Twenty patients with bronchial asthma who also had gastro-oesophageal reflux were investigated. The severity of their reflux was graded using symptom score of heartburn and regurgitation and by the following investigations: barium swallow and meal, fibreoptic endoscopy and biopsy, manometry and pH monitoring of the distal oesophagus, and an acid infusion test. Full lung function studies were performed and patients were entered into a double-blind crossover study using cimetidine to control their reflux in order to assess beneficial effects with respect to their respiratory problems. Eighteen patients completed the study. Significant improvements were seen in reflux and night time asthmatic symptoms, both these indices being measured on a scoring system. Home monitoring of peak flow values showed a statistical improvement for the last peak flow reading of the day. Fourteen patients felt that their chest symptoms had significantly improved during the cimetidine period.Gastro-oesophageal reflux commonly produces symptoms in subjects of all ages. The dominant complaints are usually related to the upper gastrointestinal tract and include heartburn, regurgitation, and occasionally dysphagia. Patients with re'lux are also liable to respiratory complications leading to severe, progressive, and disabling pulmonary damage.' More recently attention has been drawn to an association between reflux and exacerbations of bronchial asthma,23 and there have been several studies suggesting subjective improvement in such patients after surgical correction of hiatus hernia. [3][4][5] In this study we have attempted to demonstrate a measurable improvement in symptoms and respiratory function in a group of asthmatic patients, who also had well-documented reflux, by controlling their reflux with cimetidine in a double-blind, crossover trial. MethodsInformed consent for study was obtained from 20 patients, 13 men and seven women, whose ages ranged from 30-65 years (mean 54 years). All patients had bronchial asthma and were attending

Two cases of the rare condition of abdominal apoplexy are described. The two main clincial presentations of this condition are discussed as is the aetiology. It is suggested that selective visceral angiography might prove helpful in preoperative diagnosis.

Small clusters of microscopically normal thyroid follicles within cervical lymph nodes are very occasionally encountered during histological examination. We support the view that provided the thyroid gland is not palpable and a technetium thyroid scan is normal, these should be regarded as benign thyroid inclusions and do not represent small metastatic lesions from thyroid carcinoma. We report an example of these inclusions in a cervical lymph node which was removed incidentally during the excision of a branchial cyst in a 25-year-old woman. The inclusion was too small to be noticed macroscopically and consisted of a small aggregation of histologically normal thyroid follicles situated in the subcapsular region of the lymph node.

Hubert WT, Rosen MN. Pasteurella multocida infection. II. Pasteurella multocida infection in man unrelated to animal bite. AmJ7 Public Health 1970;60:1/09.

Fifty-seven patients, with chronic duodenal ulceration resistant to cimetidine therapy, underwent proximal gastric vagotomy during the period August 1979 to May 1984. Thirty-five failed to respond to cimetidine in a dose of 1 g/day, whilst 22 relapsed on reduction of dosage to 400 mg daily or on cessation of therapy. Forty have been followed up for a period of 12-53 months (median duration = 28.5 months), and assessed using the modified Visick system. Thirty-four patients (85 per cent) were graded Visick I or II. Four patients (10 per cent) had non-specific upper gastrointestinal symptoms (Visick III). In these patients endoscopy has shown no evidence of recurrent ulceration. Two patients (5 per cent) were graded Visick IV. One had recurrent ulceration on endoscopy. The other developed symptomatic gastro-oesophageal reflux, necessitating further surgery. These results support the view that cimetidine resistance is not a predictor of poor results following proximal gastric vagotomy.

Fifty patients with gastro-oesophageal reflux disease refractory to multiple courses of medical therapy were entered into a prospective randomized trial comparing Nissen fundoplication with the Angelchick prosthesis as a primary surgical procedure. The two groups were matched for age, sex, duration of symptoms before surgery, type of medical therapy, pattern of symptom presentation, endoscopic grade of oesophageal inflammation, manometric lower oesophageal pressure and 24-h pH profile. Twenty-five patients were randomized to each of the Nissen fundoplication and Angelchik prosthesis groups. Operation time and hospital stay were similar in both groups. Persistent dysphagia was reported in five of the patients with an Angelchik prosthesis compared with none in the Nissen fundoplication group. Three prostheses were removed because of severe dysphagia while no Nissen fundoplication required revision. No patient with preoperative dysphagia because of stricture reported swallowing difficulties after operation. At clinical assessment at 3, 6, 12 and 24 months after operation, 85-88 per cent of the patients having a Nissen fundoplication were graded Visick 1 or 2 compared with 60-72 per cent of patients in the Angelchik group.

SUMMARYThe changes produced by the Nissen fundoplication were measured in 12 patients, who required surgery to control their reflux oesophagitis. The gastro-oesophageal junction of each patient was studied before and three months after operation by station pullthrough manometry and prolonged pH monitoring of the distal oesophagus. All patients were free from reflux symptoms post-operatively. The Nissen fundoplication resulted in a significant increase in the pressure, but not the length, of the lower oesophageal high pressure zone. A greater proportion of this zone was situated in the abdomen postoperatively. Prolonged pH monitoring showed a significant improvement in all the measured indices of acid reflux. Nissen fundoplication restores competence to the gastro-oesophageal junction as judged by manometry and pH monitoring. This kind of study should be performed to document the efficiency of other anti-reflux procedures.Although the precise nature of the mechanism which prevents abnormal reflux of gastric contents into the lower oesophagus is not clearly defined and may be dependent upon more than one factor,l 23 it is now well recognised that failure of this mechanism may occur independently of the anatomical abnormality of a sliding hiatal hernia.45 Consequent upon this understanding of the pathophysiology of gastro-oesophageal reflux has come the reappraisal of the aim of surgery in the treatment of those patients whose symptoms and oesophagitis are unresponsive to conservative therapy.When the cause of the symptoms of heartburn and regurgitation were correctly attributed to gastrooesophageal reflux," it was assumed that this reflux was made possible by the presence of a sliding hiatal hernia. It was further assumed that, if this hernia were repaired according to the general principles of hernia repair, then the abnormal reflux would be prevented and the patient cured. Unfortunately, anatomical repair of the hiatus frequently did not prevent further reflux, however meticulously the operation was carried out and by whatever method it was performed.7 8

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