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Chronic intestinal pseudo-obstruction (CIP) has been defined as a rare and severe, disabling disorder, which is characterised by recurring episodes or continuous symptoms and signs of bowel obstruction, including radiological features of obstruction. It is suggested that the diagnosis should be broadened to include patients with severe gastrointestinal symptoms who do not have radiological features of obstruction but who have manometric features of CIP and/or have demonstrable end organ list of pathological features described in CIP. A case of pseudo-pseudo-obstruction is described in this issue of the Journal. Originally the patient was thought to have CIP, and a mechanical cause of obstruction was suspected based on small intestine manometric features, suggesting a distal mechanical obstruction and a worsening of symptoms when treated with a prokinetic agent. As patients with CIP can develop mechanical obstruction and episodes of mechanical obstruction can mimic CIP, small intestine manometry and trials of prokinetic therapy should be undertaken in all difficult cases of obstruction and particularly in patients with documented CIP.

Objective: To determine the impact of irritable bowel syndrome on personal relationships and working practices., Patients and Methods: A 60-item questionnaire about personal relationships, working practices and treatment was sent to 3090 subscribers of the IBS Bulletin, a quarterly educational publication. A total of 1855 completed questionnaires were returned. Analysis was restricted to 1597 questionnaires (86.1%), returned by respondents in whom the diagnosis of irritable bowel syndrome had been made by a general practitioner or hospital specialist., Results: Of these respondents, 57% were aged 55 or over and the male to female ratio was 1:3.4. On average, respondents had suffered from irritable bowel syndrome for 16.6 years, with 57% reporting their symptoms daily, 25% weekly and 14% monthly. Of the married or cohabiting respondents, 19% stated that their partner experienced difficulties in having a personal relationship with them and 45% stated that irritable bowel syndrome interfered with their sex life. Irritable bowel syndrome had caused 12% of respondents to give up work altogether, while 47% of employed respondents reported having lost time off work, although only 35% of these respondents gave irritable bowel syndrome as the reason. In contrast employers, when informed of the diagnosis of irritable bowel syndrome, accepted these symptoms as a valid reason for absence in 61% of instances. Over half of those employed (53%) suffered embarrassment using toilets at work and 32% stated that irritable bowel syndrome had stopped them from applying for promotion or a new job. At the time of completing the questionnaire, 80% of respondents were actually taking some form of treatment. Smooth-muscle relaxants and fibre supplements remained the commonest treatments prescribed., Conclusion: Irritable bowel syndrome impacts significantly on personal relationships and working practices. Items that stimulate responsiveness in the areas of personal relationships and working practices should be included in the construction of disease-specific questionnaires used to assess the impact of new treatments for irritable bowel syndrome on health-related quality of life.

We report a case of a 62-year-old man who developed watery diarrhoea after starting treatment with cimetidine for dyspepsia. Macroscopically, sigmoidoscopy and colonoscopy were normal. Histology revealed features consistent with a diagnosis of collagenous colitis. The diarrhoea is responding to treatment with prednisolone and withdrawal of cimetidine. We conclude that the collagenous colitis may have been drug induced.

Irritable bowel syndrome (IBS), which affects up to 25% of the population in western countries and accounts for up to 50% of referrals to gastroenterologist, remains mainly a diagnosis of exclusion. We have studied, for the first time, prolonged ambulatory motility recordings from the oesophagus, small intestine and colon of a patient who was referred to us with a 12-year history of abdominal pain and a presumptive diagnosis of IBS. The results indicated that the diagnosis was pseudo-obstruction syndrome rather than IBS. Wider clinical use of the new techniques of prolonged ambulatory intestinal motility monitoring in IBS would offer considerable potential not only in achieving a greater understanding of its pathophysiology but also in providing a more precise definition of clinical and therapeutic subgroups.

Objective: To describe the case of a women with cholestatic jaundice induced by the spontaneous fragmentation of an oestrogen implant., Patient: A 48-year-old woman, who presented with jaundice, pruritus and a flu-like illness 2 weeks after the insertion of a 100 mg oestradiol implant into her right buttock., Interventions: At presentation the implant was removed and found to be fragmented. Investigations revealed an oestradiol level of 1548 pmol/l and an oestrogen-induced cholestatic jaundice., Results: After removal of the implant and progesterone therapy, the patients symptoms resolved., Conclusion: This is the first reported case of cholestatic jaundice induced by a subcutaneous oestrogen implant.