Impact of COVID-19 pandemic restrictions on pregnancy duration and outcome in Melbourne, Australia

OBJECTIVE

To investigate the effect of restriction measures implemented to mitigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during the coronavirus disease 2019 (COVID-19) pandemic on pregnancy duration and outcome.

METHODS

A before-and-after study was conducted with cohort sampling in three maternity hospitals in Melbourne, Australia, including women who were pregnant when restriction measures were in place during the COVID-19 pandemic (estimated conception date between 1 November 2019 and 29 February 2020) and women who were pregnant before the restrictions (estimated conception date between 1 November 2018 and 28 February 2019). The primary outcome was delivery before 34 weeks' gestation or stillbirth. The main secondary outcome was a composite of adverse perinatal outcomes. Pregnancy outcomes were compared between women exposed to restriction measures and unexposed controls using the χ-square test and modified Poisson regression models, and duration of pregnancy was compared between the groups using survival analysis.

RESULTS

In total, 3150 women who were exposed to restriction measures during pregnancy and 3175 unexposed controls were included. Preterm birth before 34 weeks or stillbirth occurred in 95 (3.0%) exposed pregnancies and in 130 (4.1%) controls (risk ratio (RR), 0.74 (95% CI, 0.57-0.96); P = 0.021). Preterm birth before 34 weeks occurred in 2.4% of women in the exposed group and in 3.4% of women in the control group (RR, 0.71 (95% CI, 0.53-0.95); P = 0.022), without evidence of an increase in the rate of stillbirth in the exposed group (0.7% vs 0.9%; RR, 0.83 (95% CI, 0.48-1.44); P = 0.515). Competing-risks regression analysis showed that the effect of the restriction measures on spontaneous preterm birth was stronger and started earlier (subdistribution hazard ratio (HR), 0.81 (95% CI, 0.64-1.03); P = 0.087) than the effect on medically indicated preterm birth (subdistribution HR, 0.89 (95% CI, 0.70-1.12); P = 0.305). The effect was stronger in women with a previous preterm birth (RR, 0.42 (95% CI, 0.21-0.82); P = 0.008) than in parous women without a previous preterm birth (RR, 0.93 (95% CI, 0.63-1.38); P = 0.714) (P for interaction = 0.044). Composite adverse perinatal outcome was less frequent in the exposed group than in controls (all women: 2.1% vs 2.9%; RR, 0.73 (95% CI, 0.54-0.99); P = 0.042); women with a previous preterm birth: 4.5% vs 8.4%; RR, 0.54 (95% CI, 0.25-1.18); P = 0.116).

CONCLUSIONS

Restriction measures implemented to mitigate SARS-CoV-2 transmission during the COVID-19 pandemic were associated with a reduced rate of preterm birth before 34 weeks. This reduction was mainly due to a lower rate of spontaneous prematurity. The effect was more substantial in women with a previous preterm birth and was not associated with an increased stillbirth rate. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Foley catheter vs oral misoprostol for induction of labor: individual participant data meta-analysis

OBJECTIVE

To compare the effectiveness and safety of Foley catheter and oral misoprostol for induction of labor (IOL).

METHODS

The Cochrane Review on Mechanical Methods for Induction of Labour and Ovid MEDLINE, EMBASE via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus, from inception to April 2019, were searched for randomized controlled trials (RCTs) comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Eligible trials for which raw data were obtained were included and individual participant data meta-analysis was performed. Primary outcomes were vaginal birth, a composite of adverse perinatal outcome (including stillbirth, neonatal death, neonatal seizures, admission to the neonatal intensive care unit, severe respiratory compromise or meconium aspiration syndrome) and a composite of adverse maternal outcome (including admission to the intensive care unit, maternal infection, severe postpartum hemorrhage, maternal death or uterine rupture). The quality of the included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. A two-stage random-effects model was used for meta-analysis according to the intention-to-treat principle and interactions between treatment and baseline characteristics were assessed.

RESULTS

Of seven eligible trials, four provided individual participant data for a total of 2815 participants undergoing IOL, of whom 1399 were assigned to Foley catheter and 1416 to oral misoprostol. All four trials provided data for each of the primary outcomes in all 2815 women. Compared with those receiving oral misoprostol, Foley catheter recipients had a slightly decreased chance of vaginal birth (risk ratio (RR), 0.95 (95% CI, 0.91-0.99); I² , 2.0%; moderate-certainty evidence). A trend towards a lower rate of composite adverse perinatal outcome was found in women undergoing IOL using a Foley catheter compared with oral misoprostol (RR, 0.71 (95% CI, 0.48-1.05); I² , 14.9%; low-certainty evidence). Composite adverse maternal outcome did not differ between the groups (RR, 1.00 (95% CI, 0.97-1.03); I² , 0%; moderate-certainty evidence). Meta-analyses of effect modifications did not show significant interactions between intervention and parity or gestational age for any of the primary outcomes.

CONCLUSIONS

For women undergoing IOL, Foley catheter is less effective than oral misoprostol, as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Sulforaphane Bioavailability and Effects on Blood Pressure in Women with Pregnancy Hypertension

Sulforaphane, an isothiocyanate found in cruciferous vegetables such as broccoli, shows promise as an adjuvant therapy for preeclampsia. To inform future clinical trials, we set out to determine the bioavailability of sulforaphane in non-pregnant and preeclamptic women. In six healthy female volunteers, we performed a crossover trial to compare the bioavailability of sulforaphane and metabolites afforded by an activated and non-activated broccoli extract preparation. We then undertook a dose escalation study of the activated broccoli extract in 12 women with pregnancy hypertension. In non-pregnant women, an equivalent dose of activated broccoli extract gave higher levels of sulforaphane and metabolites than a non-activated extract (p < 0.0001) and greater area under the curve (AUC) (3559 nM vs. 2172 nM, p = 0.03). Compared to non-pregnant women, in women with preeclampsia, the same dose of activated extract gave lower levels of total metabolites (p < 0.000) and AUC (3559 nM vs. 1653 nM, p = 0.007). Doubling the dose of the activated extract in women with preeclampsia doubled levels of sulforaphane and metabolites (p = 0.02) and AUC (1653 nM vs. 3333 nM, p = 0.02). In women with preeclampsia, activated broccoli extract was associated with modest decreases in diastolic blood pressure (p = 0.05) and circulating levels of sFlt-1 (p = 0.0002). A myrosinase-activated sulforaphane formulation affords better sulforaphane bioavailability than a non-activated formulation. Higher doses of sulforaphane are required to achieve likely effective doses in pregnant women than in non-pregnant women. Sulforaphane may improve endothelial function and blood pressure in women with pregnancy hypertension.

Sulforaphane improves syncytiotrophoblast mitochondrial function after in vitro hypoxic and superoxide injury

INTRODUCTION

Placental mitochondrial dysfunction contributes to the oxidative stress that underlies preeclampsia. Here, we assessed whether sulforaphane (SFN) could improve syncytiotrophoblast mitochondrial function after in vitro hypoxic and superoxide injury.

METHODS

Placental cytotrophoblasts were isolated from healthy term placentae (n = 12) and incubated for 48 h in 8% O₂ ± 1 μM SFN before acute (4hrs) or chronic (24hrs) hypoxic (1% O₂), or superoxide (xanthine/xanthine oxidase) injury. Cytotrophoblasts were also isolated from preeclamptic placentae (n = 5) and cultured in 8% O₂ ± 1 μM SFN. Mitochondrial respiration was measured using the Seahorse MitoStress XF assay. Cells were stained with mitotracker red to assess mitochondrial membrane health and mitochondrial gene expression assessed using RT-qPCR.

RESULTS

SFN prevented significant reductions in syncytiotrophoblast mitochondrial maximal respiration, spare respiratory capacity, basal respiration and ATP production following acute hypoxia. Chronic hypoxia only reduced maximal and spare respiratory capacity. SFN prevented these negative changes and increased respiration overall. Alternatively, acute superoxide injury significantly increased mitochondrial maximal respiration and spare respiratory capacity. SFN treatment further increased basal respiration following superoxide injury and prevented significant decreases in ATP production and coupling efficiency. In preeclamptic placentae, SFN significantly increased mitochondrial maximal respiration, spare respiratory capacity, basal respiration and ATP production, and decreased proton leak. SFN up-regulated mRNA expression of mitochondrial complexes and corrected an up-regulation in fission gene expression observed after hypoxic-superoxide injury. Finally, preliminary results suggest SFN prevented hypoxia-induced impairment of mitochondrial membrane structure.

DISCUSSION

SFN mitigated hypoxia and superoxide induced changes to syncytiotrophoblast mitochondrial function in vitro, and improved mitochondrial respiration in trophoblast cells from preeclamptic placentae.

Placental-specific sFLT-1: role in pre-eclamptic pathophysiology and its translational possibilities for clinical prediction and diagnosis

Pre-eclampsia is a common obstetric complication globally responsible for a significant burden of maternal and perinatal morbidity and mortality. Central to its pathophysiology is the anti-angiogenic protein, soluble fms-like tyrosine kinase-1 (sFLT-1). sFLT-1 is released from a range of tissues into the circulation, where it antagonizes the activity of vascular endothelial growth factor and placental growth factor leading to endothelial dysfunction. It is this widespread endothelial dysfunction that produces the clinical features of pre-eclampsia including hypertension and proteinuria. There are multiple splice variants of sFLT-1. One, known as sFLT-1 e15a, evolved quite recently and is only present in humans and higher order primates. This sFLT-1 variant is also the main sFLT-1 secreted from the placenta. Recent work has shown that sFLT-1 e15a is significantly elevated in the placenta and circulation of women with pre-eclampsia. It is also biologically active, capable of causing endothelial dysfunction and the end-organ dysfunction seen in pre-eclampsia. Indeed, the over-expression of sFLT-1 e15a in mice recapitulates the pre-eclamptic phenotype in pregnancy. Therefore, here we propose that sFLT-1 e15a may be the sFLT-1 variant primarily responsible for pre-eclampsia, a uniquely human disease. Furthermore, this placental-specific sFLT-1 variant provides promise for use as an accurate biomarker in the prediction or diagnosis of pre-eclampsia.

National audit of the use of surgery and radiological embolization after failed endoscopic haemostasis for non-variceal upper gastrointestinal bleeding

BACKGROUND

Following non-variceal upper gastrointestinal bleeding (NVUGIB), 10-15 per cent of patients experience further bleeding. Although surgery has been the traditional salvage therapy, there is renewed interest in transcatheter arterial embolization (TAE). This study examined the use, clinical characteristics and outcomes of patients receiving salvage surgery or TAE after failed endoscopic haemostasis for NVUGIB.

METHODS

A UK national audit of upper gastrointestinal bleeding was undertaken in May and June 2007. A logistic regression model was used to identify clinical predictors of endoscopic failure.

RESULTS

Data were analysed from 4478 patients involving 212 UK centres. Some 533 (11·9 per cent) experienced further bleeding, of whom 163 (30·6 per cent) proceeded to salvage therapy with surgery (97), TAE (60) or both (6). Among surgical patients (mean age 71 years), 66·0 per cent (68 of 103) had a Rockall score of at least 3 and emergency surgery was carried out between midnight and 08.00 hours in 21 per cent, with a consultant surgeon present in 89 per cent of operations. Some 9 per cent of patients had further bleeding after TAE, resulting in later surgery. The mortality rate was 29 per cent after surgery, 10 per cent after TAE and 23·2 per cent among those with further bleeding after the index endoscopy that was managed by endoscopy alone. The strongest predictors of endoscopic failure were coagulopathy (odds ratio 3·27, 95 per cent confidence interval 2·37 to 4·53) and a haemoglobin level of 10 g/dl or less (odds ratio 2·22, 1·71 to 2·87, for haemoglobin 8-10 g/dl).

CONCLUSION

Salvage surgery and embolization are required in fewer than 4 per cent of patients with NVUGIB. The high postoperative mortality rate, reflecting age, co-morbidity and severity of bleeding, warrants a prospective study to establish the effectiveness and safety of TAE as an alternative to surgery in the management of bleeding after failure of endoscopic therapy.

Outcomes following acute nonvariceal upper gastrointestinal bleeding in relation to time to endoscopy: results from a nationwide study

BACKGROUND AND STUDY AIMS

Despite the established efficacy of therapeutic endoscopy, the optimum timeframe for performing endoscopy in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) remains unclear. The aim of the current audit study was to examine the relationship between time to endoscopy and clinical outcomes in patients presenting with NVUGIB.

PATIENTS AND METHODS

This study was a prospective national audit performed in 212 UK hospitals. Regression models examined the relationship between time to endoscopy and mortality, rebleeding, need for surgery, and length of hospital stay.

RESULTS

In 4478 patients, earlier endoscopy ( < 12 hours) was not associated with a lower mortality or need for surgery compared with later ( > 24 hours) endoscopy (odds ratio [OR] for mortality 0.98, 95 % confidence interval [CI] 0.88 - 1.09 for endoscopy > 24 hours vs. < 12 hours; P = 0.70). In patients receiving therapeutic endoscopy, there was a nonsignificant trend towards an increase in rebleeding associated with later endoscopy (OR 1.13, 95 %CI 0.97 - 1.32 for endoscopy > 24 hours vs. < 12 hours), with the converse seen in patients not requiring therapeutic endoscopy (OR 0.83, 95 %CI 0.73 - 0.95 for endoscopy > 24 hours vs. < 12 hours; interaction P = 0.003). Later endoscopy ( > 24 hours) was associated with an increase in risk-adjusted length of hospital stay (1.7 days longer, 95 %CI 1.39 - 1.99 vs. < 12 hours; P < 0.001).

CONCLUSIONS

Earlier endoscopy was not associated with a reduction in mortality or need for surgery. However, it was associated with an increased efficiency of care and potentially improved control of hemorrhage in higher risk patients, supporting the routine use of early endoscopy unless specific contraindications exist. These results may help inform the debate about emergency endoscopy service provision.

Mortality from acute upper gastrointestinal bleeding in the United kingdom: does it display a "weekend effect"?

OBJECTIVES

An increased mortality in patients presenting to hospital at weekends has been observed for several medical conditions. The aim of this study is to examine the relationship between weekend presentation to hospital following acute upper gastrointestinal bleeding and mortality.

METHODS

Data were collected on 6,749 patients presenting to 212 UK hospitals. A logistic regression model was used to examine the relationship between weekend presentation to hospital and mortality.

RESULTS

Patients presenting at the weekend were more likely to present with shock (39% vs. 36%), hematemesis (41% vs. 38%), and receive red cell transfusion (42% vs. 39%). Only 38% of those presenting at weekends underwent endoscopy within 24 h compared with 55% admitted on weekdays (adjusted odds ratio (OR)=0.47, 95% confidence interval (CI)=0.41-0.54), although the proportion of all patients receiving endoscopic therapy was identical at weekends compared with weekdays (24%). After adjustment for confounders, there was no evidence of a difference between weekend and weekday mortality (OR=0.93; 95% CI=0.75-1.16). Similar results were seen when restricting the analysis to those patients who underwent endoscopy (n=5,004) (OR=0.87, 95% CI=0.65-1.16). There was no difference in the OR for mortality for weekend compared with weekday presentation between patients presenting to hospitals with an out-of-hours (OOH) endoscopy rota compared with those presenting to hospitals without such a facility.

CONCLUSIONS

In this large prospective study of acute upper gastrointestinal bleeding in the United Kingdom, there was no increase in mortality for weekend vs. weekday presentation despite patients being more critically ill and having greater delays to endoscopy at weekends. Provision of an OOH endoscopy service at weekends in the remaining UK hospitals may not lead to further reductions in case fatality, although a reduction in OOH endoscopy provision from current levels could lead to an increase in mortality at weekends.

Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of RBC units transfused in the UK. In exsanguinating AUGIB the value of RBC transfusion is self evident, but in less severe bleeding its value is less obvious.

AIM

To examine the relationship between early RBC transfusion, re-bleeding and mortality following AUGIB, which is one of the most common indications for red blood cell (RBC) transfusion.

METHOD

Data were collected on 4441 AUGIB patients presenting to UK hospitals. The relationship between early RBC transfusion, re-bleeding and death was examined using logistic regression.

RESULTS

44% were transfused RBCs within 12 hours of admission. In patients transfused with an initial haemoglobin of <8 g/dl, re-bleeding occurred in 23% and mortality was 13% compared with a re-bleeding rate of 15%, and mortality of 13% in those not transfused. In patients transfused with haemoglobin >8 g/dl, re-bleeding occurred in 24% and mortality was 11% compared with a re-bleeding rate of 6.7%, and mortality of 4.3% in those not transfused. After adjusting for Rockall score and initial haemoglobin, early transfusion was associated with a two-fold increased risk of re-bleeding (Odds ratio 2.26, 95% CI 1.76-2.90) and a 28% increase in mortality (Odds ratio 1.28, 95% CI 0.94-1.74).

CONCLUSIONS

Early RBC transfusion in AUGIB was associated with a two-fold increased risk of re-bleeding and an increase in mortality, although the latter was not statistically significant. Although these findings could be due to residual confounding, they indicate that a randomized comparison of restrictive and liberal transfusion policies in AUGIB is urgently required.

The safety profile of anti-tumour necrosis factor therapy in inflammatory bowel disease in clinical practice: analysis of 620 patient-years follow-up

BACKGROUND

Anti-TNF agents are now widely used in Crohn's disease (CD), and in ulcerative colitis (UC).

AIM

To review the safety profile of anti-TNF agents in all patients treated with infliximab in Edinburgh from 1999 to 2007.

METHODS

Complete data were available on 202/207 patients comprising 157 CD, 42 UC and three coeliac disease. Median follow-up was 2.4 years (1.0-4.9) with a total of 620 patient-years follow-up. About 19.1% of CD patients were subsequently treated with adalimumab.

RESULTS

Seven deaths (3.3%) occurred in follow-up; only one death was <1 year post-infliximab (at day 72, from lung cancer). A total of six malignancies (three haematological, three bronchogenic) and six cases of suspected demyelination (three with confirmed neurological disease) were reported. In the 90 days following infliximab, 95 adverse events (36 serious) occurred in 58/202 (28.7%) patients. In all, 42/202 (20.8%) had an infectious event (22 serious) and 27/202 (13.4%) of patients had an infusion reaction: 19 acute (four serious) and eight delayed (three serious).

CONCLUSIONS

Serious infections, malignancies and neurological disease complicate anti-TNF use in clinical practice. Although evidence for causality is unclear, potential mechanisms and predisposing factors need to be explored. In individual patients, the risk/benefit analysis needs to be carefully assessed and discussed prior to commencement of therapy.

The use of adalimumab in the management of refractory Crohn's disease

BACKGROUND

Adalimumab is a humanized monoclonal antibody targeting tumour necrosis factor-alpha. Recent clinical trials have demonstrated its efficacy in Crohn's disease; however, experience in clinical practice remains limited.

AIM

To investigate the efficacy and safety of adalimumab in the clinical setting.

METHODS

The clinical outcomes of patients with medically refractory Crohn's disease treated with adalimumab in the Western General Hospital Edinburgh, over a 3-year period (2003-2006), were studied.

RESULTS

Twenty-two (14 females; age at therapy: 32.6 years) patients were treated using an 80/40 mg induction regimen followed by fortnightly 40 mg treatment. All had proven refractory/intolerant to corticosteroids and immunosuppression. Twenty patients had had previous infliximab infusions - of these eight (36%), six (27%), three (14%) had previous infusion reactions, no response and lost response to infliximab, respectively. Over a period of 1.0 years (IQR: 0.62-2.5), Kaplan-Meier analyses showed that 68% (seven nonresponders) were in clinical remission and 67% (five surgery - discounting oral CD) avoided further surgery for active disease. 59% required dose escalation to 40 mg weekly (0.55 years; IQR: 0.22-1.4). Three (50%) primary nonresponders to infliximab achieved remission. Two patients developed serious infective complications and one patient developed lung cancer.

CONCLUSIONS

Adalimumab is efficacious in refractory Crohn's disease, with benefit observed in infliximab primary nonresponders. However, many patients require escalation of dosing regimen.

Endoscopic transpapillary stenting of pancreatic duct disruption

BACKGROUND/AIMS

Endoscopic transpapillary stenting of the pancreatic duct is increasingly being used in the management of pancreatic duct disruption. In contrast to its more established role in pancreatic duct obstruction, little is reported on the spectrum of indications and outcome in management of pancreatic duct disruption.

METHODS

The indication for and outcome of transpapillary pancreatic duct stenting was analysed retrospectively in a UK supra-regional specialist pancreatobiliary centre, between January 1998 and August 2004.

RESULTS

Data were obtained on 30 patients (19 male, 11 female, median age 53 years). The main indications for pancreatic duct stenting were: pancreatic pseudocyst, pancreatic ascites, pancreatic duct leak following necrosectomy, and pancreaticopleural fistula. The median duration of stenting was 6 weeks for fistulae and 10 weeks for pseudocysts. Twenty-one patients (70%) had complete resolution. After a median follow-up of 45 months, no recurrence was noted in successfully treated patents.

CONCLUSION

Endoscopic transpapillary pancreatic duct stenting is an increasingly valuable treatment option in the management of pancreatic fistulae and pseudocysts.

Genetic deletion of murine SPRY domain-containing SOCS box protein 2 (SSB-2) results in very mild thrombocytopenia

The SSB family is comprised of four highly homologous proteins containing a C-terminal SOCS box motif and a central SPRY domain. No function has yet been ascribed to any member of this family in mammalian species despite a clear role for other SOCS proteins in negative regulation of cytokine signaling. To investigate its physiological role, the murine Ssb-2 gene was deleted by homologous recombination. SSB-2-deficient mice were shown to have a reduced rate of platelet production, resulting in very mild thrombocytopenia (25% decrease in circulating platelets). Tissue histology and other hematological parameters were normal, as was the majority of serum biochemistry, with the exception that blood urea nitrogen (BUN) levels were decreased in mice lacking SSB-2. Quantitative analysis of SSB mRNA levels indicated that SSB-1, -2, and -3 were ubiquitously expressed; however, SSB-4 was only expressed at very low levels. SSB-2 expression was observed in the kidney and in megakaryocytes, a finding consistent with the phenotype of mice lacking this gene. Deletion of SSB-2 thus perturbs the steady-state level of two tightly controlled homeostatic parameters and identifies a critical role for SSB-2 in regulating platelet production and BUN levels.

A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer

BACKGROUND & AIMS

This multicenter, double-blind, controlled trial compared the efficacy of combined endoscopic hemostatic treatment using the heater probe plus thrombin injection with that of the heater probe plus placebo injection as treatment for peptic ulcers with active bleeding or nonbleeding visible vessels. Efficacy was defined in terms of primary hemostasis, prevention of rebleeding, and need for urgent surgery.

METHODS

Two hundred forty-seven patients presenting with major peptic ulcer bleeding were randomized to heater probe plus thrombin or to heater probe plus placebo. The groups were well matched for all risk categories including age, endoscopic stigmata, shock, and severity of comorbid diseases. Endoscopic therapy was applied using the heater probe followed by injection of thrombin or placebo.

RESULTS

Successful primary hemostasis was achieved in 97% of patients. Rebleeding developed in 19 (15%) of thrombin plus heater probe patients and 17 (15%) of placebo plus heater probe patients. Emergency surgery was necessary in 16 and 13 patients, respectively. Eight patients in the thrombin group had adverse events compared with 4 in the placebo group. Eight (6%) of thrombin plus heater probe patients and 14 (12%) of placebo plus heater probe patients died (P = 0.21).

CONCLUSIONS

The combination of thrombin and the heater probe does not confer an additional benefit over heater probe and placebo as endoscopic treatment for bleeding peptic ulcer. Our trial does not support the use of this combination of hemostatic therapy.

Ulcers and nonvariceal bleeding

Peptic ulcer remains the commonest and most significant cause of nonvariceal upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding is rising in elderly patients, particularly for duodenal ulcer. Patients presenting with upper gastrointestinal bleeding who have low Rockall scores are at low risk of rebleeding and death. These patients currently utilize considerable health-care resources, but could safely be managed at home. The Rockall score can be used to predict the risk of rebleeding and death following variceal bleeding, but for patients with ulcer bleeding, its ability to predict death is questioned. Acid suppression is effective in preventing rebleeding from peptic ulcer. Standard doses of intravenous omeprazole may be as effective as high-dose regimens. Oral omeprazole also reduces rebleeding following endoscopic therapy for peptic ulcer. Mallory-Weiss tears result in significant bleeding in 23 % of cases. Endoscopic therapy may only be required in cases in which active bleeding is present. Endoscopic therapy is effective and safe in patients with major peptic ulcer bleeding who are over 80 years old. For peptic ulcer, injection of larger volumes of epinephrine (adrenaline; mean 16.5 ml) are more effective than small volumes (mean 8 ml). Injection of normal saline alone is less effective than bipolar electrocoagulation. The addition of fibrin glue to epinephrine injection does not confer an additional benefit over epinephrine alone. Argon plasma coagulation can be used to treat a range of lesions in the gastrointestinal tract. It is also effective for treatment of bleeding ulcer, but is no better than established methods. Haemoclips may be useful in bleeding Mallory-Weiss tears, but their use is difficult in patients bleeding from peptic ulcer. The presence of a large ulcer and active bleeding at the time of endoscopy are independent predictors of failure of endoscopic therapy.

Inflammatory bowel disease: developing a short disease specific scale to measure health related quality of life

AIM

To report on the preliminary development of a short scale, the Edinburgh inflammatory bowel disease questionnaire (EIBDQ) to measure disease specific aspects of inflammatory bowel disease (IBD) in terms of both physical impact and health related quality of life (HRQoL) consequences.

METHODS

A survey of individuals with Crohn's disease (n=50), ulcerative colitis (n=50) and psoriatic arthritis (n=28) was carried out using the EIBDQ. The data were subject to factor analysis in order to investigate underlying dimension of the EIBDQ which were then analysed for internal consistency. Data for disease specific aspects of the EIBDQ were compared between IBD patients and psoriatic arthritis patients using contingency tables and the underlying dimension of the EIBDQ were correlated with measures of quality of life and psychological morbidity and a disease specific measure.

RESULTS

There are three underlying dimensions to the EIBDQ: a disease specific factor, a bowel specific factor and an information factor. The disease specific factor and the bowel specific factor are internally consistent and correlate with other measures of disease activity, quality of life and psychological morbidity. The EIBDQ is able to discriminate between IBD and another inflammatory disease: psoriatic arthritis.

CONCLUSION

The EIBDQ is a reliable and valid instrument for measuring disease specific aspects of IBD but further development is required.

Alverine citrate fails to relieve the symptoms of irritable bowel syndrome: results of a double-blind, randomized, placebo-controlled trial

BACKGROUND

Alverine citrate has been used in the treatment of irritable bowel syndrome for many years.

AIMS

To compare the efficacy and safety of a new formulation of alverine citrate, a 120-mg capsule, with placebo given three times daily for 12 weeks.

METHODS

One hundred and seven patients with irritable bowel syndrome were entered into this three-centre, double-blind, randomized, placebo-controlled, parallel group trial. The primary end-point was relief of abdominal pain indicated by improvement in the scores for severity and frequency. Secondary efficacy variables included scores for other clinical symptoms and for overall well-being.

RESULTS

The severity and frequency of abdominal pain improved in 66% and 68% of patients treated with alverine citrate vs. 58% and 69% of the placebo group, but these differences were not significant. The mean percentage reduction in the scores for abdominal pain from baseline to the final assessment, although greater in the alverine citrate group (43.7%) compared with the placebo group (33.3%), was not statistically significant.

CONCLUSIONS

Alverine citrate is no better than placebo at relieving the symptoms of irritable bowel syndrome. Future trials should be designed to take into account the high and persistent placebo response seen in this condition.

A randomized trial of thermal ablative therapy versus expandable metal stents in the palliative treatment of patients with esophageal carcinoma

BACKGROUND

Expandable metal stent insertion and thermal tumor ablation (TTA) both improve dysphagia in patients with advanced esophageal cancer, but no direct comparison study of their efficacy on health-related quality of life has been published. The aim of this study was to compare survival, relief of dysphagia, quality of life, and cost in patients treated by thermal ablation or stent insertion.

METHODS

Sixty-five patients with histologically proven, inoperable esophageal and esophagogastric cancer were initially assessed by endoscopy, barium contrast radiography, and CT of the thorax and abdomen. Dysphagia and quality of life were serially assessed at monthly intervals. Patients were randomized to either repeated TTA or insertion of an expandable metal stent.

RESULTS

Median survival was significantly longer for patients who underwent TTA; 125 days (17-546) versus 68 days (8-602) for those in whom a stent was inserted (p < 0.05), although relief of dysphagia was disappointing in both groups. Several patients in both groups had serious treatment-related complications and required further therapy. Median length of hospital stay and cost were greater for patients treated by TTA. Health-related quality of life was globally impaired in both groups at randomization and deteriorated significantly in the stent group. Pain was reported more commonly by patients with stents.

CONCLUSIONS

The palliation of patients with advanced esophageal and esophagogastric cancer remains unsatisfactory. Health-related quality of life deteriorated in the stent group but not in the TTA group. Patients treated by TTA live longer than patients treated by stent insertion, but the cost of TTA is higher.

Relevance of the Rockall score in patients undergoing endoscopic therapy for peptic ulcer haemorrhage

OBJECTIVE

To assess the ability of the Rockall score to predict outcome in patients who undergo endoscopic therapy for peptic ulcer haemorrhage.

DESIGN

Retrospective data analysis.

SETTING

Patients admitted to the three major acute hospitals in Lothian, UK.

PARTICIPANTS

Details of 211 patients involved in two randomized trials of endoscopic therapy between 1995 and 1999 were accessed, and Rockall scores calculated. All patients had ulcers with active bleeding or non-bleeding visible vessels requiring endoscopic therapy. The patients were followed up for 6 months and end points included rebleeding and death.

MAIN OUTCOME MEASURES

A comparison of mean Rockall scores for those patients who did not rebleed, those who re-bled and those who died. Identification of those patients at greatest risk of rebleeding or death after endoscopic therapy.

RESULTS

One hundred and seventy-six patients did not rebleed, with mean score 6.17 (SD = 1.61). Rebleeding occurred in 35 patients whose mean score was 6.97 (SD = 1.52). There were 29 deaths with mean score 7.34 (SD = 1.40). The differences between the three groups were significant by one-way ANOVA (P < 0.001). Fifty-six patients had a Rockall score of 8 or over and, of these, 16 (29%) re-bled and 14 (25%) died. Of the 155 patients with scores of 7 or less, 19 (12%) re-bled and 15 (10%) died. The difference between these groups was significant with chi2 = 7.912 (P = 0.005) for rebleeding and chi2 = 8.147 (P = 0.004) for death.

CONCLUSIONS

The Rockall score can be used to predict poor outcome in patients who undergo therapeutic endoscopy for major peptic ulcer bleeding.

Injection therapy for endoscopic haemostasis

Endoscopic injection is widely used for the arrest of active ulcer bleeding and for prevention of re-bleeding from ulcers with visible vessels. Although of proven value in clinical trials, mechanisms of action are unclear; tamponade, vasoconstriction, endarteritis and a direct effect upon the clotting process at the site of the arterial defect have been proposed. Clinical trials show that dilute adrenaline is an effective agent and that the addition of sclerosants or alcohol confirms no extra benefit, yet risks serious side-effects. The best results are associated with injection of fibrin glue or thrombin which stimulate formation of a stable blood clot. The efficacy of injection, thermal modalities such as the heater probe and electrocoagulation using BICAP are comparable. In general, there is an advantage in combining injection with a thermal modality, although this may have merit in patients with severe, active ulcer bleeding. Patients who re-bleed following successful primary haemostatic injection treatment can be considered for further endoscopic intervention, but the decision to undertake a surgical operation or repeat endoscopic therapy is a matter of clinical judgement.

Ulcers and nonvariceal bleeding

Although peptic ulcer continues to be the commonest cause of acute upper gastrointestinal bleeding, obscure haemorrhage from the Dieulafoy malformation and haemobilia must be considered, and may be amenable to endoscopic therapy. The patients who are at the highest risk of rebleeding and death are elderly, in shock at presentation, and have major stigmata of recent haemorrhage (SRH). The endoscopist must identify SRH, and identification may be made easier by washing the area with hydrogen peroxide. The natural history of SRH has been defined. There is wide interobserver variation in the interpretation of SRH, and there is probably therefore little value in the endoscopist describing subtle appearances. Although the value of endoscopic haemostatic therapy is established, it has still not been taken up by all institutions. Endoscopic injection of fibrin glue into the bleeding ulcer is a logical and relatively easy approach, and a systematic histological study of resected ulcers has shown that this does not adversely affect the ulcer healing process. Thermal therapies such as argon plasma coagulation and the heater probe have comparable efficacy. Although a combination of injection and thermal treatments may be logical, there are only trends suggesting that this is better than monotherapy. Nevertheless, the gold probe continues to be used in clinical practice. Experiments in an animal model of gastric bleeding suggest that the gold probe is effective, and that the version with a wide-gauge needle is best. Haemoclips may stop acute upper gastrointestinal bleeding from a range of sources. Patients who rebleed after initial endoscopic haemostasis have a tenfold increase in the risk of death. An important study from Hong Kong suggests that repeat endoscopic treatment after rebleeding has comparable morbidity and mortality to a policy of urgent surgery without endoscopic repeat intervention.

Diagnostic and therapeutic endoscopy

Endoscopic therapy improves the outcome of nonvariceal upper gastrointestinal hemorrhage. Routine second-look procedures may not improve outcome. Patients who rebleed after endoscopic therapy for ulcer hemorrhage should be treated by further endoscopic therapy, rather than urgent surgery. Thinner endoscopes offer adequate visualization with improved patient tolerance, and new endoscopic therapeutic methods continue to be evaluated. Stigmata of recent hemorrhage and their endoscopic interpretation remain a topic for discussion. The Rockall scoring system is validated. Percutaneous endoscopic gastrostomy insertion may be possible without prior transillumination of the stomach. Routine use of antibiotics prior to insertion reduces wound infection. Percutaneous endoscopic gastrostomy feeding is well established, and follow-up studies confirm its value. Endoscopic ultrasound is a rapidly developing technique. Its uses and potential have evolved, resulting in wider applications in benign disease of the esophagus, biliary tree, and pancreas, in addition to its increasing role in the diagnosis and staging of malignancy.

The effect of octreotide on gastroduodenal blood flow measured by laser Doppler flowmetry in rabbits and man

OBJECTIVE

The somatostatin analogue, octreotide is valuable in the management of variceal bleeding, and it has been suggested that it may stop peptic ulcer hemorrhage by reducing gastroduodenal blood flow or increasing intragastric pH. The aim of this study was to determine the effect of intravenous octreotide infusion on gastroduodenal mucosal blood flow and gastric pH.

METHODS

Seven New Zealand white rabbits and five healthy human volunteers were used. Mucosal blood flow was measured using a laser Doppler flowmeter (LDF). The Doppler probe was positioned in the upper gastrointestinal tract of the seven rabbits and five human volunteers. Blood flow was measured before and after octreotide infusion.

RESULTS

In the animal experiments, mucosal blood flow was decreased in a dose dependent manner in the gastric body (209.1-56.3 U) (p < 0.008), antrum (143.3-33.3 U) (p < 0.02) and duodenum (254-67.6 U) (p < 0.016) by doses of octreotide ranging from 10-50 microg/kg of body weight. In the human studies, mucosal blood flow was decreased in the gastric body (p < 0.016) and antrum (p < 0.009) after octreotide infusion (dose 1-1.5 microg/kg). Intragastric pH was significantly increased (p < 0.05). The change was not associated with systemic hemodynamic changes.

CONCLUSIONS

Gastroduodenal mucosal blood flow was reduced and intragastric pH increased by octreotide. This agent could be helpful in the management of gastroduodenal mucosal bleeding.

A combination of ciprofloxacin and Rowachol does not prevent biliary stent occlusion

BACKGROUND

Endoscopic insertion of biliary prostheses is now an established palliative treatment for frail and elderly patients with distal extrahepatic malignant biliary strictures who are unable to tolerate major surgery. The major limitation to long-term biliary stenting is late stent occlusion caused by bacterial adherence followed by encrustation with amorphous bacterial products. We studied the effect on the duration of stent patency of combination therapy with ciprofloxacin and Rowachol, a choleretic agent, in a group of patients who underwent stent insertion for extrahepatic malignant biliary strictures.

METHODS

Patients with this diagnosis were randomized to either active treatment with ciprofloxacin (500 mg twice daily) and Rowachol (2 tablets 3 times daily) or no drug treatment (control group). They were followed up prospectively and the end points of the study were stent occlusion and patient survival.

RESULTS

Forty-eight patients who had successful stent placement were recruited; 8 patients were excluded from the final analysis because of death in less than 1 month (5 patients) or stent replacement within a month because of persistent jaundice (3 patients). Twenty patients were randomized to the active and control groups. One patient in the active group withdrew because of nausea. The 2 groups were comparable with regard to age, gender, causes of extrahepatic malignant biliary strictures, and levels of serum alkaline phosphatase and bilirubin. There were significant reductions in mean serum bilirubin and alkaline phosphatase concentrations 1 month after stent placement. At the time of analysis, 12 patients were still alive (7 patients from the control group). Median survival was 23 weeks in both the active treatment group and the control group. There were 9 episodes (45%) of stent occlusions in the active treatment group and 10 episodes (50%) in the control group. The median time to stent occlusion was 23 (range 7 to 68) weeks for the active treatment group and 21 (range 6 to 56) weeks for the control group, p = 0.23. There was no significant difference in the duration of patient survival and of stent patency between the 2 groups. The lack of difference between treated and untreated patients in survival duration and stent patency was also shown if the results were analyzed on an intent-to-treat basis and the 8 patients who were excluded in the final analysis were also analyzed.

CONCLUSIONS

Prophylactic therapy with ciprofloxacin and Rowachol does not prolong stent patency or patient survival.

Appendicectomy and ulcerative colitis

The aetiology of ulcerative colitis (UC) is unknown. However, much interest has been devoted recently to the relationship between appendicectomy and ulcerative colitis. A case-control study was conducted, comparing appendicectomy rates between 110 patients with UC (group 1) and 136 patients attending an orthopaedic clinic free from UC (group 2). The appendicectomy rates were 0.9% (group 1) and 10.3% (group 2), respectively (P < 0.002). The present study shows that patients with ulcerative colitis had rarely undergone appendicectomy before the first manifestation of colitis. Further research on this relationship is called for.

Nitric oxide and gall-bladder motor function

BACKGROUND

The L-arginine: nitric oxide (NO) pathway has been shown to be important in the regulation of intestinal motility and NO may be the mediator for nonadrenergic noncholinergic (NANC) neurotransmission.

AIM

To determine the role of the L-arginine: NO pathway in gall-bladder motor function.

METHODS

Strips of fresh bovine and human gall-bladders were stimulated with cholecystokinin (CCK). The effects of glyceryl trinitrate (GTN), sodium nitroprusside and Kreb's solution upon CCK-stimulated muscle contraction were examined. The effect of the NO synthase inhibitor, L-NG-monomethyl-arginine (L-NMMA) upon basal muscle tone was also examined. Ten human gall-bladders were immunohistochemically stained for nitric oxide synthase (NOS) and product 9.5 to identify neurones. Postprandial gall-bladder emptying was measured on separate occasions in six healthy volunteers during systemic intravenous infusion of normal saline; glyceryl trinitrate; sodium nitroprusside (SNP), hydralazine and L-NMMA.

RESULTS

In the in vitro study, GTN and SNP significantly reduced the tension of CCK-stimulated muscle contraction whilst Kreb's solution had no effect. L-NMMA increased tonic and phasic muscle contractions. Immunohistochemical staining for NOS was consistently absent in human gall-bladders. In the in vivo study, both GTN and SNP caused significant impairment of gall-bladder emptying; the ejection fraction was only 50% at the end of the study period involving these infusates, this contrasted with ejection fractions in excess of 80% during infusions with hydralazine, saline and L-NMMA.

CONCLUSION

Pharmacological doses of NO donors impair postprandial gall-bladder emptying in vivo and relax gall-bladder smooth muscle in vitro. However, negative immunohistochemical staining suggest NOS is unlikely to be the neurotransmitter for NANC innervation regulating gall-bladder motility.

Caroli's disease

Caroli's disease is characterized by multifocal segmental dilatation of the intrahepatic bile ducts. It is a rare congenital condition, which appears to be autosomal recessively inherited in most cases. There are two forms of disease, one associated with congenital hepatic fibrosis and a simple form occurring alone. Recent reports suggest that the simple form may be as common as that with congenital hepatic fibrosis. Other conditions, including choledochal cyst and renal cystic disease, are frequently associated. The major clinical feature is recurrent cholangitis, which may be complicated by intrahepatic calculi and hepatic abscess formation. There is good evidence that malignancy complicates Caroli's disease in approximately 7% of cases. The diagnosis rests on demonstrating that the cystic liver lesions are in continuity with the biliary tree. Modern imaging techniques allow the diagnosis to be made more easily and without invasive imaging of the biliary tree. The treatment depends on the clinical features and the location of the biliary abnormality. When the disease is localized to one hepatic lobe, hepatectomy relieves symptoms and appears to remove the risk of malignancy. In diffuse Caroli's disease, treatment options include conservative or endoscopic therapy, internal biliary bypass procedures and liver transplantation in carefully selected cases.

Influence of cholecystectomy on sphincter of Oddi motility

BACKGROUND

Gall bladder and sphincter of Oddi (SO) function are coordinated by hormonal and neuronal mechanisms. Nerve fibres pass between the gall bladder and the SO via the cystic duct. It is therefore possible that cholecystectomy may alter SO motility.

AIM

To investigate the effect of cholecystectomy on SO function.

METHODS

SO manometry was performed in five women (median age 52 years), a few days before and six months after laparoscopic cholecystectomy which was undertaken for uncomplicated cholelithiasis. Basal and post-cholecystokinin (CCK) SO motility were measured.

RESULTS

All patients were symptom free after laparoscopic cholecystectomy. Prior to surgery common bile duct pressure, and tonic and phasic SO motility were normal and phasic contractions were inhibited by intravenous CCK (1 Ivy Dog Unit/kg). Six months later, common bile duct pressure and baseline tonic and phasic activity were unchanged but CCK failed to suppress phasic activity.

CONCLUSION

Cholecystectomy, at least in the short term, suppresses the normal inhibitory effect of pharmacological doses of CCK on the SO. The mechanism of this effect is unknown but it could be due to SO denervation.

Pharmacokinetics of valsartan in patients with liver disease

OBJECTIVES

Valsartan (CGP 48933), an orally active angiotensin II antagonist, is eliminated mainly by hepatic clearance. To characterize the compound(s) excreted in the bile, biliary excretion of valsartan was investigated by collection of bile after an intravenous dose of valsartan. In addition, to determine the exposure to valsartan when liver function is impaired, a pharmacokinetic study (open, single dose) was performed in patients with mild and moderate impairment of liver function.

PATIENTS

Biliary excretion of valsartan (after intravenous administration of 20 mg valsartan) was assessed in a patient who underwent a hepaticojejunostomy with subsequent bile drainage. Exposure to valsartan in patients with mild (n = 6) or moderate (n = 6) impaired liver function (Child's-Pugh classification) and matching (sex, age, and weight) healthy volunteers (n = 12) was studied after oral administration of a single dose of 160 mg valsartan.

RESULTS

After intravenous administration, valsartan was eliminated mainly as unchanged drug in the bile. Mean exposure (measured as area under the plasma valsartan concentration-time curve) to valsartan was increased about twofold in both the mild and the moderate groups compared with matched (age, sex, and weight) healthy volunteers.

CONCLUSION

These data are consistent with the pharmacokinetics of valsartan in that biliary excretion is the main route of elimination.

Quality of life in patients stented for malignant biliary obstructions

BACKGROUND/AIMS

Endoscopic stent placement is the standard treatment for patients with extrahepatic malignant biliary strictures (EMBS) who are too frail to undergo surgical resection. Stenting relieves jaundice and pruritus but the effects upon other systemic symptoms and quality of life (QOL) are not known.

METHODS

Forty-seven patients (age: 46-89 years) with jaundice due to EMBS completed the European Organisation for Research and Treatment of Cancer QOL questionnaire, EORTC QLQ-C30, and two further questions assessing jaundice and pruritus, at the time of diagnosis and 1 month after endoscopic stenting. Thirty-eight patients successfully completed the study; nine patients succumbed to their illness within a month.

RESULTS

No significant difference was found in the baseline QOL measurements and liver function tests between those patients who completed the study and those who were either too weak to answer the questionnaire or died within the first month of stenting. For patients who successfully completed follow-up, liver function tests (apart from serum albumin) improved after stenting. They also reported significant improvement in emotional, cognitive and global health scores (P < 0.01). In addition to the expected improvement in pruritus and jaundice (P < 0.01), anorexia, diarrhoea and sleep pattern were also reported to be improved (P < 0.01).

CONCLUSION

Endoscopic stent insertion considerably improves a range of symptoms and enhances quality of life.

Experimental studies of injection therapy for ulcer haemorrhage in rabbits

BACKGROUND

Endoscopic injection therapy is a well established method of controlling peptic ulcer haemorrhage but the optimum injection solution and the mechanism involved in inducing haemostasis are unknown.

METHODS

The efficacy and effects on tissue of various therapeutic agents used in the control of gastric mucosal haemorrhage were studied in ten rabbits. Thirty-eight bleeding mucosal ulcers (blood loss above 1.5 ml/min) created at gastrotomy were studied. Adrenaline (1:100,000), thrombin, fibrin (thrombin plus fibrinogen), 5 per cent ethanolamine and 50 per cent dextrose were injected; a fibrin suspension was also sprayed around bleeding ulcers.

RESULTS

Sclerosants were found to be least effective in the control of bleeding and were associated with significant tissue necrosis. Although all the other solutions significantly decreased blood loss within 30 min of injection (median blood loss 0.25 ml/min), only an injected mixture of adrenaline plus thrombin and sprayed fibrin achieved complete haemostasis within 2 min of treatment and with no recurrence of bleeding. Neither agent caused significant tissue damage. Histological examination showed that no solution caused arterial thrombosis when injected next to a major ear artery.

CONCLUSION

Sclerosants caused extensive tissue necrosis and were least effective in the control of ulcer haemorrhage. A combination of dilute adrenaline and human thrombin may represent optimal haemostatic therapy for peptic ulcer haemorrhage.

Topical glyceryl trinitrate relaxes the sphincter of Oddi

BACKGROUND/AIM

Nitric oxide (NO) may be involved in non-adrenergic non-cholinergic (NANC) inhibitory innervation of the sphincter of Oddi (SO). The effects of topical application of glyceryl trinitrate (GTN), a NO donor, upon SO motility were examined.

METHODS

Nineteen patients undergoing routine SO manometry for investigation of abdominal pain were studied. After routine recording of SO motility, they were randomised into three groups to receive 10 ml of normal saline, 5 mg GTN (0.5 mg/ml) or 10 mg (1 mg/ml) GTN. Drug solutions were infused topically onto papilla via the manometry catheter and recordings were continued for a further 5 minutes.

RESULTS

There was no significant change in SO motor variables following application of normal saline. GTN reduced SO tonic and phasic contractions. In four patients, there was complete abolition of all phasic contraction.

CONCLUSIONS

Local application of GTN inhibits SO motility. This may have application for diagnostic and therapeutic biliary endoscopy.

Reduced long-term survival following major peptic ulcer haemorrhage

BACKGROUND

The late outcome of patients who present with major peptic ulcer haemorrhage is unclear. An examination was made of the hypothesis that prognosis may be poor because many such patients have severe co-morbid diseases.

METHODS

Some 121 patients treated endoscopically for severe peptic ulcer haemorrhage were followed for a median of 36 (range 30-76) months and outcome was compared with that of age- and sex-matched controls.

RESULTS

Thirty patients (25 per cent) died during the follow-up period and Kaplan-Meier plots showed reduced survival in patients with ulcers (P < 0.01). Death was restricted largely to patients who had co-morbid diseases. Eight of the remaining 91 patients had further peptic ulcer bleeding; two of these were taking maintenance acid-reducing therapy and only one had significant dyspepsia before rebleeding. Eighty-three per cent of surviving patients had little or no dyspepsia.

CONCLUSIONS

The late prognosis of patients who present with major ulcer haemorrhage is poor, but most deaths are a consequence of co-morbid disease and not recurrent ulcer bleeding. Most patients have little dyspepsia and those who rebleed are largely free from dyspepsia.

Transhepatic venous angioplasty and stenting: a treatment option in bleeding from gastric varices secondary to pancreatic carcinoma

We present a case of recurrent variceal bleeding due to subtotal occlusion of the splenoportal junction by a pancreatic carcinoma. This was effectively treated by transhepatic venous angioplasty and stenting.

The outcome of urgent surgery for major peptic ulcer haemorrhage following failed endoscopic therapy

OBJECTIVE

To review the outcome of patients who underwent emergency surgery for major peptic ulcer haemorrhage after failed endoscopic therapy. To address whether 'conservative' or 'aggressive' surgery is best.

DESIGN

A retrospective analysis of emergency surgery for ulcer bleeding which could not be controlled by endoscopic therapy.

SETTING

The four admitting units in the Lothian region of Scotland.

PARTICIPANTS

Sixty-seven patients who failed endoscopic therapy for bleeding peptic ulcer and underwent emergency surgery between December 1990 and December 1995. Simple underrunning or excision of ulcer alone was done in 31 patients whilst 36 had more radical surgery.

MAIN OUTCOME MEASURES

Rebleeding and 30-day mortality rates.

RESULTS

Rebleeding was significantly higher in patients treated by underrunning (7 versus 1, P < 0.013). There were fewer deaths in the radically treated group (5 versus 7, not significant).

CONCLUSION

Patients undergoing surgical operation for severe peptic ulcer haemorrhage after failed endoscopic therapy may be best served by a relatively aggressive approach.

Incidence of persistent symptoms after laparoscopic cholecystectomy: a prospective study

BACKGROUND AND AIMS

Laparoscopic cholecystectomy is the standard treatment for symptomatic gall stone disease. This study aimed to assess the effect of the operation on patients' symptoms.

METHODS

One hundred consecutive patients undergoing laparoscopic cholecystectomy between June 1994 and June 1995 were evaluated using standard questionnaires examining demographic details, indication for laparoscopic cholecystectomy, characteristics of pain, and other associated dyspeptic and colonic symptoms. A history of psychiatric disturbances and of hysterectomy were also recorded. The same questionnaires were administered again six months after the operation. Operation notes and histological reports were reviewed.

RESULTS

Three patients were converted to open surgery and were excluded from analysis. The median age of the remaining 97 patients was 50.9 (19-85) years; 19 were men. There was one complication each of bleeding and biliary leak. Indications for laparoscopic cholecystectomy were biliary type pain (66 patients) and complicated gall stone disease (acute cholecystitis 21, cholestatic jaundice six, and pancreatitis four). Thirteen patients (13%) had persistent pain and two (3%) developed diarrhoea at follow up. Only one patient with persistent pain after laparoscopic cholecystectomy originated from the complicated gall stone disease group. Logistic discriminant analysis showed that bloating (p < 0.001), constipation (p < 0.05), and previous and current use of psychotrophic drugs (p < 0.001) were significantly more common among those with a poor outcome after laparoscopic cholecystectomy. Heartburn was unaffected. Of patients with persistent symptoms after cholecystectomy 77% had no or mild histological changes of cholecystitis as compared with 30% in the pain free group.

CONCLUSIONS

The incidence of persistent pain after laparoscopic cholecystectomy was 13%. Abdominal bloating and psychiatric medications were predictive for persistence of pain after laparoscopic cholecystectomy.