Distal esophageal contractile amplitude and duration after wet swallows increases with age. Triple-peaked waves and wet-swallow-induced simultaneous contractions should suggest an esophageal motility disorder. Double-peaked waves are a common variant of normal. Dry swallows have little use in the current evaluation of esophageal peristalsis.

SUMMARY We describe a long term study of 76 patients with dermatitis herpetiformis. Unlike patients with coeliac disease, where the peak incidence was during the first and fourth decades, no dermatitis herpetiformis patients presented in the first decade; also, there was a male preponderance in dermatitis herpetiformis which contrasts with the excess of females in coeliac disease. The apparent prevalence of dermatitis herpetiformis was 11 per 100 000 in our population; approximately one fifth of that of coeliac disease. Jejunal villous atrophy was present in 78% of our dermatitis herpetiformis patients, and a single jejunal biopsy was as effective at detecting this as the multiple biopsy technique. A majority of patients were able to stop, or radically reduce their dapsone or sulphapyridine treatment after the institution of a gluten free diet. Spontaneous remission of the skin lesion occurred in only two patients not receiving a gluten free diet. Gastric parietal or thyroid antibodies were detected in 38% of patients, and three cases of thyroid disease and two cases of pernicious anaemia were detected. Lymphoma developed in two patients, one being intestinal in origin. We conclude that a gluten free diet is of therapeutic benefit in dermatitis herpetiformis and that spontaneous remission is uncommon in those not on a diet. Despite patchiness of the enteropathy, a single jejunal biopsy is quite adequate to diagnose the presence of upper intestinal villous atrophy.Since the first report of the association of dermatitis herpetiformis with coeliac disease in 1966,1 evidence of close links between the two disorders has accumulated. Well documented points of similarity include the response of the enteropathy to a gluten free diet,23 the high prevalence of HLA B8 and DR3 phenotypes, the occurrence of hyposplenism78 and a predisposition to the development of lymphoma.9 10 While these associations are not in dispute, controversy has arisen in relation to the major differences between the two disorders. By definition, the appearance of the skin lesions characterises dermatitis herpetiformis, but, while some authors believe that exclusion of gluten from the diet leads to remission of the skin disease 11-14 others disagree.5 16 Similarly, there is disagreement about the frequency with which intestinal villous

SUMMARY Fifty two patients were studied to investigate the patterns of gastro-oesophageal reflux during ambulatory pH monitoring and the relationship of reflux to presence and severity of oesophagitis. Twenty nine had evidence of oesophagitis which was graded according to severity. Acid exposure (pH<4) was calculated in each case for the total study period, the recumbent and upright periods, and the three hour period after the evening meal. Exposure in the upright period correlated closest (r=0.92: p<00 (1) with that during the total period. Recumbent exposure correlated with both upright and postprandial exposure (p<0001). Acid exposure during all four periods correlated significantly with the severity of oesophagitis, but postprandial acid exposure correlated best and recumbent acid exposure least well. Although acid clearance in the total, recumbent and upright periods correlated with oesophagitis, postprandial clearance showed the closest relationship. Thus the magnitude of daytime reflux, especially postprandial reflux and acid clearance, is more closely related than nocturnal reflux to oesophagitis. The results do not support the contention that night time reflux is inherently more injurious than daytime reflux to the oesophageal mucosa.

SUMMARY A scintigraphic method is described to measure the transit of a fluid bolus through the oesophagus. Transit times in 16 normal subjects ranged from five to 15 seconds and were highly reproducible. Prolonged transit times were observed in 16 of 19 patients with known oesophageal motility disorders, and in these patients inspection of the time activity curves frequently permitted an adynamic oesophagus to be distinguished from one showing excessive incoordinate contractions. The technique was then applied prospectively to 50 patients referred for oesophageal motility studies and a comparison made between the oesophageal transit measurements and the findings on conventional oesophageal manometry. There was agreement between these tests in 42 (84%) of the 50 patients. The measurement of oesophageal transit may be made quickly and safely, without causing discomfort to the patient, and it appears to be at least as sensitive as manometry in the detection of oesophageal motility disorders.Investigation by contrast radiology and upper gastrointestinal endoscopy provides a precise diagnosis in most patients with symptoms suggestive of oesophageal disease. When such symptoms are due to oesophageal motility disorders, however, the diagnosis is often more elusive. Manometry is currently the definitive investigation whereby motility disorders may be recognised but suffers the disadvantage of causing some discomfort to the patients and demands a considerable outlay of both time and expertise in the performance of the study and in the interpretation of the recording. In consequence, a quick and reliable procedure to detect oesophageal motor dysfunction would be of considerable value.Stimulated by these considerations we have assessed a scintigraphic technique' using a radionuclide tracer and gamma camera for the quantitation of the rate of passage of bolus through the oesophagus. The procedure was first validated in normal subjects and in patients with previously diagnosed oesophageal motility disorders, and was then applied prospectively to 50 consecutive patients in whom an oesophageal motility disorder was suspected.