The effects of intravenous metiamide on the pancreatic exocrine response to intravenous infusion of secretin plus cholecystokinin has been studied in eight patients with duodenal ulceration. The secretion of bicarbonate and water was not altered by metiamide. The secretion of enzymes was significantly less than control during infusion of metiamide. The differences between the pancreatic and gastric responses to metiamide are discussed.

To assess the value of clotting factor concentrate infusions in fulminant hepatic failure, a controlled trial was performed in which nine patients were randomly allocated to treatment with either concentrate alone or concentrate plus heparin. The five patients receiving concentrate alone all died, with major bleeding as the direct cause of death in three, whereas in the four receiving heparin as well there was only one instance of bleeding and one patient survived. Clinical evidence of intravascular coagulation appeared in two patients treated with concentrate alone and the laboratory evidence of this progressed during the period of infusions in all patients in both treatment groups, although to a lesser extent in those receiving heparin. Additional evidence for intravascular coagulation came from the changes observed in factor VIII levels which, although initially high in all patients, fell subsequently, particularly in those given concentrate alone. There was some improvement in the prothrombin ratio in both groups of patients but not complete correction, and serial assays of clotting factors showed that although factor II rose to high levels during treatment, factors IX and X showed little response. Thus, the use of concentrate of factor IX in this trial, as well as potentiating intravascular coagulation, was inadequate as replacement for the clotting factor deficiencies.

The occurrence of cholesterol crystals was studied in 20 consecutive gallstone patients with functioning gallbladders. The frequency with which crystals were found rose sharply with the number of stones. Gallbladder bile was found more often to contain cholesterol crystals than hepatic bile of the same individual. Such crystals were absent in T tube drain bile from 10 consecutive choledochostomy patients, studied after the reestablishment of the enterohepatic circulation for at least five days. In gallstone patients in whom the gallbladder was visualized at cholecystography the hepatic bile contained cholesterol crystals more often than in patients with gallbladders not so visualized. In the latter patients the crystals tended to disappear after prolonged fasting. Bile analysis showed hepatic bile of patients with non-functioning gallbladders to be less lithogenic than bile in cases with functioning gallbladders. In the former group bile contained relatively more chenodeoxycholic acid than in the latter. The composition of bile with cholesterol crystals did not differ significantly from that of bile without crystals. In the final analysis it is important to identify possible factors responsible for the precipitation of cholesterol from supersaturated bile.

Three of six patients with chronic hepatic encephalopathy treated with levodopa showed a significant improvement. One patient was probably improved whilst the remaining two patients failed to show any benefit. Serial electroencephalography did not demonstrate significant changes. Treatment with levodopa was associated with an improvement in ;speed-based' tasks as assessed by computerized psychometry. A significant rise in cerebral oxygen consumption was found during levodopa therapy. Gastrointestinal side effects were dose limiting. It is concluded that a therapeutic trial of levodopa in patients with chronic hepatic encephalopathy is indicated when the response to conventional therapy has been poor.

Treatment of the coagulation disturbances developing with hepatic damage following a paracetamol overdose was assessed in a controlled trial of 22 patients, one half being given heparin and fresh frozen plasma and the other fresh frozen plasma alone. No significant difference was observed either in the speed of correction of the coagulation defect or in the clinical outcome. Two-thirds of the patients had evidence of disseminated intravascular coagulation, but despite the presence of a severe coagulation defect, significant bleeding occurred in only five patients. This may be because with paracetamol-induced hepatic necrosis both the coagulation defect (and possibly other features attributable to severe hepatic insufficiency) are of shorter duration than in hepatic necrosis due to causes such as viral hepatitis in which the liver damage may be a continuing process.

Sixty-four patients with proven ulcerative colitis who had been maintained on sulphasalazine as their sole form of treatment for a minimum period of one year were entered into a controlled trial of sulphasalazine versus dummy tablets for a period of six months. All the patients admitted were not only symptom-free but also showed no evidence of inflammation on sigmoidoscopy and rectal biopsy. A patient was judged to have relapsed when there was a recurrence of colitic symptoms accompanied by sigmoidoscopic and histological evidence of inflammation. The patients who received dummy tablets had more than four times the relapse rate of those receiving sulphasalazine. The results were similar in patients who had been on maintenance treatment with sulphasalazine for less than three years before entry into the trial and in those who had been on this treatment for more than three years. It is concluded that maintenance treatment of ulcerative colitis with sulphasalazine should be continued indefinitely unless contraindicated by side effects.

In order to investigate further the reported beneficial effect of deglycyrrhizinated liquorice in gastric ulcer, a trial with a double-blind, cross-over design was performed. The patients were treated during two consecutive periods of four weeks each with either liquorice extract during the first period and placebo during the second or placebo during the first period and liquorice during the second. Only patients with chronic ulcer disease were accepted for the trial. The dosage of the liquorice extract was 760 mg three times daily. During the first period 38 patients with 47 ulcers in the ventricle and during the second period 30 patients with 36 ulcers took part in the trial. The patients' sex, age, site of the ulcer in the ventricle, and ulcer size in the groups treated with liquorice and placebo during periods I and II were similar. Nor could any difference be shown between the groups treated with liquorice and placebo with respect to heredity, duration of ulcer disease, alcohol consumption, smoking, or the use of drugs. There was no tendency to quicker healing in either group as regards change of ulcer area or complete healing. Small ulcers healed more quickly than big ones. Ulcers at the angulus healed very poorly. No side effects of treatment were observed.Our study was not able to demonstrate any healing effect of the liquorice extract (Caved-S) on gastric ulcer.

In 14 healthy volunteers, the addition of 12 g cholestyramine to a vitamin A-containing test meal reduced the expected rise in serum vitamin A by 59.5% (p<0.001). By contrast, lignin had no significant effect in 12 subjects. This study confirms the importance of bile acids in vitamin A absorption and the ineffectiveness of lignin as a sequestrator of conjugated bile acids.

A prospective randomized trial of 40 duodenal ulcer patients is reviewed. The patients had one of four operations (selective vagotomy, proximal gastric vagotomy, selective vagotomy plus pyloroplasty, or proximal gastric vagotomy plus pyloroplasty). The gastric emptying of a hypertonic fluid meal was assessed before and three to four months after operation. Selective vagotomy without a drainage procedure results in gastric retention and should no longer be considered as a method of treatment for duodenal ulcer. Proximal gastric vagotomy without a drainage procedure does not lead to gastric retention. Initial gastric emptying is more rapid after proximal gastric vagotomy but the final emptying time is the same as before operation and this operation alters the pattern of gastric emptying less than the other operations. Pyloroplasty added to either selective or proximal gastric vagotomy results in loss of the normal regulation of gastric emptying, very rapid initial gastric emptying, and a significant increase in the incidence of ;dumping'. It appears from these studies that ;dumping' is due to rapid gastric emptying and mainly due to the drainage procedure.

The result of a prospective trial of 40 patients with duodenal ulcer treated either by proximal gastric vagotomy (antrum innervated) or by selective vagotomy (antrum denervated) shows that they are equally effective in reducing gastric acid and pepsin secretion. Preservation of antral innervation by proximal gastric vagotomy reduces gastric secretion as effectively as denervation of the entire stomach.

The gastric secretory response to insulin is mediated predominantly by the vagus. The associated hypoglycaemia stress response is mediated by the sympathetic nervous system. Inhibition of the sympathetic response by simultaneous alpha and beta receptor blockade was studied in five healthy young adults. No appreciable modification of gastric secretory output resulted.

The absorption of synthetic pteroyltriglutamate has been measured in nine normal students with and without the anticonvulsant drug phenytoin. It has been shown that phenytoin has no effect on the absorption of this folate polyglutamate. The reasons are discussed for the disparity between this result and those reported in the literature when folate polyglutamates derived from yeast were used.