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The incidence of adenocarcinoma of the oesophagus is increasing; this type of carcinoma commonly arises on Barrett's oesophagus. We report a case of in-situ adenocarcinoma of the lower oesophagus arising in submucosal oesophageal mucous glands without intestinal metaplasia. We describe the histological findings, discuss the difficulties of differentiating this from invasive disease and review the current literature regarding this rare condition.

Although hepatobiliary involvement is common in the acquired immunodeficiency syndrome, it infrequently leads to biliary tract abnormalities. We describe a 39-year-old man with human immunodeficiency virus infection and no previous acquired immunodefiency syndrome-defining illnesses, who presented with malaise, right upper quandrant pain, lymphadenopathy and cholestasis. An endoscopic retrograde cholangiopancreatography demonstrated sclerosing cholangitis due to disseminated B-cell non-Hodgkin's lymphoma. Following chemotherapy, his symptoms and signs rapidly improved, so that 1 month later his endoscopic retrograde cholangiopancreatography has returned entirely to normal.

Omeprazole causes irreversible inhibition of the hydrogen/potassium adenosine triphosphatase enzyme, leading to a marked reduction in both acid secretion and volume of gastric juice. Reported side-effects include nausea, vomiting, diarrhoea, constipation, and headache. We report the development of dry mouth during omeprazole therapy.We have identified six patients taking omeprazole for more than 6 weeks who complained of a dry mouth. Salivary production was measured as whole salivary flow produced over a 10-min period spat into a collecting vessel and as 5% citric acid-stimulated parotid salivary flow collected with a Lashley cup device placed over the parotid duct. Flow rates were evaluated both during and after cessation of treatment. Saliva produced was then cultured for microbes.Four of the six had subnormal parotid or whole salivary flow rates on treatment that recovered after stopping treatment. The increase after treatment was marked in four. Significant amounts of Candida albicans grew from the saliva of the three patients with the lowest salivary flows; one saliva also grew Staphylococcus aureus.Salivary flow is reduced in some patients treated with omeprazole, returning to normal after cessation of treatment. This reduction may predispose to opportunistic infection, particularly in the edentulous.

Introduction Colonoscopy is frequently performed in patients presenting with melaena who have a negative upper gastrointestinal endoscopy (UGIE). Published literature suggests a diagnostic yield of 8%–30%, the most common pathologies being colonic angiodysplasia and right-sided tumours. However these conditions often give rise to occult haemorrhage and a microcytic profile before patients present with overt bleeding. In patients presenting de novo with melaena a raised urea is known to be predictive of upper GI haemorrhage before any endoscopic assessment. Our aim was to examine the value of colonoscopy in the subgroup of patients with a negative UGIE, and to assess whether the absence of a raised blood urea and/or the presence of a microcytic erythrocyte profile at presentation are predictors of positive colonoscopy. Methods Our reporting software was interrogated for the interval November 2007–October 2011. All cases of colonoscopy where melaena was the main indication, and which were preceded by a negative UGIE were analysed. In addition, we collected data on the admission blood urea and mean corpuscular volume (MCV). Patients for whom altered/fresh rectal bleeding were included in the indications in addition to melaena were excluded. Results 724 patients had a total of 829 endoscopic evaluations of melena, and of these 62 patients (53% female) with a median age of 69 year (range 27–91) met our inclusion criteria. 6 of 62 (9.6%) had a cause for the melena identified on colonoscopy: cecal angiodysplasia in 2/6, right-sided malignancies in 2/6 and right-sided diverticular bleeds in 2/6. The admission urea was not significantly lower in patients with a positive colonoscopy (median 11.5 mmol/l, range 5.1–14.7) compared to those with a negative colonoscopy (median 7.2 mmol/l, range 1.4–33.6) (p=0.43). Admission MCV however was significantly lower in patients with a colonic haemorrhage (median 77 fL, range 64–89) compared to patients with a negative colonoscopy (median 90 fL, range 66–116) (p=0.012), with 3/6 (50%) having a low MCV compared to 5/56 (8.9%) of those with a negative colonoscopy (normal = 84–99 fL). Conclusion The diagnostic yield of colonoscopy in patients with melaena and a non-contributory UGIE in our centre was low (9.6%). A normal/low blood urea on admission did not predict a positive diagnosis for the haemorrhage at colonoscopy in our cohort. However, patients with a colonic source of bleeding had a significantly lower MCV, suggesting a chronic natural history for such right sided colonic haemorrhages. Competing interests None declared. References 1. Tedesco FJ. Gastrointest Endosc 1981. 2. Ibach MB . Dig Dis Sci 1995. 3. Blatchford O . Lancet 2000.

Introduction The Global Rating Scale (GRS) and Joint Advisory Group on GI Endoscopy (JAG) auditable outcome standards have been used to improve quality and define minimum standards for colonoscopy across the UK. 1 JAG also provides a clear competency based framework to assess trainee performance; however, there is reluctance in some units to allow independent senior registrars, who have passed JAG assessment, to practise independently. At our teaching centre we encourage appropriately trained registrars to perform their own lists. Supervision is available if needed and departmental protocols define limits of therapy to be undertaken independently (eg, large polypectomies). Attendance at training lists to continue development is also actively encouraged. Our aim was to evaluate whether this provided a quality of service comparable to national standards. Methods We used data collected retrospectively from endoscopy reporting software (Ascribe-Scorpio) on the caecal intubation rate, polyp detection rate, sedation usage and complication rate, to evaluate the performance of senior gastroenterology trainees between 2007 and 2011, against the JAG auditable outcomes for colonoscopy. Results Over a 4-year period, 17 senior gastroenterology registrars performed a total of 2917 colonoscopies. 2221 (76.1%) procedures were unsupervised and 696 (23.9%) were supervised. An uncorrected caecal intubation rate of 94.9% was achieved during unsupervised procedures, 96.6% with supervision (p=0.93, X 2 ). Polyp (all type) detection rate was 30%. Average sedation dose for patients aged >70 years, was pethidine 30 mg and midazolam 1.96 mg; aged Conclusion Our findings show that given appropriate training and support, independently practising senior UK gastroenterology registrars contribute significantly to service delivery, providing high quality colonoscopy, meeting JAG auditable outcome standards. Competing interests None declared. Reference 1. Roland V . BSG Quality and Safety Indicators for Endoscopy (JAG) . 2007.

To date there have been no published studies which have reliably compared the general protein synthesis rates of the three major salivary glands either between themselves or with reference to other exocrine tissues. The main shortcoming of previous work has been the failure of the experimentalists to recognize the need to define the specific radioactivity of the precursor pool at the site of protein synthesis i.e. aminoacyl-tRNA [l]. By flooding the intracellular pool of phenylalanine with tritiated amino-add we have accurately measured the fractional rates of protein synthesis in the salivary glands and compared data with that from liver in this study. Mde wstar rats weighing approximately 150 g were purchased from B. and K. Universal Ltd (Hull, UK) and housed in a temperature controlled. humidified animal houseon a 12 hour light: 12 hour dark cycle. The rats were maintained on a commercial peileted chow and water ad libitum. On attaining 200-220 g body weight the rats were divided into 3 groups. Food, but not water, was withdrawn from al the animals a14 pm the day before the experiment. On the day of the experimentation rats were either injected i.p. with 10 ml/ kg ethanol (Ethanol-treated Group) or saline (Control Group) or allowed to refeed (Refed Group) in a darkened room.Two and a half hours later the rates of protein synthesis were measured by the 'flooding dose' technique as described by Garlidc et d 121. At 2 min and 10 min afler an i.v. dose of L-[4 3H]-phenylalanine the rats were decapitated and salivary glands and livers rapidly dissected out and plunged into liquid nitrogen. Processing of tissues for phenylalanine specific radioactivities was as described previously [2] and modified later to include the addition of protease inhibitors during the initial processing steps [3]. The fractional rate of protein synthesis, k, , was defined as the percentage of the protein pool renewed each day, and is calculated from the formula

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

The effects of the cytokine tumour necrosis factor alpha and the calcium ionophore A23187 upon CD11a, CD11b, CD11c and CD18 leucocyte membrane expression was analysed in whole blood using monoclonal antibodies and flow cytometry. Both agents significantly increased the density of CD11b/CD18 membrane expression on monocytes and granulocytes, but had no effects on adhesion molecule expression on lymphocytes. The effects of sulphasalazine, 5-aminosalicylic acid (5-ASA) and sulphapyridine upon adhesion molecule upregulation were then examined; 10(-3) and 10(-4) M sulphasalazine and 5-ASA significantly reduced tumour necrosis factor alpha induced CD11b/CD18 upregulation on monocytes and granulocytes but had no effects upon A23187 mediated upregulation. Sulphapyridine was inactive. These results suggest that sulphasalazine and 5-ASA may interfere with mechanisms of leucocyte recruitment in inflammatory bowel disease.

Introduction Gastro-oesophageal reflux disease (GORD) is a common condition with a prevalence of about 20% in Western countries.1 In some patients GORD symptoms are associated with oesophageal mucosal injury, yet in others there is no macroscopic evidence of erosive disease. We sought to assess the natural history of patients with GORD symptoms with respect to the persistence or emergence of erosive disease over time, as well as the development of complications, including oesophageal strictures, Barrett9s epithelium (BE) and oesophageal cancer. Methods We analysed a database of over 50 000 oesophagogastroduodenoscopies (OGDs) performed at our unit between 1985 and 2006. From this database, we identified all patients undergoing OGD for GORD symptoms, who had subsequently undergone at least one further OGD at least 6 months after the index OGD. At the index OGD patients were categorised as having erosive oesophagitis (EE) or non-erosive reflux disease (NERD) based upon the presence or absence of mucosal injury. Changes or persistence of the index phenotype (EE or NERD) during follow-up OGDs were defined, as were the development of strictures, BE or oesophageal cancer. Results We identified 394 patients undergoing at least two OGDs for GORD symptoms. EE was present at the index endoscopy in 38% of patients (50% male, mean age 54 years) and NERD in 62% (53% male, mean age 54 years). Mean follow-up time was 4.8 years for EE and 5.2 years in NERD patients. Results of follow-up OGDs are shown in Abstract 062. Conclusion Patients with symptomatic GORD who undergo repeat OGD, even over extended time periods (mean follow-up 5 years) have a stable phenotype with respect to the persistence of EE or NERD, although NERD is significantly more likely to persist as a phenotype than EE. Patients with EE are significantly more prone to GORD complications.

A 51 year old woman presented with rectal bleeding from a mass lying just above the dentate line. Multiple biopsies were taken before the diagnosis of a benign lymphoid polyp was made. This is a rare condition that more commonly presents in children and poses a diagnostic challenge.

SummaryBackgroundColonoscopy is the gold-standard test for investigation of symptoms suggestive of colorectal cancer; computed tomographic colonography (CTC) is an alternative, less invasive test. However, additional investigation after CTC is needed to confirm suspected colonic lesions, and this is an important factor in establishing the feasibility of CTC as an alternative to colonoscopy. We aimed to compare rates of additional colonic investigation after CTC or colonoscopy for detection of colorectal cancer or large (≥10 mm) polyps in symptomatic patients in clinical practice.MethodsThis pragmatic multicentre randomised trial recruited patients with symptoms suggestive of colorectal cancer from 21 UK hospitals. Eligible patients were aged 55 years or older and regarded by their referring clinician as suitable for colonoscopy. Patients were randomly assigned (2:1) to colonoscopy or CTC by computer-generated random numbers, in blocks of six, stratified by trial centre and sex. We analysed the primary outcome—the rate of additional colonic investigation—by intention to treat. The trial is an International Standard Randomised Controlled Trial, number 95152621.Findings1610 patients were randomly assigned to receive either colonoscopy (n=1072) or CTC (n=538). 30 patients withdrew consent, leaving for analysis 1047 assigned to colonoscopy and 533 assigned to CTC. 160 (30·0%) patients in the CTC group had additional colonic investigation compared with 86 (8·2%) in the colonoscopy group (relative risk 3·65, 95% CI 2·87–4·65; p

OBJECTIVES: Biliary tract abnormalities are well recognised in AIDS, most frequently related to opportunistic infection with Cryptosporidium, Microsporidium, and cytomegalovirus. We noted a high frequency of pancreatic abnormalities associated with biliary tract disease. To define these further we reviewed the clinical and radiological features in these patients. METHODS: Notes and radiographs were available from two centres for 83 HIV positive patients who had undergone endoscopic retrograde cholangiopancreatography for the investigation of cholestatic liver function tests or abdominal pain. RESULTS: 56 patients had AIDS related sclerosing cholangitis (ARSC); 86% of these patients had epigastric or right upper quadrant pain and 52% had hepatomegaly. Of the patients with ARSC, 10 had papillary stenosis alone, 11 had intra- and extrahepatic sclerosing cholangitis alone, and 35 had a combination of the two. Ampullary biopsies performed in 24 patients confirmed an opportunistic infection in 16. In 15 patients, intraluminal polyps were noted on the cholangiogram. Pancreatograms were available in 34 of the 45 patients with papillary stenosis, in which 29 (81%) had associated pancreatic duct dilatation, often with associated features of chronic pancreatitis. In the remaining 27 patients, final diagnoses included drug induced liver disease, acalculous cholecystitis, gall bladder empyema, chronic B virus hepatitis, and alcoholic liver disease. CONCLUSION: Pancreatic abnormalities are commonly seen with ARSC and may be responsible for some of the pain not relieved by biliary sphincterotomy. The most frequent radiographic biliary abnormality is papillary stenosis combined with ductal sclerosis.

Background This pilot study assessed the diagnostic accuracy of rapid evaporative ionization mass spectrometry (REIMS) in colorectal cancer (CRC) and colonic adenomas. Methods Patients undergoing elective surgical resection for CRC were recruited at St. Mary’s Hospital London and The Royal Marsden Hospital, UK. Ex vivo analysis was performed using a standard electrosurgery handpiece with aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Histological examination was performed for validation purposes. Multivariate analysis was performed using principal component analysis and linear discriminant analysis in Matlab 2015a (Mathworks, Natick, MA). A modified REIMS endoscopic snare was developed (Medwork) and used prospectively in five patients to assess its feasibility during hot snare polypectomy. Results Twenty-eight patients were recruited (12 males, median age 71, range 35–89). REIMS was able to reliably distinguish between cancer and normal adjacent mucosa (NAM) (AUC 0.96) and between NAM and adenoma (AUC 0.99). It had an overall accuracy of 94.4 % for the detection of cancer versus adenoma and an adenoma sensitivity of 78.6 % and specificity of 97.3 % (AUC 0.99) versus cancer. Long-chain phosphatidylserines (e.g., PS 22:0) and bacterial phosphatidylglycerols were over-expressed on cancer samples, while NAM was defined by raised plasmalogens and triacylglycerols expression and adenomas demonstrated an over-expression of ceramides. REIMS was able to classify samples according to tumor differentiation, tumor budding, lymphovascular invasion, extramural vascular invasion and lymph node micrometastases (AUC’s 0.88, 0.87, 0.83, 0.81 and 0.81, respectively). During endoscopic deployment, colonoscopic REIMS was able to detect target lipid species such as ceramides during hot snare polypectomy. Conclusion REIMS demonstrates high diagnostic accuracy for tumor type and for established histological features of poor prognostic outcome in CRC based on a multivariate analysis of the mucosal lipidome. REIMS could augment endoscopic and imaging technologies for precision phenotyping of colorectal cancer. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5121-5) contains supplementary material, which is available to authorized users.

An enzymatic recycling method has been applied to the measurement of total and oxidized glutathione with a centrifugal analyzer. When the reduced form of glutathione (GSH) was masked with 2-vinylpyridine to measure the oxidized glutathione (GSSG), the time to ensure full derivatization was three times longer than has been reported. The method is quick, simple, accurate, and precise (1.27% for GSH, 3.3% for GSSG intraassay CV; 2.15% for GSH, 5% for GSSG interassay CV), and the automation allows large numbers of samples to be conveniently assayed.