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  1. Robin Spiller

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ENDOSCOPIC TREATMENT OF REFLUX IN CHILDREN

The results of endoscopic treatment for reflux in adults do not yet equal those of conventional surgery. However, the results in children look more promising. Seventeen patients aged 6–16 years underwent endoluminal fundoplication with excellent symptomatic responses and a marked fall in reflux documented by 24 h pH profile. All but one patient managed to stop anti-reflux medication, which is significantly better than most adult series. The use of general anaesthesia for all procedures and the use of three sutures may account for the improved response because most adult procedures are done under intravenous sedation and use only two sutures. The lack of a control group prevents any estimate of the placebo effect so interpretation must be cautious and the key question as to how they will fare as they grow to adulthood remains to be answered.
See p 1745

SAVING ENDOSCOPIES BY TEST AND TREAT STRATEGIES FOR H PYLORI INFECTION

Dyspepsia of varying degrees affects nearly a quarter of the adult population, so cost effective management is vital. Because endoscopy is an important component of cost, a test and treat (T&T) policy for dyspepsia that avoids endoscopy is, in principle, attractive. The current study from Denmark provides a convincing support for the non-endoscopic approach. Outcome 6–7 years later after randomisation to T&T versus early endoscopy were nearly identical, apart from the fact that the T&T patients had 0.6 fewer endoscopies on average in the follow up period. T&T therefore appears to be the optimum strategy in the long term.
See p 1758

VISCERAL HYPERSENSITIVITY INDUCED BY ACUTE TRYPTOPHAN DEPLETION

The technique of acute tryptophan depletion has been used by psychiatrists to deplete brain serotonin and depress mood. Using this technique for the first time to examine its effect on GI function, the authors show that within 9 h, acute tryptophan depletion reduces serotonin turnover and increases sensitivity to rectal distension in diarrhoea predominant irritable bowel syndrome (IBS) patients. Although mood scores did not change, there was an impaired recall of positive words, which may be a more sensitive measure of depression that may account for the exacerbation of visceral hypersensitivity.
See p 1794

INFLAMMATION IN THE BOWEL—IS IT ALL A MATTER OF DEGREE?

A wide range of bowel disorders are known to be associated with inflammation ranging from the macroscopically and endoscopically obvious colitis to the more subtle changes found in coeliac disease and IBS. A sensitive method of detecting mucosal inflammatory mediators using absorbent cellulose patches, brought into contact with the mucosa by an inflatable balloon is described by Krisstjansson et al. This shows the expected high levels of neutrophil products, including lipocalin and myeloperoxidase, not only in ulcerative colitis but also in ulcerative colitis in remission, coeliac disease, Crohn’s disease, and perhaps surprisingly IBS when compared with controls. The numbers are still small and need reproducing, but they certainly suggest a novel way whereby the role of inflammation in functional diseases can be further assessed.
See p 1806

SIGNIFICANCE OF A MACROSCOPICALLY NORMAL LOOKING COLONOSCOPY IN PREDICTING CANCER RISK IN ULCERATIVE COLITIS

Surveillance for colon cancer in patients with long standing ulcerative colitis is plainly worthwhile but costly without proper targeting of endoscopic effort. Those with chronic ongoing inflammation are known to be at greater risk from cancer, but what of those with an apparently normal looking colonoscopy? The current paper suggests that when compared with those with endoscopic stigmata of chronic disease those with an apparently normal looking colon have a substantially reduced risk of developing colon cancer. Indeed, over the next 5 years, their risk was no different from that of an aged and sex matched population. Such patients may therefore reasonably be offered 5 year surveillance intervals, a fact that will be of great help to hard pressed colonoscopists everywhere.
See p 1813

ENDOTHELIN 1 ANTAGONISTS AS A WAY OF REDUCING SEPSIS ASSOCIATED LIVER INJURY

Cirrhotics often deteriorate during septic episodes, and TNF is known to be an important mediator of this effect. Endothelin1, a potent vasoconstrictor, is increased in cirrhosis and its production is enhanced by endotoxin. When animals with experimentally induced biliary cirrhosis are given lipopolysaccharide (LPS) intravenously, there is an acute rise in plasma endothelin and TNF, with an associated infiltration of neutrophils into the liver and rises in liver enzymes. The endothelin antagonist, tezosentan, markedly ameliorates neutrophil infiltration of the liver and the liver enzyme rise. It also significantly decreases plasma TNF levels and reduces mortality. As expected, hepatic iNOS and COX2 activity were increased by LPS, an effect that was not altered by tezosentan. The authors conclude that the main effect of endothelin in this system, as in the lung and vasculature, appears to be by inhibition of neutrophil accumulation. Because it is effective after the LPS injection, it raises the possibility that such drugs would be useful in treating acutely ill septic cirrhotics.
See p 1844

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