the initial work-up (sigmoidoscopy, stool examination, screening blood tests), anatomical and functional assessment of the gastrointestinal tract, and further investigation of the difficult case (osmotic or secretory diarrhoea?, hormone levels, tests for laxative abuse, perfusion studies, laparotomy, etc.) Most cases are diagnosed after clinical assessment or the initial work-up. In the remainder, there are usually clues to the diagnosis or to the area of the gastrointestinal tract which needs to be investigated. Only a small number of cases require extensive investigation including the third stage of work-up. Analysis of the symptom of diarrhoea requires all the attributes of the good physician: wide clinical experience, careful history and examination, diagnostic and therapeutic acumen, a sound understanding of normal and abnormal physiology, skill and experience in selecting the appropriate investigations and interpreting their results, meticulous attention to detail and finally, a caring and sympathetic attitude to the patient.

Small intestinal permeability as an indicator of jejunal mucosal recovery in patients with celiac sprue on a gluten-free diet

Lactulose/mannitol excretion ratios were measured in 13 patients with celiac disease at diagnosis and after 5-8 months on a gluten-free diet. Jejunal biopsies were assessed histologically at diagnosis and during treatment. The excretion ratios in untreated patients were significantly higher than in 25 normal controls (P less than 0.01). On the diet, the excretion ratios fell in every patient, but in only eight did the ratio return to normal. There was a good correlation between the ratio and jejunal histological grading. During treatment, the ratios significantly inversely correlated with jejunal villous height/mucosal thickness ratios (P less than 0.001). Therefore, excretion ratios provide a well-tolerated noninvasive means of assessing the jejunal mucosa in patients with celiac disease on a gluten-free diet.

Gastrocnemius myositis in a patient with inflammatory bowel disease

A young woman with long-standing inflammatory bowel disease presented with a tender left gastrocnemius myositis in association with an exacerbation of her disease. Muscle biopsy showed a chronic inflammatory cell infiltrate and atrophic muscle fibres, but no granulomata or vasculitis, and her symptoms responded to high-dose steroids. Twelve months later she underwent subtotal colectomy for troublesome symptoms and incidentally was discovered to have an adenocarcinoma of the sigmoid colon. Myositis without granulomata has not been reported previously in either Crohn's disease or ulcerative colitis.

Small intestinal permeability to mannitol, lactulose, and polyethylene glycol 400 in celiac disease

Mannitol (molecular weight 182), lactulose (342), and polyethylene glycol 400 (range 242-550) absorption was studied in 25 controls, 22 untreated celiacs, and 13 treated celiacs. Untreated celiacs absorbed less mannitol and more lactulose than controls. Absorption of higher as well as lower molecular-weight polyethylene glycols was reduced in untreated celiac disease. Absorption returned towards normal on treatment. Polyethylene glycol and lactulose absorption was enhanced by administering them in a hypertonic solution. Polyethylene glycol 400 but not lactulose or mannitol was lipid soluble in vitro. It was concluded that the mucosa in untreated celiac disease was more "leaky" than normal. Polyethylene glycol 400 absorption data suggested that its absorption may largely be determined by its lipid solubility and was decreased in celiac disease because of the reduced surface area of the small intestine. Polyethylene glycol 400 cannot be recommended as a suitable marker for permeability studies of the small intestine.

Small intestinal permeability to sugars in patients with atopic eczema

Absorption of lactulose and mannitol was measured in eleven patients with atopic eczema and lactulose/mannitol excretion ratios were calculated. Mean lactulose absorption was increased in the patients with exzema and their excretion ratios were higher than those of controls. There was no correlation between either eczema extent or severity and the excretion ratio. We conclude that small intestinal passive permeability is increased in some patients with atopic eczema.

Abnormal small intestinal permeability to sugars in patients with Crohn's disease of the terminal ileum and colon

The absorption of lactulose and mannitol in 20 patients with Crohn's disease limited to the ileum or colon was studied, and lactulose/mannitol excretion ratios were calculated. The results were compared to those from 16 normal controls and 6 patients with ulcerative colitis. The 13 patients with ileal Crohn's disease had significantly higher lactulose/mannitol excretion ratios than the controls (p less than 0.01) or ulcerative colitics (p less than 0.01). Similarly, the 7 patients with Crohn's disease limited to the colon had significantly higher excretion ratios than the controls (p less than 0.01) or ulcerative colitics (p less than 0.01). The results provide support for the concept that Crohn's disease may be more extensive than is apparent macroscopically.

Galactorrhoea, hyperprolactinaemia, and pituitary adenoma presenting during metoclopramide therapy

A 49-year-old woman presented with a one month history of headaches, loss of libido and galactorrhoea. She had been taking metoclopramide for the previous 3 months for reflux oesophagitis. She was found to have substantially elevated serum prolactin levels and a pituitary adenoma, which have not been previously described in a patient taking metoclopramide. The drug was stopped and the serum prolactin level fell progressively to normal with resolution of symptoms over 4 months. This suggested that contrary to our original impression that she had a prolactin-secreting pituitary adenoma which had been stimulated by metoclopramide, she had metoclopramide-induced hyperprolactinaemia and an incidental pituitary tumour.

Lymphoma risk in coeliac disease of later life

From 314 patients with coeliac disease, 20 patients were found to have developed a lymphoma. The incidence of lymphoma was much greater in the 6th, 7th and 8th decades of life than in the previous two decades. In 12 patients, the lymphoma was diagnosed within 4 years of the diagnosis of their coeliac disease and there were significantly more of these lymphomas appearing in coeliacs diagnosed between 51 and 80 years, who made up 23% of the series, than in those diagnosed between 21 and 50 years. We conclude that lymphoma is particularly a complication of older coeliacs and that coeliacs newly diagnosed at more than 50 years of age should be more closely followed up for they have a 1 in 10 chance of harbouring a lymphoma.

Serum lysozyme activity in coeliac disease: a possible aid to athe diagnosis of malignant change

Serum lysozyme activities were measured in 34 control subjects, 13 untreated adult coeliac patients, 21 adult coeliac patients on gluten-free diet, and eight coeliac patients with a histiocytic lymphoma. Serum lysozyme activities were raised in three untreated patients, three patients treated with a gluten-free diet, and in only two patients with coeliac disease and lymphoma. Serum lysozyme estimations cannot be recommended as an aid to the diagnosis of lymphoma in patients with coeliac disease.