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EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).

Transnasal EGD is generally well tolerated, feasible and safe. It can be performed with topical anesthesia in an outpatient setting. The low complication rate, high patient satisfaction and potential cost savings make transnasal endoscopy an attractive alternative to conventional EGD to screen patients for upper gastrointestinal tract diseases.

Biochemical analyses were performed on blood samples obtained from two children (P1, P2) who presented with acute immune thrombocytopenic purpura (ITP) following a recent varicella zoster virus (VZV) infection. Patient sera had antibodies that were reactive with normal blood-group O platelets as measured by flow-cytometric assay. Western blot analysis of electrophoretically separated normal blood-group O platelets under reducing and non-reducing conditions demonstrated that these sera were reactive with platelet antigens of approximately 50 and approximately 110 kD, respectively. These 50/110 kD antigens were not reactive with seven sera from acute ITP patients whose illness was not preceded by VZV infection, with serum from a patient with a prior history of VZV and no thrombocytopenia, nor with normal healthy control sera. VZV antibodies (IgG and IgM), isolated from patient sera by affinity chromatography using immobilized purified VZV glycoproteins, were found to bind to gel-filtered autologous platelets and with normal blood-group O platelets, as analysed by flow cytometry. No binding was observed using antibodies similarly prepared from healthy volunteer sera. To investigate their ability to sensitize platelets to complement activation, affinity-purified VZV antibodies were incubated with platelets and then with purified complement components C1 and 125 I-labelled C4. Platelets reacted with VZV-specific antibodies from the two patients and showed increases of 2.3-2.4-fold of platelet-surface deposition of 125 I-C4b, compared to controls. These data provide evidence that virus-specific antibodies occurring in children with varicella-associated acute ITP cross-react with normal platelet antigens, and may contribute to platelet clearance.

The Ontario Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.

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Rudra and Haiderl have reported a case of strangulated femoral hernia presenting as haematemesis. The following case suggests that hernia can be a cause of chronic bleeding. CASE HISTORYA man aged 67 consulted his general practitioner because of increasing lethargy and shortness of breath on exertion over the previous few months. His haemoglobin proved to be 3.4 g/dL and he was urgently referred to the casualty department where a repeat haemoglobin was 2.9 g/dL with mean cell volume 58.9 fL and mean cell haemoglobin concentration 28.3 g/dL. On admission he was given a blood transfusion and started on oral iron supplements. Inquiry did not elicit any symptoms of gastrointestinal disease and there had been no change of bowel habit. Faecal occult blood analyses were positive; nothing abnormal was seen on sigmoidoscopy but barium enema revealed diverticular disease. Colonoscopy showed no other lesion and upper gastrointestinal endoscopy was normal. A smallbowel enema showed a stenotic lesion in the region of the right iliac fossa and a surgical opinion was sought. On laparoscopy a collection of small bowel matted by fibrous adhesions was seen in the right iliac fossa relating to a previously undetected inguinal hernia. A herniorrhaphy was performed. Iron supplements were stopped, and at latest follow-up (18 months after operation) his haemoglobin was 12.9 g/dL. COMMENTIn hiatus hernia, blood loss is partly explained by repeated incarceration, which causes mucosal congestion by interfering with vascular supply and lymph drainage2. A similar mechanism may have operated in this case, through repeated mechanical injury to the gut at the internal ring.