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Assessment of the physiological effects of physical and emotional stress has been hampered by a lack of suitable laboratory techniques. Since hypnosis can be used safely to induce specific emotional states of considerable intensity, we studied the effect on distal colonic motility of three hypnotically induced emotions (excitement, anger, and happiness) in 18 patients aged 20-48 years with irritable bowel syndrome. Colonic motility index was reduced by hypnosis on its own (mean change 19.1; 95% CI 0.8, 37.3; p less than 0.05) and this change was accompanied by decreases in both pulse (12; 8, 15) and respiration (6; 4, 8) rates (p less than 0.001 for both). Anger and excitement increased the colonic motility index (50.8; 29.4, 72.2; and 30.4; 8.9, 51.9, respectively; p less than 0.01 for both), pulse rate (26; 22, 30; and 28; 24, 32; p less than 0.001 for both), and respiration rate (14; 12, 16; and 12; 10, 14; p less than 0.001 for both). Happiness further reduced colonic motility although not significantly from that observed during hypnosis alone. Changes in motility were mainly due to alterations in rate than in amplitude of contractions. Our results indicate that hypnosis may help in the investigation of the effects of emotion on physiological functions; this approach could be useful outside the gastrointestinal system. Our observation that hypnosis strikingly reduces fasting colonic motility may partly explain the beneficial effects of this form of therapy in functional bowel disorders.

Recent controlled studies in the field of gastroenterology have shown that hypnotherapy is unequivocally beneficial in conditions such as irritable bowel syndrome and peptic ulceration. There is also some evidence for influence on certain physiological functions. Further research should help to define more clearly the role of this controversial form of therapy.

Hyperventilation is associated with some symptoms suggestive of irritable bowel syndrome and has been implicated in provoking excessive oesophageal contractility. Sixteen patients with irritable bowel syndrome were therefore studied in order to assess the effect of hyperventilation on distal colonic motility and rectal sensitivity. No significant change in either the amplitude or frequency of colonic contractile activity was noted following hyperventilation, nor was any alteration in rectal sensitivity observed. This study shows that acute hyperventilation does not affect colonic motor activity or visceral sensitivity and suggests that hyperventilation and irritable bowel syndrome are not causally related.

A case of small bowel phytobezoar formed from unusual ingested vegetation is described. The patient presented with recurrent subacute obstruction and a right iliac fossa mass mimicking the presentation of Crohn's disease. None of the usual gastrointestinal disorders that predispose to bezoar formation were present. The phytobezoar passed spontaneously following small bowel enema and colonoscopy. It is possible that relaxation of the gut secondary to the antispasmodics administered at investigation or the physical disturbance during these procedures enabled migration through the ileocecal valve. Antispasmodics may be of use in the conservative management of bezoars obstructing otherwise normal bowel.

Chest pain indistinguishable from angina may arise from causes other than ischaemic heart disease. Careful history-taking may help to clarify the situation but further investigation is often needed. Techniques are now available to help assess those patients with normal coronary angiograms and thus lead to more appropriate management.

12 cases of toxic dilatation of the colon in Crohn's disease were reviewed. In 11 this complication seemed to be the first manifestation of the disease and a considerable diagnostic delay may partly account for the strikingly high mortality (50%). On admission 83% had clinical features suggestive of Crohn's disease and 58% had experienced symptoms suggestive of preceding gastrointestinal disease. An iatrogenic precipitating factor was identifiable in all but the 1 patient with established disease and in 83% of cases antidiarrhoeals had been prescribed. Preoperative perforation occurred in 4 patients, 3 of whom had had a barium-enema examination, and thromboembolism was a common postoperative complication (50%). Fever, tachycardia, low serum calcium, and low serum albumin in a patient with diarrhoea, abdominal pain, and distension should alert the physician to the possibility of Crohn's disease even in the absence of preexisting symptoms. Sigmoidoscopy should be an early investigation with particular attention being paid to perianal disease.

A study of the prevalence of symptoms suggestive of irritable bowel syndrome in 798 women referred to a gynecological clinic is reported; 321 women referred to dermatology and ear, nose, and throat clinics served as controls. Data were collected by a mailed symptom questionnaire. The prevalence of irritable bowel syndrome in the gynecological group was 37.3% compared with 27.7% in controls (P = 0.003). Approximately 50% of women referred with abdominal pain, dyspareunia, and dysmenorrhea had symptoms compatible with irritable bowel syndrome (P less than 0.005), whereas the prevalence in those referred for cervical abnormalities, termination/sterilization or perineal problems was similar to that of controls (28%). Patients referred with urinary symptoms, heavy periods, nonmenstrual bleeding, vaginal discharge, and infertility had an intermediate prevalence of irritable bowel syndrome (35-45%). This study suggests that either many women with irritable bowel syndrome are being wrongly referred to gynecologists or raises the possibility that symptoms currently regarded as indicative of irritable bowel syndrome may be associated with certain gynecological disorders.

The effect of intercurrent diarrhoea on relapse of ulcerative colitis was investigated. Diarrhoea resulting from travel abroad, gastroenteritis or antibiotic usage resulted in an approximately 50% relapse rate. With regard to colonoscopy and barium enema, only the latter was followed by relapse and this may reflect differences in the preparation for the procedure.

30 patients with severe refractory irritable-bowel syndrome were randomly allocated to treatment with either hypnotherapy or psychotherapy and placebo. The psychotherapy patients showed a small but significant improvement in abdominal pain, abdominal distension, and general well-being but not in bowel habit. The hypnotherapy patients showed a dramatic improvement in all features, the difference between the two groups being highly significant. In the hypnotherapy group no relapses were recorded during the 3-month follow-up period, and no substitution symptoms were observed.

Oesophageal motility was assessed in 30 patients with the irritable bowel syndrome and controls matched for age and sex. Lower oesophageal sphincter pressure was significantly lower in the patients than their controls (mean pressures 13.8 and 23.8 cm H2O respectively), and the same degree of difference between patients and controls was maintained in all age groups. In addition, spontaneous activity, repetitive contractions, and the presence of variable-amplitude and simultaneous waves were significantly more common in the patients, who were also more likely to have more than one abnormal pattern of motility. There was no difference in upper oesophageal sphincter pressure between the two groups. These findings may help to explain why patients with the irritable bowel syndrome may complain of upper gastrointestinal symptoms, including heartburn and dysphagia. The results suggest that the syndrome may be a more widespread disorder of smooth muscle, or its innervation, than was previously thought.

A double-blind crossover trial of the alpha 2 agonist lidamidine hydrochloride in 72 patients with irritable bowel syndrome is reported. Lidamidine was found to have no significant effect on frequency and severity of abdominal pain or abdominal bloating. It did cause a statistically significant reduction in frequency of defaecation (P = 0.005), but this was of a degree unlikely to be of clinical importance. Although alpha 2 agonists inhibit gastrointestinal motility in animals this study suggests that lidamidine hydrochloride does not have a useful therapeutic role in irritable bowel syndrome.

Oesophageal function was assessed in 52 patients with angina pectoris whose coronary angiograms were completely normal and in 21 patients with angina pectoris who had significant coronary artery disease. During a standard oesophageal manometric study, abnormalities were found in 23 (44%) patients with normal coronary angiograms but in only 2 (10%) patients with coronary artery disease (p less than 0.01). Twenty-four (46%) patients with normal coronary angiograms were found to have gastro-oesophageal reflux disease during 24-hour oesophageal pH monitoring. Of the 52 patients with normal coronary angiograms, 19 (37%) had gastro-oesophageal reflux disease and abnormal oesophageal motility, 5 (10%) had gastro-oesophageal reflux disease alone, and 7 (13%) had oesophageal motility disorder alone. The use of provocation procedures, including intravenous edrophonium during oesophageal manometry and treadmill exercise testing during pH monitoring, enabled the oesophageal abnormality to be demonstrated simultaneously with chest pain in 25 of these 31 patients. Typical angina pectoris, coincident with abnormal oesophageal motility, was precipitated in a subgroup of patients who had been shown to have oesophageal manometric abnormalities and gastro-oesophageal reflux disease by the infusion of hydrochloric acid into the oesophagus; both the chest pain and manometric abnormality resolved following the oral administration of antacid.

30 patients with rapidly relapsing duodenal ulceration were studied to assess the possible benefit of hypnotherapy in relapse prevention. After the ulcer had healed on treatment with ranitidine, the drug was continued for a further 10 weeks during which time patients received either hypnotherapy or no hypnotherapy. The two randomly selected groups were comparable in terms of age, sex, smoking habits, and alcohol consumption. Follow-up of both groups of patients was continued for 12 months after the cessation of ranitidine. After 1 year, 8 (53%) of the hypnotherapy patients and 15 (100%) of the control subjects had relapsed. The results of this study suggest that hypnotherapy may be a useful therapeutic adjunct for some patients with chronic recurrent duodenal ulceration.

220 nm filtrates of intestinal resections from 6 of 10 patients with Crohn's disease produced a cytopathic effect in WI-38 tissue-culture monolayers, whereas controls had no effect. Characterisation of the virus responsible has been completed in 3 of the 6 positive isolates and indicates that it is an R.N.A. virus, 55-60 nm in diameter, heat, ether, and acid stable, and antigenically related to Nebraska calf-diarrhoea virus. It therefore belongs to the Reoviridae family.

A skin lesion previously unassociated with Crohn's disease is described. Although superficially resembling erythema nodosum it runs a different clinical course and has different histological appearances, the central feature being necrobiotic collagen. The term ;nodular necrobiosis' is suggested.

Abdominal ultrasound was performed in conjunction with liver function tests in 38 patients with small bowel Crohn's disease and a similar number of age- and sex-matched healthy controls. Five (13%) patients had had previous cholecystectomies for cholelithiasis, and eight (21%) were found to have gallstones on ultrasound. Thus, a total of 34% of patients as compared with 8% of controls had gallstones (P less than 0.01). Compared with 8% of controls, 53% of patients had evidence of at least one biochemical or ultrasonic hepatobiliary abnormality (P less than 0.001). A bright liver echo pattern may be indicative of portal triaditis. The high prevalence of gallstones in Crohn's disease should be considered in any patient who continues to complain of abdominal pain despite otherwise appearing to be in remission.

Gastric mucosal lymphocyte subpopulations were determined by an indirect immunoperoxidase method applied to cryostat sections of gastric biopsies obtained from 12 patients with pernicious anemia (PA group) and from 12 patients whose stomachs were endoscopically and histologically normal (comparison group). T-Cell populations were identified by means of monoclonal antibodies directed against all T cells (UCHT1), T suppressor cells (anti-Leu-2a), and T helper cells (anti-Leu-3a). Non-T cell numbers were estimated indirectly. Concentrations of all T cells, T suppressor cells, T helper cells, and non-T cells were all significantly greater in the PA than in the comparison group. The most striking difference was in non-T cell numbers, which showed an approximately sixfold increase in the PA group. Mean T/non-T cell ratios in PA and comparison groups were significantly different (0.49 and 1.50, respectively). T suppressor/T helper cell ratios were similar in the two groups. There were highly significant positive correlations between numbers of non-T and T helper cells, and non-T and T suppressor cells in PA, but not in comparison groups. If, as seems likely, the majority of non-T cells in these gastritic stomachs were in fact cells of B lineage, these results would be consistent with the hypothesis that gastric mucosal damage in pernicious anemia is mediated primarily by a humoral mechanism, which may involve cytotoxic autoantibodies.

A patient taking an overdose of 3.4 g of amiodarone is described. Consciousness and physical examination remained normal throughout. Continuous electrocardiographic monitoring for 48 hours after admission revealed only a self-limiting episode of ventricular tachycardia, despite high serum levels of the drug (serum desethylamiodarone levels 4.4 mg/l). The pharmacokinetic properties of amiodarone and treatment strategies for the overdose situation are discussed. It is suggested that there may be a role for the use of cholestyramine in the treatment of both acute and chronic amiodarone toxicity.

Patients with irritable bowel syndrome appear to suffer from more psychiatric disorders than control subjects although it remains to be established whether this is cause or effect. The chronic nature of the condition in conjunction with unsympathetic encounters with the medical profession often serves to exacerbate the situation.

A 38-year-old white male with small bowel Crohn's disease presented with an acute right-sided cerebrovascular accident. He died 36 hr later and postmortem revealed thrombosis over the whole length of an otherwise completely normal left internal carotid artery. Histological examination of the artery revealed no abnormalities and in particular no evidence of arteritis. This brings the total number of such cases reported to three, but this is the first with postmortem data. The occurrence of such an event in a young person with normal carotid arteries and no other risk factors would suggest an association with his Crohn's disease, possibly as a result of a coagulation abnormality.

Monocyte function as reflected by phagocytosis of Candida albicans and chemotaxis towards zymosan-activated serum has been assessed in Crohn's disease and ulcerative colitis. Phagocytosis and random movement were significantly increased to a similar degree in both diseases when compared with controls (p less than 0.001). There was no significant difference in chemotaxis between the disease and control groups, although there was a trend towards its being increased in ulcerative colitis. There was no correlation between the results obtained and disease activity or medication.

Rectal biopsies from healthy control subjects, and from patients with Crohn's disease whose rectal mucosa appeared normal by sigmoidoscopy and light microscopy, were examined by scanning electron microscopy. Appearances within both groups were quite variable, and no clear differences between the groups could be distinguished.

Specific lymphocyte transformation to three micro-organisms that have been implicated in Crohn's disease was performed. These were Pseudomonas maltophilia, Mycobacterium kansasii and Rotavirus. No significant differences were observed for any of the antigens tested. Simultaneous testing of nonspecific stimulation by PHA also showed no difference between patients and controls. These results do not support an aetiological role for these organisms mediated by a purely cellular mechanism.

Few drugs are of proven efficacy in irritable bowel syndrome. Bulking agents probably relieve constipation, spasmolytics may alleviate pain and antidiarrhoeals help control urgency and diarrhoea. With a combination of reassurance and therapeutic intervention up to 75% of patients can be expected to improve. For the 25% who do not, alternative therapies such as stress management, psychotherapy or hypnotherapy may prove effective.

Two sisters presenting with Barrett's oesophagus both at the age of 66, are described. The endoscopic appearances revealed striking similarities in terms of severity and extent of the lesion and the presence of a hiatus hernia. At oesophageal manometry low lower oesophageal sphincter pressures were recorded in each case. These observations raise the possibility that familial factors may influence the development of this condition, and likely mechanisms are discussed.

Crohn's-disease tissue was tested by indirect immunofluorescence for antigens of rotavirus, Pseudomonas maltophilia, and Mycobacterium kansasii. No reactions were obtained with anti-serum to P. maltophilia and M. kansasii, and a granular fluorescence seen with rotavirus antibody was probably non-specific.

The cause of death was obtained for 77 members of the Coeliac Society resident in England and Wales. Proportional mortality analysis revealed a significant deficiency in deaths from ischaemic heart-disease in males and a non-significant deficiency in females. It is suggested that this apparent protective effect of coeliac disease might result from malabsorption of dietary lipids. The study also confirmed findings of an excess of deaths from lymphoma and upper gastrointestinal neoplasms.

In a prospective study, a comparison between immediate and next-day endoscopy has been made in 100 patients with acute upper gastrointestinal haemorrhage. Neither regime was statistically superior to the other. It is concluded that in the majority of patients immediate emergency endoscopy is unnecessary.

Irritable bowel syndrome affects up to 20% of the population, is more common in females and is one of the commonest disorders dealt with by gastroenterologists. It is now recognised that the disorder is not confined to the colon and can give rise to a wide variety of different symptoms.

The case-histories of a husband and wife in whom Crohn's disease developed after more than 30 years of marriage are described.

In 100 patients with irritable bowel syndrome a wide variety of non-gastrointestinal symptoms were significantly more common than in a group of 100 age, sex, and social class matched controls. Nocturia, frequency and urgency of micturition, incomplete bladder emptying, back pain, an unpleasant taste in the mouth, a constant feeling of tiredness and in women dyspareunia were particularly prominent (p less than 0.001). With reference to non-colonic gastrointestinal symptoms nausea, vomiting, dysphagia and early satiety were very common (p less than 0.0001). This symptom diversity was observed irrespective of whether the patient had a psychiatric disorder or not. Patients smoked more than controls (p = 0.02) drank more caffeine containing drinks (p = 0.03) and 26% had taken at least one week off work in the previous 12 months. Thirty three per cent of patients had a family history of irritable bowel syndrome. Cognisance of these diverse symptoms may prevent referral to the wrong medical specialty and inappropriate investigation. They may also be indicative of a much more diffuse disorder of smooth muscle than has previously been appreciated.