Aim: To determine associations between enterogastric bile reflux and gastric mucosal pathology. Method: A retrospective study using fasting gastric juice bile acid measurements and antral or prestomal biopsy specimens from 350 patients, 66 of whom had previously undergone surgery that either bypassed or disrupted the pyloric sphincter.Results: Bile reflux was positively associated with reactive gastritis and negatively with Helicobacter pylon density. After stratification for previous surgery, age, and H pylon status, the histological feature most strongly associated with bile reflux was intestinal metaplasia, including all its subtypes. The aim of this study was therefore to determine the role of bile reflux in the causation of gastric mucosal pathology, specifically controlling for the presence of H pylon, in patients both with and without previous gastric surgery. A large study population was required to disentangle the effects of bile reflux from those of H pyloni infection. We achieved this by performing a meta analysis on gastric biopsy results and gastric juice bile acid measurements obtained during the course of our studies over the past 10 years. In particular, we sought to examine more closely the association we have previously reported between bile reflux and reflux or reactive gastritis, to report on the relative importance of the individual components of the histological reflux score we have previously proposed,' and to confirm and further explore the association between bile reflux and intestinal metaplasia. We also attempted to derive a histological index predicting the presence of abnormal bile reflux. MethodsBiopsy and gastric juice bile acid results were available from 350 patients who had participated in five published studies.'45-7 The 168 patients in the first three studies had been selected for their known pathology or previous gastric surgery; 60 of these had also undergone surgery that had destroyed or bypassed the pylorus. The fourth study comprised 135 consecutive patients attending an open access endoscopy clinic, excluding those with neoplastic disease. The 47 patients in the last study were attending diagnostic endoscopy lists and were selected on criteria of convenience of the timing of sample collection and of absence of previous gastric surgery. All patients had at least two biopsy specimens taken from the antrum, or in the 35 with Billroth gastrectomies, from the remnant of stomach within 5 cm of the stoma.All patients gave informed consent. The studies were individually approved by the local research ethics committee.Gastric juice was aspirated through a nasogastric tube in the first two studies, and at the time of endoscopy in the latter three. Bile acid concentration was then determined by the steroid dehydrogenase method8 in the same laboratory throughout.The biopsy specimens were fixed in 10% formalin. After routine processing sections were taken at three levels and stained with haematoxylin and eosin. Additional sections were stained with alcian blue (pH 2 5) and pe...

No abstract

We conducted a prospective, multi-centre, open, randomized study in 11 UK hospitals to compare iv meropenem 1 g tds with the combination of iv cefotaxime 1 g tds and iv metronidazole 500 mg tds in patients with serious infections. One hundred and sixty-one patients were enrolled, of whom 131 were clinically evaluable (meropenem, n = 68; cefotaxime/metronidazole, n = 63). The most common infections were subsequent to intra-abdominal pathology (meropenem, n = 77%; cefotaxime/metronidazole, n = 75%), and were usually accompanied by septicaemia (meropenem, n = 61%; cefotaxime/metronidazole, n = 53%). The incidence of a satisfactory clinical response was similar in the two groups at the end of treatment (93% for meropenem; 92% for cefotaxime/metronidazole) and up to 8 weeks later (96% for meropenem; 93% for cefotaxime/metronidazole). Satisfactory bacteriological response (success or presumed success) was recorded at the end of therapy in 86% of meropenem and 88% of cefotaxime/metronidazole patients. Adverse events were reported in 32% of meropenem and 25% of cefotaxime/metronidazole patients, and most were mild or moderate and did not require discontinuation of therapy. Twenty-one patients (ten meropenem and 11 cefotaxime/metronidazole) died during the trial, underlining the severity of the infections being treated in this group of patients. None of the deaths was thought to be related to study therapy.

Ninety-seven Royal Naval and Royal Marine officers and ratings undergoing repair of a unilateral inguinal hernia were randomized postoperatively into two groups: A, those who returned to full working duties 21 days after operation; B, those who returned to light duties 21 days after operation and to full duties at 3 months. Patients were reviewed at 3 and 12 months. One patient was withdrawn because of the development of late sepsis. Two patients in group B developed a recurrence of hernia within 1 year. No patient who returned to full duties at 21 days was unable to do any duty assigned to him. In a concurrent trial 119 male civilian patients were treated in the same hospital under identical conditions. All patients were reviewed 21 days after operation and were randomized into two groups: C, those advised to return to work immediately; D, those given no advice. Patients in group C returned to work in a mean of 38 days (range 14-96 days), whereas those in group D returned in a mean of 71 days (range 14-280 days). There was no recurrence of hernia in either group within the review period. It is concluded that there is no contraindication to resuming physical work 3 weeks after the uncomplicated repair of a unilateral inguinal hernia, and that active encouragement shortens the interval before return to work.

Intussusception through loop ileostomy is rare and must be treated without delay to avoid further complications. Retrograde intussusception is even rarer. We report a case of small bowel obstruction caused by retrograde intussusception through the distal limb of loop ileostomy in a male patient. A literature search is also carried out regarding this entity and published reports are discussed.Ann R Coll Surg Engl 2011; 93: e81-e82 doi 10.1308/147870811X590838Intussusception is the invagination of a portion of intestine into an adjacent segment in the manner of a telescope. Usually, this is in the direction of peristalsis but, unusually, it can occur in retrograde fashion against the normal flow of muscular contractions. Once started, intussusception can rapidly progress until the supplying blood vessels are drawn into the intussuscipiens (the portion of bowel containing the invagination) and become compressed with subsequent loss of blood supply to the intussusceptum (the part of the bowel that has telescoped in) and ischaemic with or without gangrene.Intussusception through a loop ileostomy is rare and must be treated without delay to prevent progression and further complications. Retrograde intussusception is even rarer and therefore less likely to be recognised early. We report a case of retrograde intussusception through the distal limb of a loop ileostomy in a male patient. A literature search is also carried out and published reports are discussed.Loop ileostomy was first described by Turnbull et al in 19711 and since then has become an important procedure in colorectal surgery for faecal diversion to treat a wide range of conditions including inflammatory bowel disease, trauma, radiation proctitis and benign and malignant conditions of the colon and rectum and pelvic organs.2 It can be fashioned and reversed with relative ease. A number of postoperative complications are reported including prolapse, parastomal hernia, retraction and obstruction. Intussusception has been reported on only five occasions. case historyWe report a 72-year-old male patient who underwent an elective low anterior resection with covering loop ileostomy for low rectal cancer. Histology confirmed an adenocarcinoma of the rectum (pT2 pN0). Postoperatively, the patient was commenced on free fluids, as tolerated, and a light diet was commenced on the second postoperative day. His stoma output was good on day two. On the third postoperative day he developed nausea and then vomited 900ml overnight.On examination of the stoma it was noted that the proximal limb lumen of the ileostomy was normal but that there was small bowel protruding through the site of the distal limb. Small bowel mucosa was evident rather than serosa, giving a high suspicion of intussusception rather than a prolapse as serosa would then have been visible. The protruding bowel was engorged and oedematous and a putative diagnosis of retrograde intussusception was made. Initially, reduction of the intussusception was attempted manually by applying gentle pressure ...

These data have major implications with regard to patient safety, service provision and cost to the NHS.

Bile acid and lysolecithin concentrations in the stomach were measured in normal subjects and in patients with gastric ulcer (GU) before operation and more than 1 year after highly selective vagotomy, Billroth I partial gastrectomy (PG) and truncal vagotomy and pyloroplasty. Before operation, patients with GU had significantly (P less than 0.001) higher bile acid concentrations in the stomach than normal people. After highly selective vagotomy, bile acid concentrations were significantly lower than in preoperative GU patients and were also significantly lower than in patients after PG, but were still higher than in normal people. Postprandial and peak lysolecithin concentrations after highly selective vagotomy were significantly lower than after partial gastrectomy. The therapeutic effect of highly selective vagotomy in the surgical treatment of GU may be due not only to reduced acid-peptic 'attack' on the gastric mucosa, but also to reduced duodenogastric reflux of 'bile'.

No abstract