I Ten consecutive patients with hypertriglyceridaemia who adhered to a low carbohydrate diet without complete control of serum triglycerides were started on chenodeoxycholic acid 750 mg daily and followed monthly for 6 months. Nine of these patients were then followed for a further month on placebo capsules and thereafter monthly for a further 6 months on clofibrate 2 g daily. 2 The mean serum triglyceride level fell by 36% after dietary treatment alone (P <0.05) and by 47% from initial values on diet plus chenodeoxycholic acid (P < 0.01). In the nine patients who proceeded to clofibrate therapy there was a rise in triglyceride levels on placebo capsules to the level achieved by diet alone, and a further fall on diet plus clofibrate of 47% of initial values (P < 0.05). 3 Chenodeoxycholic acid therapy is effective in the management of hypertriglyceridaemia not completely cured by dietary measures, and may be as efficacious as clofibrate.

SIRS, Despite initial enthusiasm, triple therapies for Helicobacter pylori have proved disappointing in the long term. Bismuth-tetracycline-metronidazole and omeprazole-amoxicillin-metronidazole are no longer promoted, because of low efficacy. Toxicity for bismuth-tetracycline-metronidazole, and alleged or real penicillin sensitivity for omeprazole-amoxicillin-metronidazole are added serious drawbacks.As Graham et al. observe, the Maastricht 2-2000 consensus triple therapy with proton pump inhibitor (PPI) or ranitidine bismuth citrate plus two antibiotics is also not of high enough efficacy.1 The use of gatifloxacin appeared promising in sequential regimens, but is not acceptable on toxicity grounds. Furazolidone is not currently available in the UK.Although the use of a quadruple regimen with PPI-bismuth-tetracyclinemetronidazole has been proposed as secondary therapy where triple therapy has failed, this also has serious toxicity problems.A more logical approach would be to use an effective acceptable quadruple therapy as first-line treatment.It does work. In spontaneous primary duodenal ulcer with positive direct urease test a 1-week regimen of lansoprazole 30 mg daily, clarithromycin 250 mg b.d., tetracycline 500 mg b.d. and metronidazole 400 mg b.d. was well tolerated and achieved a per-protocol excellent eradication rate of 95%. 2Apparent metronidazole resistance is not a problem of treatment in these combination regimens. Apparent metronidazole resistance largely disappears when in vitro testing is correctly performed to include an anaerobic phase, which is important for accuracy.3 Not least of the attractions of this simple treatment scheme is that patients do not allege 'sensitivity' to clarithromycin, tetracycline or metronidazole, unlike the 10% who state they cannot take penicillins. This quadruple regimen deserves wider use and would avoid many of the problems of other regimens. REFERENCES1 Graham DY, Abudayyeh S, El-Zimaity HMT, Hoffman J, Reddy R, Opekun AR. Sequential therapy using high-dose esomeprazoleamoxicillin followed by gatifloxacin for Helicobacter pylori infection. Aliment Pharmacol Ther 2006; 24: 845-50.2 Bateson MC. Quadruple therapy for symptomatic spontaneous duodenal ulcer disease.

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SummaryThe records of all upper digestive endoscopies performed in one year in the Clinical Measurement Department of a teaching hospital serving a population of 250 000 were reviewed; 25 % of patients had oesophagitis, which was usually associated with other significant findings such as peptic ulcer and gastroduodenal erosions. Only about 1 in 6 patients with oesophagitis had an endoscopically identified hiatus hernia.Oesophagitis was associated with gastric acid hypersecretion in both men and women.