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We report a 44-year-old woman in whom intestinal bypass for obesity at age 23 resulted in chronic malabsorption. After hysterectomy for menorrhagia due to atypical endometrial hyperplasia, the finding of myometrial lipofuscinosis led to a demonstration of vitamin E deficiency. Vitamin E supplementation led to an unexpected improvement in the unsteadiness of gait and slurring of speech of which she had also complained. We suggest that supplementation with vitamin E should be routine in all patients with persistent severe steatorrhoea.

Thirty-nine infants suspected of having cow's milk protein intolerance (C.M.P.I.) were investigated, and jejunal biopsies were performed before and after challenge with cow's milk. Thirty patients had significant jejunal mucosal damage after milk challenge, but symptoms of diarrhoea and vomiting developed in only twenty-two. The patients with symptoms were subsequently managed on a diet free from cow's milk until tolerance developed. However, the eight infants without symptoms (but with jejunal mucosal damage) made satisfactory clinical progress, with adequate weight-gain, on a diet of cow's milk. Repeat jejunal biopsy specimens from two of these patients showed that there had been a definite improvement since the immediate post-challenge biopsy specimens were taken. Most patients with C.M.P.I. who need to be treated with a diet from which cow's milk has been eliminated may be detected by clinical means alone, and the remainder may continue on a cow's milk diet unless or until symptoms develop. There seems to be no clinical justification for routine jejunal biopsy in infants in whom C.M.P.I. is suspected.

Probable bacterial contamination of the small bowel without an anatomical sump occurred in 5 elderly patients (age 68--94). They presented with severe general deterioration in health rather than with obvious features of malabsorption. This syndrome has not been clearly described before. Bacterial deconjugation of bile salts was indentified by the 14C-glycocholic-acid breath test. Investigations for other causes of malabsorption, including small-bowel biopsy and pancreatic scan, revealed no abnormality. After prolonged ill-health despite an adequate diet in hospital, all 5 subjects made a striking recovery after treatment with antibiotics. This condition may be quite common, particularly in malnourished elderly people.

The percentage fatty-acid composition of the various plasma-lipid fractions from cystic-fibrosis patients with and without pancreatic insufficiency, obligate heterozygotes, and normal subjects was determined. Only the cystic-fibrosis patients with pancreatic insufficiency had significantly abnormal fatty-acid composition. This general observation did not correlate with vitamin-E deficiency, age, sex, or severity of the disease. Thus the altered fatty-acid composition of the different plasma-lipid fractions appears to be a secondary consequence of the pancreatic insufficiency commonly associated with cystic fibrosis and not a direct metabolic defect related to the cystic-fibrosis gene itself.

A simple and reliable test for the diagnosis of hyposucrasia is required, since this may be an unsuspected cause of long-standing gastrointestinal disorder. Furthermore little has been done to define the epidemiology of this condition, possibly because of the limitations of multiple blood-sampling. Breath hydrogen (H2) production after lactose ingestion is a reliable test for hypolactasia, and has now been measured after sucrose ingestion in eleven patients with various gastrointestinal symptoms. Six who had normal sucrase activity on jejunal biopsy produced no H2 after taking 50 g of sucrose. No H2 was produced in three patients with borderline hyposucrasia, either after 50 g sucrose or when retested using 100 g sucrose (two patients). However, the two patients with low jejunal sucrase activity showed rises of breath H2, after only 25 g glucose. Breath H2 measurement is a simple, accurate, and non-invasive test for diagnosing gastrointestinal symptoms due to hyposucrasia.

18 mothers of 19 breast-fed infants with infantile colic were put on a diet free of cow's-milk protein. The colic disappeared promptly from 13; in 12, it reappeared on at least two further indirect challenges (in the form of a diet containing cow's milk to the mother). Most infants became symptom-free at age 2 to 4 months; at 4 months, only 4 reacted with colic when the mother took cow's milk. 5 infants were directly challenged with cow's milk; 4 reacted promptly with colic. Other signs of intolerance to cow's-milk protein developed in 3 infants during weaning. The treatment of infantile colic in breast-fed infants by a diet free of cow's milk for the mother appears worthwhile.

Histological examination of bone from 25 patients with small-intestinal resection showed that 9 (36%) had osteomalacia, which was severe in 5 and mild in 4. The serum-alkaline-phosphatase concentration was raised in all patients with severe osteomalacia, but serum calcium, phosphate, and alkaline-phosphatase concentrations were normal in the 4 patients with mild disease, 2 of whom had symptoms. Osteomalacia was diagnosed radiologically in only 3 patients. Osteomalacia appears to be commoner in patients with small-intestinal resection than has previously been thought, and bone biopsy is essential if all cases are detected. Although high-dose parenteral vitamin-D therapy is usually effective in the treatment of osteomalacia after small-intestinal resection, our findings showed that oral vitamin-D metabolites and their analogues may also be effective. This has important practical advantages.