Biliary brushings are currently the best accepted method to obtain a cytological diagnosis of pancreatic cancer or cholangiocarcinoma. The technique has good specificity but poor sensitivity. Two dedicated pathologists reviewed 137 consecutive biliary brushings from 127 patients between February 1997 and February 2000. The ultimate diagnosis was determined by review of radiology, operative diagnosis and patient outcome. The sensitivity, specificity, positive predictive value and negative predictive value of the original results and the review results were calculated and compared. Additional diagnostic categories 'suspicious' and 'atypical possibly benign' were included on review. After review, the sensitivity improved from 49.4% to 89.0% and the specificity remained 100%. The use of the additional diagnostic category 'suspicious' increased the sensitivity to 90.4%, at the expense of a fall of the specificity to 66.7%. We conclude that review by two dedicated pathologists and additional diagnostic categories can improve the diagnostic accuracy of biliary brushings.

Introduction: Azathioprine is a useful therapy in patients with inflammatory bowel disease that is difficult to control. However, 10% of patients are unable to tolerate azathioprine, and the best form of treatment for this group of patients is unknown. The azathioprine metabolite 6‐mercaptopurine may be a useful therapy for these patients. Aim: To review our clinical experience of the use of the 6‐mercaptopurine in inflammatory bowel disease patients who are intolerant of azathioprine. Methods: All patients who were prescribed 6‐mercaptopurine in a 2‐year period were identified from pharmacy records. The case notes were reviewed and those who had previously been intolerant of azathioprine were included. Results: A total of 19 with either ulcerative colitis and Crohn’s disease were included. The reasons for discontinuing azathioprine were side‐effects (13 patients), failure of efficacy (four patients) and leucopenia (two patients). Eleven of the 19 patients (68%) tolerated 6‐mercaptopurine, including seven out of 13 patients (54%) who discontinued azathioprine due to side‐effects. The length of follow‐up of patients on 6‐mercaptopurine was between 126 and 780 days (median 390 days). Discussion: 6‐mercaptopurine should be considered in patients with inflammatory bowel disease who require continuing immunosuppressive therapy, but are intolerant of azathioprine.

Summary Aim : Patients with primary biliary cirrhosis may be at increased risk of osteoporosis but to what extent this is reflected in an increased fracture risk is unknown. We have enquired about the fracture experience of female primary biliary cirrhosis patients compared with sex‐ and age‐matched controls. Methods : Patients aged 30–75 with primary biliary cirrhosis and age‐matched controls were sent a postal questionnaire asking about their fracture history and details of risk factors for osteoporosis. Results : 85 eligible patients with primary biliary cirrhosis and 116 controls responded. Forty‐one per cent of patients with primary biliary cirrhosis and 30% of controls reported ever having had a fracture odds ratio 1.5 (95% confidence interval: 0.80–2.89). Twenty‐eight per cent of primary biliary cirrhosis patients and 23.3% of controls reported a fracture after the age of 30, odds ratio 1.2 (95% confidence interval: 0.57–2.56), and 14.1% of primary biliary cirrhosis patients and 12.1% of controls reported a low impact fracture of the long bones or of the vertebrae odds ratio 1.0 (95% confidence interval: 0.31–2.68). Conclusions : No overall increased fracture risk in patients with primary biliary cirrhosis was observed. As a group, unselected patients with primary biliary cirrhosis do not represent a population at particularly high risk of osteoporotic fracture and thus targeting them for osteoporosis screening and treatment is not justified. Further work investigating subgroups of patients with primary biliary cirrhosis at potentially high risk of osteoporosis, such as those with advanced disease or severe cholestasis is required.

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