These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically, with those failing having either choledochotomy or postoperative ERCP. However, because of the small trial size, a significant chance exists that small differences in outcome may exist. We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection. We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy, failed ERCP access, or where long delays would occur for patient transfer to other locations for the ERCP.

The relationship between serum levels of conjugates of cholic acid measured by radioimmunoassay, bile acid absorption, and hepatic clearance was studied in order to define the determinants of fasting and postprandial serum bile acids in healthy man. Acute or chronic interruption of the enterohepatic circulation caused a significant decrease in basal serum levels of cholyl conjugates, while liquid or solid meals caused a marked and reproducible increase in serum cholyl conjugates. A temporal correlation was demonstrated postprandially or after intravenous cholecystokinin between intestinal transit of bile acids and simultaneous changes in levels of serum cholyl conjugates. Finally, the plasma disappearance of intravenously injected cholylglycine was shown to be unaffected by serum levels of endogenous cholyl conjugates. These data are consistent with the interpretation that, in the presence of normal hepatic function, the major determinant of serum bile acids is their rate of intestinal absorption.

Eleven patients (nine females, two males) with anaemia due to acute and chronic gastrointestinal blood loss were found to have gastric antral vascular ectasia (watermelon stomach). Nine patients were transfusion-dependent, receiving a mean of 13.1 units over a mean period of 12.3 months. All patients received neodymium:yttrium-aluminium-garnet laser coagulation with a median of 3.0 treatment sessions. Post-treatment transfusion needs were abolished in six patients and minimal in two patients during a mean follow up of 27.3 months (range 12-60 months). Overall there was a mean reduction in transfusion requirement with treatment from 2.5 units per month to 0.4 units per month (P < 0.02). Mean pretreatment haemoglobin improved from 7.7 to 11.9 g/dL after treatment (P < 0.001). No complications occurred. Laser coagulation is safe and effective treatment for anaemia due to watermelon stomach and should be considered as first line therapy.

The cleaning of flexible endoscopes is difficult and time consuming. Any method of attempted sterilization or high level disinfection will fail if prior cleaning has been defective. Inadequate reprocessing of endoscopes may result in patient to patient transmission of serious bacterial and viral diseases or infection with endemic hospital pathogens. Antibiotic prophylaxis is required to prevent septicemia and bacterial endocarditis in high risk patients undergoing specific endoscopic procedures. Prevention of serious endoscopy-associated clinical infections requires strict compliance with detailed reprocessing protocols by specially trained nursing staff.

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Conclusions-Study of duodenal and colonic polyps in further cases with mutations in this region is warranted. Such mutations may preferentially cause duodenal adenomas and desmoid tumours as somatic mutations in these tumours also occur in this region, unlike colorectal tumours where somatic mutations occur more proximally. This study emphasises the importance of screening the upper gastrointestinal tract even when the colonic disease is mild. (Gut 1997; 41: 518-521)

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