Gut
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Bleeding from oesophageal varices has a high death rate. Injection sclerotherapy is the most appropriate treatment but facilities for this are not always available. Balloon tamponade and vasoactive therapy may be used as stop gap measures. ⋯ A meta analysis of the group of trials of placebo or H2 antagonists v somatostatin or octreotide showed a significant advantage of somatostatin or octreotide in terms of efficacy, but no difference in mortality. The trials discussed seem to show that somatostatin and octreotide are at least as effective as other treatments, with the benefit of fewer adverse effects, and thus represent the best vasoactive agents. Additionally, they may have a role as adjuvant treatment to emergency sclerotherapy for active bleeders and this must be further investigated.
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The gastrointestinal tract, besides being the organ responsible for nutrient absorption, is also a metabolic and immunological system, functioning as an effective barrier against endotoxin and bacteria in the intestinal lumen. The passage of viable bacteria from the gastrointestinal tract through the epithelial mucosa is called bacterial translocation. Equally important may be the passage of bacterial endotoxin through the mucosal barrier. ⋯ The clinically observed failure of multiple organ systems might thus be explained by the interaction of tissue necrosis and high concentrations of endotoxin because of translocation. Future therapeutic strategies could therefore focus more on binding endotoxin in the gut before the triggering event, for example before major surgery. Such a strategy could be combined with the start of early enteral feeding, which has been shown in animal studies to have a beneficial effect on intestinal mucosal barrier function and in traumatized patients to reduce the incidence of septic complications.
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Gastroenterological training differs so greatly from country to country in Europe it is impossible to believe that training is equally good in each one. This in turn, provides a barrier to the free migration of doctors with the European Community. These differences also create confusion for migrating patients, and call into question the validity of the European Commission directives, which pronounce all qualifications obtained in European Community countries to be equally acceptable within the community. ⋯ The European Board of Gastroenterology, a working party of the Gastroenterology Section of the UEMS has agreed acceptable and fair standards of training for gastroenterologists, and has developed a system for external assessment of training centres and faculty. All three, candidates, faculty, and centre would, in the event of a successful application, be awarded the European Diploma of Gastroenterology or, in full, the Diploma of Recognition of Quality of Training in Gastroenterology. This paper discusses these problems, some of their origins, and the proposals of the European Board.
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A previous cohort study suggested that there might be an association between use of cimetidine and motor neurone disease. The Oxford Record Linkage Study was used to explore this hypothesis. In the analysis the presence of a peptic ulcer in patients after 1976 was taken as a proxy for cimetidine (and ranitidine) use. ⋯ Among those with motor neurone disease, five had been previously admitted to hospital with peptic ulcer in comparison with an expected number of 7.4 (morbidity ratio 0.68, 95% confidence interval: 0.2 to 1.6). The corresponding figures for those with multiple sclerosis were 12 and 9.7 respectively (morbidity ratio 1.24, 95% confidence interval: 0.6 to 2.2). This study provides some evidence against the possibility that cimetidine (and ranitidine) are related to motor neurone disease.
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Extra-intestinal or metastatic Crohn's disease is being recognised increasingly, most commonly in the skin and genitourinary system. Only very rarely has it been reported in the lung. ⋯ Subsequent investigation showed the presence of intestinal Crohn's disease. The evidence for abnormal lung function in Crohn's disease and the possible pathogenesis of metastatic pulmonary Crohn's disease are discussed.