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BACKGROUND AND STUDY AIMS The prevalence of esophageal squamous-cell carcinoma in high-risk patients and the advantages of systematic Lugol staining during esophagoscopy have not yet been evaluated in a large prospective study. In this study we aimed to assess the prevalence of this type of tumor in high-risk patients, to examine the role of Lugol staining in endoscopic screening for esophageal squamous-cell carcinoma, and to establish whether it is possible to identify a particularly high-risk group which would benefit from systematic screening. PATIENTS AND METHODS A prospective study was undertaken in 62 endoscopy centers. A total of 1095 patients were enrolled, none of whom had any esophageal symptoms. These patients had presented with either a past history of or a recent head and neck or tracheobronchial squamous-cell carcinoma (group 1), with alcoholic chronic pancreatitis (group 2), with alcoholic cirrhosis (group 3), or were alcohol and tobacco addicts (group 4). The patients underwent a meticulous endoscopic examination of the esophagus, followed by Lugol staining. RESULTS The prevalence of esophageal squamous-cell carcinoma was 3.2 %. The group 1 patients showed the highest prevalence of carcinoma (5.3 %) and the highest prevalence of dysplasia (4.5 %). Of the 35 carcinomas detected in the 1095 patients, seven (20 %) were early lesions, and 20 % were only detected after Lugol staining (P = 0.02). High-grade dysplasia was only observed in group 1 patients and two-thirds of these lesions were only diagnosed after Lugol staining. The overall prevalence of low-grade dysplasia was 2.4 %, and 77 % of these were detected only after Lugol staining (P < 0.001). CONCLUSIONS Lugol dye staining increases the sensitivity of esophageal endoscopy for the detection of high-grade dysplasia and cancer. The prevalence of dysplasia and cancer reached 9.9 % in group 1, and we therefore believe that an endoscopic screening program could be justified for patients with head and neck or tracheobronchial cancer.

Background—Push-type enteroscopy, a recent method for investigating the small intestine, is currently undergoing assessment. Its diagnostic yield varies in the studies reported to date.Aim—To assess the diagnostic value of push-type enteroscopy according to indication.Patients and methods—From January 1994 to September 1995, 152 consecutive patients (mean age 34 years) underwent push-type enteroscopy (jejunoscopy, n=93; retrograde ileoscopy, n=17; and double way enteroscopy, n=42). The indications were: unexplained iron deficiency anaemia or macroscopic gastrointestinal bleeding (n=76), radiological abnormalities of the small intestine (n=23), chronic diarrhoea and/or malabsorption syndrome (n=18), abdominal pain (n=12), and miscellaneous (n=23). All patients had undergone previous negative aetiological investigations.Results—The jejunum and ileum were explored through 120 cm (30–160 cm) and 60 cm (20–120 cm). Digestive bleeding: lesions of the small bowel were found in 6% of the patients with isolated iron deficiency anaemia and 20% of patients with patent digestive haemorrhage. Radiological abnormalities of the small intestine: push-type enteroscopy provided a diagnosis or modified the interpretation of radiological findings in 18/23 cases (78%). Chronic diarrhoea and/or malabsorption: push-type enteroscopy yielded explanatory findings in four cases (22%). Abdominal pain: push-type enteroscopy provided no diagnosis.Conclusion—In this series, push-type enteroscopy was of particular value in investigating patients with radiological abnormalities of the small intestine. It was of some value in the exploration of patent digestive haemorrhage or chronic diarrhoea, but not of abdominal pain. Its value was limited in the exploration of iron deficiency anaemia.

Saliva is an important factor in neutralization of oesophageal acid exposure, clinically manifested as gastrooesophageal reflux (GOR). The aim of this study is to compare the composition and the "capacity in acid neutralization" (CAN) of saliva in controls and patients suffering of GOR. We compared the composition of saliva from 56 patients who had symptoms of GOR with that of saliva from 20 healthy control subjects. After a standardized 24-hour period of pH-monitoring, 39 patients had normal pH reflux scores (normal acid score: NAc-GOR) and 17 had abnormal pH reflux scores (pathological acid score: PAc-GOR). Then, following a 10-h fast, total saliva was collected during ten minutes in all patients and in the healthy control subjects. The composition of the saliva samples was analysed and the titration curve was determined on 200 microliters aliquots by successive addition of 5 microliters volumes of 0.1 N Hcl. The GOR patients had significantly lower salivary concentrations of Na+ and of both free and bound sialic acids and had higher salivary concentrations of inorganic phosphates than the controls. These disorders were more marked in PAc-GOR patients. Initial pH was 7.43 +/- 0.43 in controls, 7.35 +/- 0.45 in NAc-GOR patients, and 6.91 +/- 0.53 in PAc-GOR patients. In the beginning of the titration curve, PAc-GOR patients were significantly different from NAc-GOR patients and from controls. Saliva of both groups of patients presented significant differences in the acidic portion of the titrations curves, at high volumes of added HCl. These data show that the composition of saliva was modified in patients with GOR disease compared to that of normal subjects. A difference in titration curves was also observed with a higher acidic buffering capacity in these GOR patients. The modifications in saliva composition suggest a role for inorganic phosophates in the acid neutralization capacity observed in GOR, perhaps linked with a adaptation to chronic acid exposure.

To define some methodological factors that could affect the measurement of the esophageal clearance, we used three different protocols, on 41 healthy control subjects. In 20 subjects, we studied the influence of a naso-esophageal probe on the frequency of swallowing. We observed a significant (44 +/- 5%) decrease in the frequency of spontaneous swallows after 15 minutes, with stabilization after this 15 minute period of adaptation. In 11 subjects, we studied the influence of the pH of the esophageal content on esophageal clearance. We found an exponential relationship between the esophageal clearance (C) expressed in minutes and the initial pH of the lumen contents: C = 43.3 exp (-0.54 pH) In 10 other subjects, we studied the influence of the volume of the esophageal contents on esophageal clearance. We found no influence for volumes less than 30 ml and a significant increase of clearance for volumes greater than 30 ml. In summary, this study of the effects of methodological factors on esophageal clearance: Gives new information about the "accommodation phase" of the esophagus after distension by a naso-gastric probe; Allows us to propose a new quantitative method for evaluation of esophageal clearance Shows the small importance of the ingested volume.

Pinaverium bromide is a specific calcium channel blocker used in the treatment of irritable bowel syndrome (IBS) for its spasmolytic activity. The aim of the present study was to evaluate the effect of orally administered pinaverium bromide on jejunal motility and total and segmental colonic transit time in control subjects. Gastrointestinal studies were performed in 10 healthy volunteers (30 +/- 3 years), before and after a treatment phase of 14 days (150 mg/d). Jejunal motility was measured by prolonged manometry (14 h) and colonic transit time by a multiple ingestion, single marker technique. No significant modification of phase III of the migrating motor complexes was demonstrated. On the contrary, a significant (p < 0.01) but weak decrease of the frequency of contraction was found. Unlike previous studies, no decrease of total or segmental colonic transit time was demonstrated.

We compared, in a cross-over study, the toxicity of 300 mg enteric-coated aspirin with regular aspirin used for the prevention of cardiovascular events. In terms of endoscopic haemorrhagic lesions, enteric-coated aspirin is less gastrotoxic than regular aspirin.

The effects of alcohol withdrawal on total and segmental transit time were evaluated in 20 chronic alcoholic subjects. After withdrawal, colorectal transit time significantly increased from 24.9 +/- 3.6 to 33.3 +/- 4.5 hours mean +/- SE (P less than 0.01). This was the result of an exclusive increase in rectosigmoid transit time from 2.8 +/- 0.7 to 9.8 +/- 2.1 hours (P less than 0.001). No variations were found in right or left colon transit time. Distal colonic motility is thus a crucial factor in the genesis of diarrhea in chronic alcoholic subjects.

BACKGROUND AND STUDY AIMS: Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy. PATIENTS AND METHODS: 105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis. RESULTS: Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding. CONCLUSION: Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

We recently showed that refractory sprue is distinct from coeliac disease, the former being characterized by abnormal intraepithelial T-lymphocytes expressing a cytoplasmic CD3 chain (CD3c), lacking CD3 and CD8 surface expression, and showing TCRgamma gene rearrangements. To take advantage of the abnormal phenotype of CD3c + CD8 - intraepithelial lymphocytes (IEL) in refractory sprue we developed a simple method to distinguish coeliac disease from refractory sprue.Comparative immunohistochemical studies using anti-CD3 and anti-CD8 antibodies were applied on paraffin-embedded and frozen biopsy specimens in refractory sprue (n = 6), coeliac disease (n = 10), healthy controls (n = 5) and suspected refractory sprue (n = 6). Comparable results were obtained on fixed and frozen biopsy specimens. In four of the six patients with suspected refractory sprue, abnormal CD3c + CD8 - IEL and TCRgamma gene rearrangements were found, as in refractory sprue; the remaining two patients had normal (CD3 + CD8 +) IEL and no TCRgamma gene rearrangements. Both patients had coeliac disease, as one failed to comply with a gluten-free diet, while the other was a slow responder.This simplified immunostaining method using anti-CD3 and anti-CD8 antibodies on paraffin sections can distinguish active coeliac disease from refractory sprue and should prove useful in clinical practice.

BACKGROUND/AIM—Some endoscopic ultrasonographic (EUS) features have been reported to be suggestive of malignancy in gastrointestinal stromal cell tumours (SCTs). The aim of this study was to assess the predictive value of these features for malignancy. METHODS—A total of 56 histologically proven cases of SCT studied by EUS between 1989 and 1996 were reviewed. There were 42 gastric tumours, 12 oesophageal tumours, and two rectal tumours. The tumours were divided into two groups: (a) benign SCT, comprising benign leiomyoma (n = 34); (b) malignant or borderline SCT (n = 22), comprising leiomyosarcoma (n = 9), leiomyoblastoma (n = 9), and leiomyoma of uncertain malignant potential (n = 4). The main EUS features recorded were tumour size, ulceration, echo pattern, cystic spaces, extraluminal margins, and lymph nodes with a malignant pattern. The two groups were compared by univariate and multivariate analysis. RESULTS—Irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern were most predictive of malignant or borderline SCT. Pairwise combinations of the three features had a specificity and positive predictive value of 100% for malignant or borderline SCT, but a sensitivity of only 23%. The presence of at least one of these three criteria had 91% sensitivity, 88% specificity, and 83% predictive positive value. In multivariate analysis, cystic spaces and irregular margins were the only two features independently predictive of malignant potential. The features most predictive of benign SCTs were regular margins, tumour size ⩽30 mm, and a homogeneous echo pattern. When the three features were combined, histology confirmed a benign SCT in all cases. CONCLUSIONS—The combined presence of two out of three EUS features (irregular extraluminal margins, cystic spaces, and lymph nodes with a malignant pattern) had a positive predictive value of 100% for malignant or borderline gastrointestinal SCT. Tumours less than 30 mm in diameter with regular margins and a homogeneous echo pattern are usually benign. Keywords: gastrointestinal; stromal cell tumours; endoscopic ultrasonography; leiomyoma; leiomyoblastoma; leiomyosarcoma

We report a case of pancreatitis as the first symptom of cystic fibrosis in a 22-year-old woman. The diagnosis was suspected upon the history of nasal polyposis and severe episodes of respiratory infections in infancy. The diagnosis was confirmed by sweat test. Genotyping showed a compound heterozygosity for mutations delta F508 and 5T. Acute pancreatitis is a rare manifestation of cystic fibrosis and an exceptional mode of initial presentation of the disease. It occurs in pancreatic sufficient patients, especially in young adults. This exceptional case shows that cystic fibrosis should be suspected in each case of idiopathic pancreatitis. Indications of cholecystectomy in patients with associated gallbladder lithiasis is discussed.

Segmental colectomy for complicated diverticulitis is often indicated, between attacks, in elderly patients. We report a retrospective study of operated patients over the age of 70. The aim of this retrospective study was to evaluate the age risk of consecutive patients operated between diverticular attacks by segmental colectomy, and whether such a surgical procedure is justified, as the life expectancy of these patients was 74 years for men and 81.9 years for women in 1996.From January 1990 to December 1996, 117 patients were operated, between attacks, for complicated sigmoid diverticulitis; 31% (n = 37) were over the age of 70 years. They were 16 men and 21 women with an overall mean age of 77 (range: 70-85 years). Indications for surgery were repeated attacks (n = 17), large bowel stenosis (n = 14) and colovesical fistula (n = 6). The operation was performed an average 8 weeks after the last infectious episode (3-10 weeks).Among patients over the age of 70 years, the postoperative morbidity rate was 40% and there was no mortality. One patient was reoperated for an anastomotic abscess and was managed by protective colostomy and pelvic drainage with conservation of the anastomosis.This retrospective study shows that in our experience, one third of patients operated for a complication of diverticulitis were over the age of 70 years. In this subgroup, left colectomy, when performed between attacks carries an acceptable specific morbidity and no mortality. A further study could compare the percentage and outcome of operated patients with those who were denied surgery.

The colonic response to food (CRF) is an integrated function of the colon that has been poorly studied in clinical practice. This study describes a new method to measure it, based on the progress of radio-opaque markers, and shows the results in healthy subjects and in patients with irritable bowel syndrome (IBS). Thirty healthy subjects and 43 patients suffering from IBS were studied. Two studies of colonic transit time (CTT), at rest and after eating a standard test meal, were performed. CRF was quantified by calculating the variation in number of markers in each zone of interest of the large bowel using X-ray films of the abdomen taken before and after eating. The results were as follows: (1) CRF is characterised by caudal propulsion of the colonic contents in the two groups. In controls, there is emptying of the cecum-ascending colon region and filling of the distal large bowel. In IBS patients, only emptying of the left transverse colon and the splenic flexure is found. (2) IBS patients have a delayed CTT because of slowing in the right and left colon, and this is both before and after a meal. The determination of the movements of markers after eating is a simple method that is useful in clinical practice to evaluate CRF.

The etiology of Crohn's disease remains unknown. A putative mycobacterial cause of the disease is still controversial.To assess the mycobacterial hypothesis in Crohn's disease using a polymerase chain reaction technique.Nested polymerase chain reaction with primers on the 16S-rRNA coding region (16S-rDNA) and with primers specific both to the insertion sequences (IS) 900, and IS 901/902 were used to amplify Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum DNA in frozen endoscopic intestinal biopsies or surgical resection specimens from patients with Crohn's disease (n = 47: 25 endoscopic biopsies and 22 surgical resection samples, +/- lymph nodes), ulcerative colitis (n = 27), and non inflammatory bowel diseases (n = 20: colonic tumors and diverticulitis). Positive as well as negative controls were used throughout the study.All strains of Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum tested were positive for both primer systems. Of the 94 biopsies tested, 5 (2 Crohn's disease, 1 ulcerative colitis and 2 controls) were positive with the 16S-rDNA primers but did not correspond to Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum. None of the specimens was positive with the IS primers.These results do not support the hypothesis that Mycobacterium paratuberculosis, or Mycobacterium avium subsp. silvaticum play a role in Crohn's disease.

A radiological examination of the small bowel is often performed in case of gastrointestinal bleeding of obscure origin. More recently, push-type enteroscopy has been reported as a valuable tool in this indication. The purpose of this study was to compare the diagnosis efficiency of these two procedures.From February 1994 to February 1996, 40 patients (mean age: 52 years) with obscure gastrointestinal bleeding (iron-deficiency anemia without obvious cause of blood loss or malabsorption: n = 17; macroscopic gastrointestinal bleeding: n = 23) were examined by small bowel follow-through and push-type enteroscopy (jejunoscopy n = 19; double way examination n = 21). Each patient had negative upper and lower gastrointestinal tract endoscopies prior to small bowel examinations.Small bowel follow-through revealed only one lesion potentially responsible for blood loss (2.5%), corresponding to a jejunal leiomyoma. Push-type enteroscopy detected small bowel lesions potentially responsible for blood loss in 6 patients (15%). The lesions were located in the jejunum in 5 cases (arteriovenous malformations: n = 3; metastasis: n = 1; leiomyoma: n = 1), in the ileum in 1 case (leiomyoma). The efficiency of push-type enteroscopy for the detection of a small bowel lesion was of 22% in case of macroscopic bleeding and of 6% in case of iron-deficiency anemia. Push-type enteroscopy also revealed lesions previously undetected by gastroscopy or colonoscopy in 8 patients (20%).Push-type enteroscopy was more effective than small bowel follow-through to detect the origin of obscure gastrointestinal bleeding. Push-type enteroscopy revealed a cause of bleeding in 35% of patients, located in the small bowel in only 15% of the patients.

Little is known of the in-situ expression of adhesion molecules in ulcerative colitis (UC) according to disease activity. In the present study we investigate the vascular expression of endothelial leucocyte adhesion molecule 1 (ELAM-1/E-selectin), vascular cell adhesion molecule (VCAM-1) and intercellular adhesion molecules (ICAM-1 and ICAM-3) on the rectal mucosa of patients with UC in order to identify links between in-situ expression of these adhesion molecules and clinical, endoscopic and histological parameters.At inclusion, 16 untreated patients with UC at different stages of disease activity were assessed clinically and endoscopically and underwent rectal biopsy. Ten patients had similar assessments during follow-up. Quantitative histological and immunohistochemical scores were established with anti-E-selectin, VCAM-1, ICAM-1, ICAM-3 and HLA-DR monoclonal antibodies on frozen biopsy specimens.(1) At inclusion, E-selectin in-situ expression correlated with clinical activity (r = 0.7, P = 0.05), endoscopic severity (r = 0.74, P = 0.04), the histological score (r = 0.57, P = 0.02) and in-situ expression of HLA-DR on epithelial cells (r = 0.74, P = 0.01). (2) After remission, there was a significant decrease in ELAM-1 in-situ expression (P = 0.04). (3) In patients with clinical, endoscopic and histological remission the level of residual E-selectin expression appeared to be predictive of clinical relapse. (4) Vascular expression of VCAM-1 and ICAM-1 did not correlate with clinical, endoscopic or histological parameters, or with changes in disease activity. (5) ICAM-3 was never detected on endothelial cells of the colonic mucosa of controls or patients with UC.In ulcerative colitis, E-selectin, but not VCAM-1, ICAM-1 or ICAM-3, appears to play a central role in leucocyte migration into the colonic mucosa. Elevated vascular expression of E-selectin after remission may be involved in clinical recurrence.

The evaluation of the rate of gastroduodenal toxicity of anti inflammatory drugs is a difficult problem. We tried to analyse that question by studying the general endoscopic registers of the Gastro-Enterologic department of the hospital. This retrospective study concerns 2,945 endoscopies performed during the year 1988 and 1992 randomly chosen among the last 5 years. 992 results show injuries suggestive of non steroidal anti inflammatory drugs (NSAID) toxicity, however only in 65 cases the potential role of an anti inflammatory drug is mentioned: 36 men and 29 women, mean age: 50.6 +/- 19.6 years. Concerning the drugs, only the pharmacological classes they belong to are mentioned except for Aspirin. Acetyl salicylate acid 7 cases, NSAIDS 36 and Steroids 22. In the drug group 63% of injuries are located to the stomach (ulcers 13%, gastritis 50%), 37% to the duodenum (19% ulcers, 18% duodenitis). Compared to the groups with the same kind of injuries, but without any mention of drugs, there are no statistical difference in the proportion of ulcers. Aging and sex are not influent in our results on the genesis of drug induced ulcers. These results must be discussed because a lot of datas are missing in the registers and so the number of patients taking drugs is probably underestimated. This means that unless a prospective study is held with someone enquiring for all the risk factors, the study of the general endoscopic registers is not a good way to estimate gastrointestinal damages due to drugs.

The authors report seven cases of tuberculoid granulomatous gastritis. Tuberculosis was the cause in three cases. Bilharziasis was the cause in two cases. Sarcoidosis was identified in one patient. In only one case was the etiology undetermined. This seems rare. Some of these form should be compared with experimental tuberculoid granulomatous gastritis, obtained after sensitisation to foreign substances included in the gastric mucosa. The organisation of the epithelioid and giant cell granuloma corresponds to an immune defence reaction of the stomach, bringing into play immunoglobulins IgG and IgM to lead to the formation of antigen antibody complexes in these tissues.

Congenital malformations and tumours of the bladder are the commonest indications of uretero-sigmoidostomy, an operation associated with the name of Coffey who perfected the technique. A part from the renal and metabolic complications of this operation, the risk of benign or malignant tumours at the anastamosis should not be overlooked. Four cases are reported which underline the incidence of juvenile polyps and mixed juvenile and adenomatous polyps which tend to degenerate. The medical literature is reviewed. Uretero-sigmoidostomy is a definite cause of tumour formation. The different pathogenic hypotheses are discussed. Colonoscopy is a method of detecting the tumour, of obtaining a histological diagnosis and treating benign polyps by diathermy under endoscopic control. This technique allows preservation of the anastomosis. The prevention of these lesions should be assured by annual endoscopy for 5 years after operation.

A nutritional support was indicated in 52 patients, most of whom had deglutition problems linked with post-therapeutic after-effects of neoplasia of the ORL sphere. Assistance was possible in all the cases, with difficulty in 9 cases. There were only three major complication (two of which necessitated the removal of the tube) and no fatalities. Benign, more numerous complications were all medically curable and did not necessitate the removal of the tube. The follow-up of the patients showed remarkable tolerance to, and nonproblematic use of, the GPE tube as a nutritional aid leading, in the majority of cases, to a weight gain, even when ambulatory. Our experience suggests that this technique deserves a prime place as a nutritional aid for cases of deglutition problems, of neurological origin, and in ORL cancers. Its relative safety must undoubtedly make it preferable to the surgical technique.

The indications and results of percutaneous endoscopic gastrostomy (PEG) were reviewed in 30 consecutive patients, most of whom had problems of deglutition secondary to the treatment of ENT neoplasia. The procedure was successful in all patients but some difficulty was encountered in 4 cases. There were no major complications or fatalities. The benign complications were all amenable to medical therapy and did not require ablation of the gastric tube. In general, PGE was well tolerated and an easy to use method of nutritional assistance, allowing most patients to gain weight. In the authors' experience, this technique has an important role to play in the nutritional assistance of patients with problems of deglutition due to neurological disease or ENT neoplasia. The relative innocuity of PEG gives it a great advantage over surgical gastrostomy.

The efficacy and safety of a combination of buzepide metiodide and haloperidol was assessed in a placebo-controlled double-blind trial during 2 months in 224 patients (154 women, 79 men) with the irritable bowel syndrome. The 2 groups were comparable at inclusion. The efficacy was assessed at days 15, 30 and 60. Inclusion and assessment criteria were clinical, abdominal pain being considered as the main assessment criterion. The combination proved statistically better than placebo on the frequency of symptoms at all visits and on the intensity of the most frequent symptoms (abdominal pain and distension) at the final visit. A previously defined global assessment score was found significantly better in favor of the treated group at day 15 and day 30. At the final visit, the score of a visual scale assessing the patient's global impression was also found significantly better on the combination, There was no serious side-effect. In conclusion, this study demonstrates the efficacy and safety of a combination of buzepide metiodide and haloperidol in patients with the irritable bowel syndrome.

Nutritional assistance was indicated in 31 patients with an ENT tumour at different stages of treatment and different stages of the disease. These patients presented with disorders of deglutition with false passages (68%), aspiration pneumonia (10%), dysphagia (35%) or denutrition (17%). We used an endoscopic percutaneous gastrotomy kit produced by the Bioser company (pull technique). In 29 patients, the tube was inserted under general anaesthesia in the operating theatre to prevent dyspnoea during introduction of the tube in these patients with alteration of the airway-gastrointestinal tract junction or because the tube was inserted at the beginning of anaesthesia for ENT surgery. The tube was able to be inserted in every case, with cardiac arrest in one patient who was effectively resuscitated without sequelae, two obstructions of the cuff requiring advancement of the tube with a bougie, 2 ruptures of the thread and one case of dyspnoea. Two patients subsequently developed a wound abscess which was drained and one patient required removal of the tube. Follow-up of the patients demonstrated the good tolerance of this tube which was maintained for an average of 2.9 +/- 0.5 months (0.1 to 9 months) without any major complications. 3 benign wound infections, 4 inflammatory reactions, 4 minimal leaks, 1 case of hyperthermia, 12 cases of abdominal distension and 2 cases of displacement of the tube were observed. The weight gain was equal to 4%. The authors believe that this technique of endoscopic gastrostomy should be preferred to surgical gastrostomy.

A 27-year-old patient, originally from Martinique, presented with a progressive hepatic granulomatosis with hepatomegaly, splenomegaly, and non-icteric cholestasis, associated with bronchial granulomatosis lesions. The sarcoidosis regressed rapidly after high doses (60 mg/day) of prednisone. Portal hypertension developed later and provoked a severe hematemesis from rupture of esophageal varices. Signs of pulmonary arterial hypertension were then observed, and the diagnosis confirmed by pressure tests after catheterization, and angiography. A portocaval shunt caused the esophageal varices to subside, but the pulmonary arterial hypertension, resistant to corticotherapy, was rapidly fatal. In the case reported, the pulmonary arterial hypertension, independent of any parenchymatous lesion, was attributed to fibrosis of the arterial walls. The association of portal and pulmonary arterial hypertension with sarcoidosis is a very rare occurrence, and the pathogenesis of this association remains a debatable subject.

Two cases of very probable post-hepatitis cirrhosis are presented. Both were complicated by presinusoidal portal hypertension (P. H. T.), the peroperative portal pressures measured directly being much higher than the wedged hepatic venous pressures. Although post-sinusoidal P. H. T. is the usual complication of most types of cirrhosis, these two cases support recent studies reporting the possibility of pre-sinusoidal P. H. T. in post-hepatitis cirrhosis. The wedged hepatic venous pressure is not a reliable indicator of portal pressure in these cases. The presence of presinusoidal P. H. T. does not exclude the diagnosis of cirrhosis but makes that of alcoholic cirrhosis very unlikely.