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1.  Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain. 
BMJ : British Medical Journal  1995;310(6983):853-856.
Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.
PMCID: PMC2549224  PMID: 7711627
2.  Recommendations for standards of sedation and patient monitoring during gastrointestinal endoscopy. 
Gut  1991;32(7):823-827.
(1) Safety and monitoring should be part of a quality assurance programme for endoscopy units. (2) Resuscitation equipment and drugs must be available in the endoscopy and recovery areas. (3) Staff of all grades and disciplines should be familiar with resuscitation methods and undergo periodic retraining. (4) Equipment and drugs necessary for the maintenance of airway, breathing, and circulation should be present in the endoscopy unit and recovery area (if outside the unit) and checked regularly. (5) A qualified nurse, trained in endoscopic techniques and adequately trained in resuscitation techniques, should monitor the patient's condition during procedures. (6) Before endoscopy, adverse risk factors should be identified. This may be aided by the use of a check list. (7) The dosage of all drugs should be kept to the minimum necessary. There is evidence that benzodiazepine/opioid mixtures are hazardous. (8) Specific antagonists for benzodiazepines and opioids exist and should be available in the event of emergency. (9) A cannula should be placed in a vein during endoscopy on 'at risk' patients. (10) Oxygen enriched air should be given to 'at risk' patients undergoing endoscopic procedures. (11) The endoscopist should ensure the well being and clinical observation of the patient undergoing endoscopy in conjunction with another individual. This individual should be a qualified nurse trained in endoscopic techniques or another medically qualified practitioner. (12) Monitoring techniques such as pulse oximetry are recommended. (13) Clinical monitoring of the patient must be continued into the recovery area. (14) Records of management and outcome should be collected and will provide data for appropriate audit.
PMCID: PMC1379003  PMID: 1855692
3.  Biopsy specimen appearances of ischaemic gastritis in splanchnic arterial insufficiency. 
Journal of Clinical Pathology  1998;51(3):255-256.
A 74 year old man presented with a one month history of epigastric discomfort, anorexia, weight loss, and postprandial vomiting. The diagnosis of ischaemia was made on endoscopic biopsies from the stomach and duodenum. He was too ill for major vascular surgery and died eight days after admission. Postmortem examination confirmed the diagnosis of splanchnic arterial insufficiency caused by atheroma and thrombosis. Ischaemic gastritis is rare but could easily be missed in unrepresentative biopsy specimens. Prompt diagnosis with revascularisation surgery is the only hope for long term survival.
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PMCID: PMC500654  PMID: 9659275
4.  First clinical results with a real time, electronic imager as an aid to colonoscopy. 
Gut  1995;36(6):913-917.
The early clinical results are described of a real time, electromagnetic imaging system as an aid to colonoscopy. After gaining experience with the use of the system, one experienced endoscopist was randomised to perform consecutive colonoscopies either with (n = 29) or without (n = 26) the imager view. All procedures were recorded on computer disk and replayed for retrospective analysis. Total colonoscopy was achieved in all patients except one (imager view not available). Comparing intubation time and duration of loop formation per patient, there was no significant difference between the two study groups. The number of attempts taken to straighten the colonoscope pre patient, however, was less when the endoscopist was able to see the imager view, p = 0.03. Hand pressure was also more effective when the endoscopist and endoscopy assistant could see the imager display, p = 0.02. Preliminary experience suggests that real time, electronic imaging of colonoscopy is safe, effective, and will improve the accuracy of the procedure.
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PMCID: PMC1382632  PMID: 7615283
5.  Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. 
Gut  1995;36(3):462-467.
A prospective audit of upper gastrointestinal endoscopy in 36 hospitals across two regions provided data from 14,149 gastroscopies of which 1113 procedures were therapeutic and 13,036 were diagnostic. Most patients received gastroscopy under intravenous sedation; midazolam was the preferred agent in the North West and diazepam was preferred in East Anglia. Mean doses of each agent used were 5.7 mg and 13.8 mg respectively, although there was a wide distribution of doses reported. Only half of the patients endoscoped had some form of intravenous access in situ and few were supplied with supplementary oxygen. The death rate from this study for diagnostic endoscopy was 1 in 2000 and the morbidity rate was 1 in 200; cardiorespiratory complications were the most prominent in this group and there was a strong relation between the lack of monitoring and use of high dose benzodiazepines and the occurrence of adverse outcomes. In particular there was a link between the use of local anaesthetic sprays and the development of pneumonia after gastroscopy (p < 0.001). Twenty perforations occurred out of a total of 774 dilatations of which eight patients died (death rate 1 in 100). A number of units were found to have staffing problems, to be lacking in basic facilities, and to have poor or virtually non-existent recovery areas. In addition, a number of junior endoscopists were performing endoscopy unsupervised and with minimal training.
PMCID: PMC1382467  PMID: 7698711
6.  Appropriate use of upper gastrointestinal endoscopy--a prospective audit. Steering Group of the Upper Gastrointestinal Endoscopy Audit Committee. 
Gut  1994;35(9):1209-1214.
Work by this group has shown that there is a wide range of opinion as to patients' suitability for endoscopy. In a recent study, 1297 questionnaires were sent to a random selection of doctors, including 350 general physicians, 400 surgeons, 477 gastroenterologists, and 70 general practitioners. The respondent was asked to indicate whether or not he would refer the patient described by each case vignette for endoscopy. Depending on the indication, the positive referral rate varied from 4.5% to 99% overall, and from 4.5% to 63.8% for all those clinical situations that the working party felt to be inappropriate. A second study examined the appropriateness of 400 consecutive cases referred from four units within one health region; these cases were judged independently, and without conferring, by a panel of seven gastroenterologists. The same cases were rated by software that incorporated American opinion (the Rand criteria). Although only 45 (11%) of the cases were classed as inappropriate by the British panel, 120 cases (31%) assessed by the American software were rated inappropriate. These differences occurred largely because in the USA it is recommended that one month's antiulcer treatment be tried before considering endoscopy for dyspepsia and thus many referrals were seen as inappropriate by the American database. Of the 45 cases found to be inappropriate by the British doctors no important abnormality was found at endoscopy; whereas of 120 cases judged inappropriate by the Rand criteria, three duodenal and two gastric ulcers, and one gastric cancer were diagnosed at gastroscopy. This study attempts a quantitative assessment of inappropriate use and serves to encourage further work to define appropriateness.
PMCID: PMC1375695  PMID: 7959225
7.  Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. 
Gut  1991;32(1):12-15.
A postal questionnaire inquiring about routine sedation and premedication practice for upper gastrointestinal endoscopy was sent to 1048 doctors. Of 665 appropriate returns, 81% were from consultant physicians and surgeons. Most endoscopists (90%) reported using an intravenous benzodiazepine for at least three quarters of endoscopies and 54% of physicians and 69% of surgeons always did so. Midazolam was the intravenous sedative used by a third of all respondents and 13% also used an additional intravenous agent, usually pethidine. Over the previous two years a total of 119 respiratory arrests, 37 cardiac arrests, and 52 deaths were identified. Adverse outcomes were reported more frequently by consultant physicians, by those who 'titrated' the intravenous sedative, and by those who used an additional intravenous agent, but were reported equally frequently by endoscopists using midazolam and endoscopists using diazepam. There is an urgent need for a prospective study to identify the circumstances and risk factors associated with adverse outcomes related to endoscopy.
PMCID: PMC1379205  PMID: 1991631
8.  Stones in the common bile duct: experience with medical dissolution therapy. 
Postgraduate Medical Journal  1985;61(714):313-316.
Thirty-one patients with radiolucent common bile duct stones received medical treatment. Nineteen had Rowachol, a terpene preparation, eight (42%) achieving complete stone disappearance within 3 to 48 months. Fifteen (including 3 of the above) took Rowachol with bile acid (chenodeoxycholic in 11, ursodeoxycholic in 4) for 3 to 60 months: 11 (73%) achieved complete dissolution within 18 months. Persistent symptoms and complications settled on conservative management: 8 (25%) patients required admission (2 biliary colic, 1 obstructive jaundice, 4 cholangitis, 1 pancreatitis). One patient died of a myocardial infarction during recovery from pancreatitis; the other continued treatment, 2 achieving complete dissolution/disappearance. Oral dissolution therapy with Rowachol and bile acids should be considered when endoscopic sphincterotomy or surgery is not feasible, but careful attention to potential complications is required while stones persist.
PMCID: PMC2418220  PMID: 4022860
9.  An unusual cause of variceal haemorrhage in an elderly patient. 
Postgraduate Medical Journal  1984;60(705):476-477.
An elderly patient with nodular regenerative hyperplasia of the liver and hypothyroidism who presented with life-threatening bleeding from oesophageal varices is discussed. Progress has been uneventful following a semi-emergency portocaval shunt 5 years ago with no evidence of hepatic encephalopathy. This is presumably a tribute to the relatively well-preserved hepatic function in this condition.
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PMCID: PMC2417939  PMID: 6611548
10.  Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation. 
Thirty patients with radiolucent stones in a radiologically functioning gall bladder were treated for up to two years with a combination of Rowachol (one capsule twice daily), a mixture of cyclic monoterpenes, and chenodeoxycholic acid (7.0-10.5 mg/kg/day). The patients were not selected for body weight or size of stones. All complete dissolutions diagnosed by oral cholecystography were confirmed or refuted by ultrasound examination. Control of symptoms was excellent, only one patient withdrawing from the study because of persistent biliary pain. No evidence of hepatotoxicity was detected biochemically, and diarrhoea due to chenodeoxycholic acid was minimal at this dose. Stones disappeared completely in 11 patients (37%) within one year and in 15 (50%) within two years. These results compared favourably with those obtained with similar doses of chenodeoxycholic acid alone, in particular those of the National Co-operative Gallstone Study (complete dissolution in 13.5% of patients at two years). Treatment with a combination of medium dose chenodeoxycholic acid with Rowachol for radiolucent gall stones is economical, effective, and likely to minimise persistent symptoms and adverse effects of treatment.
PMCID: PMC1442019  PMID: 6430390
11.  Gall-stone dissolution and recurrence: are we being misled? 
Oral cholecystography repeated at six-months intervals is the standard method for determining reduction in size of gall stones (partial success) and complete dissolution of stones (complete success). In a comparative study of oral cholecystography and cholecystosonography six out of 14 patients with gall stones achieving complete success by oral cholecystographic criteria had stones still detectable by ultrasonography. Repeat oral cholecystography in a further 11 patients receiving post-dissolution maintenance treatment detected stones in two, whereas ultrasonography detected stones in seven. In future complete dissolution of gall stones should be reported only if both oral cholecystography and ultrasonographic studies give negative results and the progress of patients receiving post-dissolution maintenance treatment is monitored by ultrasonography rather than serial oral cholecystography.
PMCID: PMC1498166  PMID: 6803946
12.  Cholesterol-lowering effect of mevinolin, an inhibitor of 3-hydroxy-3-methylglutaryl-coenzyme a reductase, in healthy volunteers. 
Journal of Clinical Investigation  1982;69(4):913-919.
Mevinolin reduces cholesterol synthesis by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A reductase. The safety and effectiveness of this agent was evaluated in a double-blind, placebo-controlled study in 59 healthy men (serum cholesterol 3.88--7.76 mmol/liter) in five centers. Subjects maintained their usual diet and activities. Doses of 6.25, 12.5, 25, or 50 mg twice daily for 4 wk produced mean reductions of total serum cholesterol fo 23--27% [vs. placebo (4%), P less than 0.01]. Mean low density lipoprotein cholesterol fell 35--45%, while high density lipoprotein and very low density lipoprotein cholesterol, and triglycerides were not significantly affected. Mean apolipoprotein B fell 27--34%. 50 mg was not significantly more effective than 6.25 mg. Mevinolin was generally well tolerated, and no serious clinical or laboratory abnormalities occurred. One subject (12.5 mg) was withdrawn because of abdominal pain and diarrhea. These results suggest that if long-term safety can be demonstrated, inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase are likely to prove useful in the treatment of hypercholesterolemia.
PMCID: PMC370145  PMID: 6918402
13.  Outcome of endoscopy and barium radiography for acute upper gastrointestinal bleeding: controlled trial in 1037 patients. 
A study was conducted to find whether the higher diagnostic yield of endoscopy compared with barium radiography improves management or survival in patients with acute upper gastrointestinal bleeding. A total of 1037 patients were entered into a randomised study comparing the outcomes after each investigation. The diagnostic yield in patients who underwent endoscopy was 73% (382 of 526 cases) and in those examined by radiography 55% (280 of 511 cases). A fifth of the patients in the radiology group and a tenth of those in the endoscopy group subsequently underwent the alternative investigation; in most cases, however, no additional diagnostic information was obtained. Operation rates were similar in two groups, though patients in the endoscopy group were generally operated on sooner. Mortality rates were also similar in the two groups, though postoperative mortality was higher in the endoscopy group. Endoscopy may be a more accurate means of diagnosis than radiography, but it offers no short-term benefits in management.
PMCID: PMC1496165  PMID: 6800536
14.  Cimetidine and ranitidine: comparison of effects on hepatic drug metabolism. 
British Medical Journal  1980;281(6243):775-777.
Paired studies of hepatic microsomal function were conducted in eight subjects during treatment with two histamine H2 antagonists, cimetidine and ranitidine. Cimetidine but not ranitidine inhibited the metabolism of antipyrine (phenazone) and demethylation of aminopyrine (aminophenazone) as measured by breath 14CO2 production after intravenous injection of 14C-aminopyrine. These results suggest that the metabolic inhibitory actions on the liver may be separated from H2 antagonist effects, and that ranitidine has an advantage over cimetidine by not inhibiting microsomal drug oxidative function.
PMCID: PMC1714006  PMID: 6107157
15.  Rowachol--a possible treatment for cholesterol gallstones. 
Gut  1979;20(4):312-317.
It has been claimed that Rowachol, a proprietary choleretic, is occasionally successful in the treatment of gallstones. In gallstone patients we have examined its effect on the lipid composition of (1) samples of fasting gall bladder bile obtained at the time of cholecystectomy, and (2) T-tube bile on the tenth post-operative day. In a dose of two capsules, three times a day for only 48 hours, Rowachol significantly lowered the cholesterol solubility of both gall bladder (P less than 0.001) and T-tube bile (P less than 0.05). Rowachol in a dose of one capsule three times a day for 48 hours did not alter bile composition, while four capsules four times a day for a similar period caused a significant (P less than 0.05) deterioration in biliary lipid composition. The possible mechanisms of action of Rowachol and their therapeutic implications are discussed.
PMCID: PMC1412390  PMID: 447112
16.  Effect of ioglycamide (Biligram) on bile flow and biliary lipid secretion in man. 
Gut  1978;19(4):300-307.
Twenty-one anicteric patients with a t-tube in situ were studied between the ninth and 11th postoperative days. Eleven patients were given an intravenous infusion of the biliary contrast agent ioglycamide (Biligram), while the other 10 acted as controls. Bile flow was recorded and the biliary concentrations of ioglycamide, bile salt, phospholipid, and cholesterol estimated in the two groups. The biliary excretion of ioglycamide was associated with a significant choleresis which was probably due to the obligatory coupling of the osmotically active contrast agent molecules with water. Biliary ioglycamide excretion did not significantly alter bile salt secretion rates. In contrast, the biliary secretion of both phospholipid and cholesterol was significantly lowered (P less than 0.001). Unlike chenodeoxycholic acid, ioglycamide significantly reduced bile acid independent cholesterol secretion (P less than 0.01), although secretion rate in terms of mumol of bile acid was essentially unchanged.
PMCID: PMC1411925  PMID: 648936
17.  The value of radiology in predicting gallstone type when selecting patients for medical treatment. 
Gut  1975;16(5):359-364.
Since medical treatment of gallstones is confined to cholesterol-rich stones, the ability of clinical radiographs to predict gallstone type was tested prospectively by comparing the preoperative radiological appearance of gallstones from 57 unselected patients with cholelithiasis coming to cholecystectomy with the subsequent analysis of the stones both by X-ray diffraction and by chemical techniques. Fifty-two per cent of the patients had 'non-functioning' gallbladders which failed to opacify after at least two contrast examinations and 25 out of 50 had radioopaque stones. Of the 25 patients with radiolucent stones, the stones in 20 ((80%) were predominantly cholesterol in type but radiology was misleading in five; three contained 40-55% calcium salts but were still radiolucent while two were amorphous and contained less than 10% cholesterol by weight on chemical analysis. While radiology was sometimes misleading when the stones were small and irregular, large radiolucent stones with a smooth profile were invariably cholesterol-rich stones. The results also show that in men calcified stones were commoner than in women and that in older women the gallstones contained more calcium salts and less cholesterol than in younger women less than 50 yr). This paper analyses critically the value and limitations of clinical radiology in predicting gallstone type.
PMCID: PMC1411064  PMID: 1140634
19.  Liver structure and function in cholelithiasis: Effect of chenodeoxycholic acid 1 
Gut  1974;15(3):165-172.
Although, in suitable patients, oral chenodeoxycholic acid (CDCA) dissolves gallstones, the results of recent animal studies suggest that it might be hepatotoxic. Liver function was therefore studied in patients with gallstones before and during treatment with CDCA and liver biopsies were carried out both in patients with cholelithiasis given bile acid therapy and in those who had been given no medical treatment. In 25 patients treated with 0·5-1·5 g CDCA/day (7-20 mg kg body weight−1 day−1) there was no significant change in serum bilirubin, albumin, globulin, transaminase, isocitric dehydrogenase, alkaline phosphatase, and gamma glutamyl transpeptidase levels before and at monthly intervals during six months' treatment. The kinetics of bromsulphthalein (BSP) clearance and its apparent transport maximum were not significantly changed during CDCA therapy. The mean fasting serum bile acid concentrations of 18·0 ± SEM 1·2 μmoles/litre before and 20·0 ± 3·5 μmoles/litre during treatment were both significantly greater than control values. Liver histology was not appreciably different in 11 patients treated with CDCA from that in eight patients with untreated cholelithiasis and in three patients who had received CDCA three to four months before biopsy. These results suggest that in doses of 0·5 to 1·5 g/day CDCA is not hepatotoxic in man.
PMCID: PMC1412889  PMID: 4152191
20.  Serum Lipids in Cholelithiasis: Effect of Chenodeoxycholic Acid Therapy 
British Medical Journal  1973;3(5879):520-523.
Hypercholesterolaemia has been predicted as a possible complication of chenodeoxycholic acid treatment for gall stones. To exclude this, fasting serum lipids were measured in patients with stones before and at monthly intervals for six months after starting chenodeoxycholic acid. Before treatment half of a group of 36 patients with presumed cholesterol gall stones had serum cholesterol levels exceeding 260 mg/100 ml or serum triglyceride values greater than 160 mg/100 ml or both; these lipid levels were significantly greater than those in control subjects matched for age and sex. Treatment with chenodeoxycholic acid (0·5-1·5 g/day by mouth) did not change serum cholesterol levels but did significantly reduce serum triglyceride concentrations from a pretreatment level of 118 (± S.E. of mean 11·7) mg/100 ml to 95 (± 7·2) mg/100 ml after six months of therapy. The mechanism of this triglyceride-lowering action of chenodeoxycholic acid is not known, but it may have therapeutic value in patients with hypertriglyceridaemia.
PMCID: PMC1586970  PMID: 4741607
21.  Helicobacter pylori infection and duodenal ulcer. 
BMJ : British Medical Journal  1991;303(6796):248.
PMCID: PMC1670499  PMID: 1884072
22.  13C-urea breath test for Helicobacter pylori infection. 
Gut  1991;32(5):551-552.
PMCID: PMC1378939  PMID: 2040481

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