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Background Ageing populations are increasing in many countries and bleeding peptic ulcers in patients older than 60 years carry a greater risk of rebleeding and death. This study aimed to identify the risk factors for rebleeding and death in very elderly patients with peptic ulcer bleeding. The efficacy of treatment in preventing recurrent bleeding and death in this group of patients was also studied by means of prospective data collection and analysis. Methods Data relating to 1744 patients treated between September 1985 and January 1994 for peptic ulcer bleeding were collected prospectively and analysed. Patients were stratified by age to one of three groups: group 1 (less than 60 years, n = 833), group 2 (60–79 years, n = 706) and group 3 (80 or more years, n = 205). Results Univariate and multivariate analyses of 21 factors possibly affecting either rebleeding or death identified age greater than 80 years as one of the factors significantly affecting rebleeding and death. In a comparison of groups 1, 2 and 3, the likelihood of rebleeding and death was significantly greater in group 3. Univariate and multivariate analyses for rebleeding and death were performed for each group. The severity of initial bleeding had a marked bearing on subsequent rebleeding rates for all three groups. In group 3, however, large ulcer size and impaired liver function were additional factors which correlated significantly with final outcome. No rebleeding or morbidity occurred when endoscopic treatment was performed early for patients in group 3 but there was a significantly greater risk of further recurrent haemorrhage and treatment-related morbidity when treatment was performed after the onset of rebleeding. Conclusion Patients aged 80 years or greater had the highest risk of rebleeding and death. For patients below 80 years of age, significant factors related to a fatal outcome included co-morbid illness, complications and the need for mechanical ventilation. For patients aged 80 years or older, the significant factors were ulcer size greater than 2 cm and admission with serum bilirubin level above 20 mmol/l. Endoscopic treatment for the very elderly was effective if carried out early.

PATIENTS--Laparoscopic Nissen fundoplication was undertaken in 200 patients between 1991 and 1994. METHODS--Pre-operative assessment included symptom score, endoscopy, manometry, and 24 hour pH monitoring of the oesophagus. Patients were evaluated at three and 12 months after surgery with symptom scoring and 96 patients also underwent 24 hour pH studies at three to six months postoperatively. RESULTS--In the first 100 patients median duration of operation was 155 minutes (range: 70-330), conversion rate to laparotomy was 7%, median hospital stay was three days (range: 2-57), and total morbidity was 16%. This compared with a median operation time of 120 minutes (60-240) (p = 0.0003, 95% CI 10, 40), a conversion rate of 2% (p = 0.2), a hospital stay of three days (1-18) (p = 0.0016, 95% CI 0, 1), and total morbidity of 7% (p = 0.15) in the second 100 patients. Median total symptom scores fell from 5/9 to 0/9 after fundoplication (< 0.0001) while median 24 hour oesophageal acid exposure in 96 patients was reduced from 10% to 1% (p < 0.001). CONCLUSIONS--Laparoscopic Nissen fundoplication is a safe and effective procedure for gastro-oesophageal reflux disease. With experience, the duration of operation falls and the hospital stay is shorter. Shortterm symptomatic and pH results are consistently improved by surgery.

Perforated peptic ulcer may be suspected following the sudden onset of abdominal pain in a patient presenting with signs of peritoneal irritation, even in the absence of a history of peptic ulceration. A diagnosis of visceral perforation may be substantiated by the presence of free gas on plain abdominal radiographic examination and this is evident in up to 92% of patients with perforated duodenal ulcer; it is possible to detect as little as 1 ml of free gas on scrutiny of erect and supine films Voluminous free gas is usually evident following gastric perforation.

Gastro-oesophageal reflux has been assessed in 10 symptomatic patients and 10 asymptomatic normal subjects during a study period of 24 hours at work and in the home using a newly developed pH sensitive radiotelemetry capsule and a portable receiving system. Oesophageal pH was continuously monitored by the tethered radiotelemetry capsule and recorded with a portable receiver and a 24-hour cassette recorder, allowing the patient complete freedom of movement so that ambulatory studies could be undertaken during a normal working day. The number and duration of reflux episodes was greater in symptomatic patients than normal subjects during 24-hour studies at home (p less than 0.002). In both groups, reflux occurred more during the day than at night (p less than 0.01). Patients refluxed significantly more at home than when they were in hospital (p less than 0.01). Ambulatory outpatient oesophageal pH monitoring may be useful in the management of patients with atypical symptoms and may demonstrate significant reflux when inpatient investigations and endoscopy findings show minimal abnormality.

Oesophageal pH monitoring has been undertaken in 20 symptomatic patients and 20 normal subjects for periods of 24 hours at work and in the home using a pH sensitive radiotelemetry capsule and a portable receiving system. There was no correlation between symptoms and endoscopic findings in symptomatic patients. The number and duration of reflux episodes was greater in symptomatic patients than normal subjects during 24 hour ambulatory study (P < 0·002). A frequency-duration index for the evaluation of recordings is described which was significantly greater in symptomatic patients than in normal subjects during both day (P < 0·002) and night (P < 0·008) periods of recording. Discrimination between the two groups was more clearly seen using the frequency-duration index compared to either the frequency of reflux episodes or the cumulative duration of acid reflux.

Summary In a series of 100 patients with carcinoma of the oesophagus or cardia undergoing palliative intubation at endoscopy using a latex rubber or a silicone rubber tube 2 cases of tube fragmentation were encountered and are described. The effects of hydrochloric acid, bile and irradiation on the tubes have been studied in vitro. After incubation in hydrochloric acid (0·1 mol/l), the breaking force of latex rubber tubes fell by 31 per cent (48 N) but did not change significantly for silicone rubber tubes. The addition of bile to the hydrochloric acid (0·1 mol/l) did not further influence the breaking force of either type of tube. Megavoltage irradiation with 7500 rad did not affect the breaking strength of silicone rubber tubes but caused a reduction of breaking strength of latex rubber tubes. These findings suggest that silicone rubber has advantages over latex rubber as a material for prosthetic oesophageal tubes.

Two case studies of inflammatory fibroid polyps are described. The most important feature of these lesions is that they represent a non-malignant cause of intestinal obstruction in elderly patients which is easily resected and does not recur.

Gastro-oesophageal reflux (GOR) most commonly occurs postprandially especially during activities associated with increases in intra-abdominal pressure which may provoke reflux in susceptible subjects. Inflation of a gastric balloon, in increments up to 750 ml, significantly increases the frequency of transient lower oesophageal sphincter (LOS) relaxations in both normal subjects and patients with GOR [1]. These authors conclude that meal-induced gastric distension provokes LOS relaxations so contributing to postprandial reflux. We have developed a short-term acid reflux provocation test (ARPT) for diagnostic purposes.

Simple closure, the conventional operation for perforated acute duodenal ulcers, is associated with symptomatic relapse in a large proportion of patients. In order to assess the role of immediate definitive surgery, 78 fit patients with perforated acute ulcers were prospectively randomized to undergo either closure alone or proximal gastric vagotomy with closure (PGV). Patients taking potentially ulcerogenic drugs or who had severe stress were excluded from the study. Both groups were comparable with respect to age, sex, general medical health, duration of perforation, length of ulcer history, and presence of duodenal scarring. There was no hospital mortality. Minor complications occurred in 7.3% after closure and 10.8% after PGV. At 3 years follow-up, the cumulative recurrence rates were 36.6% and 10.6% after closure and PGV, respectively (p = 0.001). Eighty-five per cent of recurrences after closure were symptomatic, and half of them required reoperation. Duodenal scarring itself did not appear to influence the outcome after closure. PGV was not associated with dumping, diarrhea or other unwanted side effects. Although less than that in chronic ulcers, there is a substantial risk of symptomatic relapse after closure of perforated acute duodenal ulcers. With judicious patient selection, PGV effectively reduces this risk without incurring disabling side effects associated with other ulcer operations.

A case is presented of isolated pancreatic transection sustained in the course of a game of Association Football. The difficulty of early diagnosis is discussed. Emphasis is laid on the importance of possible pancreatic injury in the normotensive patient and on inspecting the posterior abdominal structures on opening the lesser sac during laparotomy.