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From October 1980 to September 1983 all patients with upper gastrointestinal bleeding were admitted to a centralised unit and investigated by early endoscopy. A total of 142 patients with a proved duodenal or gastric ulcer were randomised after stratification for age and site of ulcer to early (aggressive) surgical management or a delayed (conservative) policy. Significantly more operations (n= 42; 60%) were performed in the early than in the delayed (n=9; 20%) groups (p <0 01). There were no deaths among the 42 patients under 60. The overall mortality in the 100 patients aged over 60 was 10% and when analysed on an "intention to treat" basis there was no difference between early and delayed surgery. When, however, an unrelated death from a bleeding colonic polyp was excluded and the data analysed on "treatment received" the mortality was only 2% in the early group compared with 13% in the delayed group (p <005). When analysis was confined to gastric ulcer the difference between early (0%) and delayed (24%) treatment was even greater.The results of this trial indicate that for patients over 60 an aggressive surgical policy is associated with a significant reduction in mortality.

A multicentre randomized prospective trial compared minimal surgery (under-running the vessel or ulcer excision and adjuvant ranitidine) with conventional ulcer surgery (vagotomy and pyloroplasty or partial gastrectomy) for the treatment of bleeding peptic ulcer. This report is based on 137 patients (eight withdrawn through misdiagnosis or lost data), of whom 62 received conservative surgery and 67 conventional operation. Twenty-nine patients died, 16 (26 per cent) after conservative surgery and 13 (19 per cent) after conventional operations. The only significant difference between the groups was the incidence of fatal rebleeding, which occurred in six patients after conservative surgery compared with none after conventional surgery (P less than 0.02, Fisher's exact test).

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SUMMARY Carcinoembryonic antigen (CEA) levels have been measured in the serum of 490 patients and 93 normal controls using the double antibody radioimmunoassay technique. Levels were elevated in 71 of patients with carcinomata of the gastrointestinal tract and in 42% with other types of malignancy. In patients with non-neoplastic disease of the gastrointestinal tract and liver, elevated levels were found in 14 and 66 % respectively. In general the CEA level tends to be higher in cancer patients with haematogenous dissemination. Following complete surgical removal of a tumour, levels fall to normal within 14 days in the majority of patients. Of 33 patients studied during follow up, elevated levels were found in 12, 10 of whom had evidence of recurrence.The significance of these findings and the possible application of CEA assay in clinical practice are discussed.In recent years many attempts have been made to detect macro-molecular substances specific for human tumours, which if liberated into the body fluids could form the basis of an assay useful in the early diagnosis and management of malignant disease. One of the best such examples is the assay of chorionic gonadotrophin in patients with choriocarcinomata (Bagshawe, 1969).Well documented evidence has existed for some time of specific antigens in experimentally induced tumours of animals (Old, Boyse, Clarke, and Carswell, 1962 (Gold and Freedman, 1965a). They later detected the same antigen in extracts of other gastrointestinal carcinomata together with extracts of foetal intestine, liver, and pancreas during the first two trimesters of pregnancy (Gold and Freedman, 1965b colon (Martin and Martin, 1970) and pooled normal serum (Chu, Reynoso, and Hansen, 1972). This change in view of the specificity of CEA is reflected in the reports of radioimmunoassay results in a wide range of clinical groups. An initial claim of 97% positivity in patients with carcinoma of the colon

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