Though local practice will reflect the previously acquired expertise of the operators, it seems reasonable to employ a minimum of percutaneous transhepatic cholangiography, and, ideally, this in combination with ERCP for preoperative cholangiography in patients with cholestatic jaundice. Few cases will defy both techniques. The morbidity is well known and if properly anticipated can be reduced to a minimum by judicious use of antibacterial agents and early surgical intervention when appropriate. Grey-scale ultrasonography by indicating the diameter of the bile ducts enables one to select percutaneous transhepatic cholangiography for dilated ducts and ERCP for non-dilated ducts with an almost 100% success rate for the former and only slightly less for the latter in experienced hands.

The internal and sphincter receives its parasympathetic nerve supply from the sacral outflow and its sympathetic supply from the thoracicolumbar outflow of the spinal cord. In order to investigate the influence of the tonic discharge of these nerves, eight healthy subjects receiving high spinal anaesthesia (T 6-T 12) and five receiving low spinal anaesthesia (L 5-S 1) were examined. Continuous recordings of anal pressure and electromyographic activity from the external sphincter were obtained during rest and during expansion of the ampulla recti by means of an air-filled balloon. The results were compared with those obtained in an earlier study from 10 subjects with a bilateral pudendal block which paralysed the striated sphincter muscles without affecting the autonomic nerve supply to the internal sphincter. Anal pressure at rest decreased significantly more with high spinal anaesthesia (32 +/- 3-2 mm Hg) than with low (11 +/- 7-1 mm Hg) or with pudendal block (10 +/- 3-9 mm Hg) and the relaxations of the internal sphincter induced by rectal distension were somewhat smaller with high spinal anaesthesia. However, the remaining anal pressure at maximal relaxation, induced by a substantial rectal distension, was essentially the same with the three forms of anaesthesia. It is concluded that, at rest, there is a tonic excitatory sympathetic discharge to the internal anal sphincter in man. However, this seems to be without excitatory effect when the sphincter is relaxed after a substantial rectal distension. Furthermore, the results indicate that at rest there is no tonic parasympathetic discharge affecting the sphincter tone.

Serum lysozyme levels were determined in healthy volunteers, patients with Crohn's disease, and patients with ulcerative colitis. The mean concentration in Crohn's disease was significantly greater than in the other groups. In patients with Crohn's disease, as well as in patients with ulcerative colitis, the lysozyme levels correlated with the severity of the disease process and with the extent of the lesions: the more severe the disease and the more extensive the involvement, the higher the lysozyme levels. However, the lysozyme values of the different groups overlapped considerably. Our results indicate that lysozyme determinations have only limited discriminative value for the diagnosis of Crohn's disease and for determining the severity and the extent of the disease process in the individual patient.

Bile acid loss (mg/m2 24h) in the stools of 43 cystic fibrosis (CF) children with pancreatic insufficiency was 751-1 +/- 48-3, while that of six without clinical evidence of pancreatic disease (133-4 +/- 15-9) did not differ from values in 25 controls (109-8 +/- 9-8). There was a good correlation between the degree of bile acid (BA) and fat sequestration. Concomitant changes in bile acid and fat loss were observed in the one group of six patients studied on and off pancreatic enzymes as well as in a second group of seven children treated with pancreatic supplements and maintained on a normal diet followed by a low fat diet supplemented with medium chain triglycerides. Administration of NA bicarbonate led to a significant decrease in fat loss (15-8 +/- 2-7 leads to 10-3 +/- 1-9) without any simultaneous change in bile acid excretion (533-1 +/- 58-3 leads to 500-4 +/- 58-6). Qualitative bile acid patterns in controls, in infants after an ileal resection, and in patients with CF or with coeliac disease showed that the percentage of primary BA followed closely the total amount excreted except in situations where antibiotics were administered. The exact mechanism for the increased loss of BA in CF is unknown. It is found in all age groups and is related to the presence and degree of pancreatic insufficiency. The possibility that unhydrolysed triglycerides may interfere with the intestinal absorption of bile acid needs further confirmation.

A method of in vivo calculation of liver volume using a gamma camera and a 1600 or 4096 channel analyser is described. Topographically, the maximum thickness giving the highest counts in matrix data in the right anterior oblique projection is measured as the maximum breadth in the right posterior oblique projection. Then the total counts given by the liver can be transformed to the volume. The necropsy criteria indicated that the errors were between --11-9 +/- 14-7% in 13 cases by the use of 198Au-colloid. In 20 selected normal control subjects, the mean of measured liver volumes was 779 +/- 99 cm3/m2 of surface area. The volumetric calculation using 99mTc-Sn-colloid or 99mTc-phytate was compared with 198Au-colloid in the same patients. The results with 99mTc-Sn-colloid were well correlated with those with 198Au-colloid, but the results with 99mTc-phytate and 198Au-colloid were almost equal. It was concluded that, excluding rare severe cases of liver cirrhosis, liver volume can be measured with reasonable accuracy.

Administration of pentagastrin in depot form to 20 pregnant bitches produced pyloric hypertrophy in about 28% and gastroduodenal ulceration in about 16% of their pups. The two lesions were not necessarily found in the same individuals. Histological appearances of the pylorus in affected pups closely resembled those of human infantile pyloric stenosis.

By continuous monitoring of a solid meal labelled with a radiopharmaceutical it has been possible to determine the effects of drugs on gastric emptying and motility during a single study. Predictably hyoscine delayed, and bethanechol increased, the rate of gastric emptying. Pentagastrin initially produced marked antral activity resulting in a physiological stricture and subsequent delay in the overall rate of gastric emptying. Fundal motility was unaffected though reflux from the antrum occurred.

Using a double-lumen tube jejunal perfusion system in vivo, the mutual effects of carnosine (beta-alanyl-L-histidine) and glycylglycine on their respective absorption rates have been studied in six Zambian African adults. Data on the effect of the constituent amino-acids of carnosine on glycylglycine absorption rate have similarly been obtained. The solutions infused in each subject contained (A) carnosine (50 mmol l.-1), (B) carnosine (50 mmol l.-1) and glycylglycine (50 mmol l.-1), (C) glycylglycine (50 mmol l.-1), and (D) glycylglycine (50 mmol l.-1), L-histidine (50 mmol l.-1) and beta-alanine (50 mmol l.-1). Glycylglycine produced a significant impairment in the mean rate of histidine absorption from carnosine (P less than 0-01). However, carnosine did not have a significant effect on the mean rate of glycine absorption from glycylglycine. Mean rate of histidine absorption from solution D was significantly higher than that from solution A (P less than 0-01). Mean rate of glycine absorption from glycylglycine was not significantly different during infusion of solutions B, C, and D. The results are consistent with the concept that carnosine on glycylglycine is probably because the affinity of mechanism; the lack of influence of carnosine on glycylglycine is probably because the affinity of carnosine for the dipeptide uptake mechanism is relatively low. A gross difference has been shown between mean absorption rate of histidine from free L-histidine (solution D) (25-8 mmol h-1) and when it is given in the form of carnosine in the presence of another dipeptide (solution B) (8-7 mmol h-1); that emphasizes the complexity of amino acid and peptide interaction during absorption, which must be important in nutrition.

An absorption screen was performed in 10 chronic alcoholic patients within a few days of admission due to an acute alcoholic episode. Impaired absorption of d-Xylose was noted in three patients and low leucocyte ascorbic acid and serum folate levels in five. No abnormality was detected in jejunal histology. The absorption of water and electrolytes from the jejunum was studied in these patients using a triple-lumen tube perfusion system. The mean rate of absorption of water in the alcoholic subjects (50-0 +/- 2-3 ml/h) was significantly lower (P less than 0-001) than the mean value in 14 healthy control subjects (205 +/- 15-9 ml/h). A significant reduction of Na+ and Cl-absorption was also demonstrated in the alcoholic subjects. These results indicate that patients with acute-on-chronic alcoholism may have a function impairment of water and electrolyte absorption from the jejunum. This may, in part, account for some of the nutritional deficiencies in such patients and for symptoms such as diarrhoea which may be present.

The treatment with streptozotocin of a patient with metastatic gastrinoma is described. Two courses of intravenous streptozotocin were without effect. However, three months after two doses of 4 g streptozotocin were given into the coeliac axis, there was a marked reduction in hepatic size and a fall in fasting plasma gastrin levels from 1430 pmol/l to 240 pmol/l. Seven months after treatment fasting plasma gastrin levels were 125 pmol/l.

This review set out to answer several questions related to tumour immunology and the gut. It is evident that in patients with gastrointestinal cancer there is a general depression of the immune response and this seems to be correlated with the stage of the disease. Paradoxically a specific immune response against definable tumour antigens can be demonstrated, both cellular and humoral mechanisms being involved although the complexities of this paradox require further analysis. Immunotherapy has been employed in gastrointestinal tumours in a sporadic way. The results suggest that gastrointestinal neoplasms may respond at least as well as other tumours. A firm conclusion awaits the results of controlled trials in which the bulk of the tumour has been effectively dealt with by other means or where combined immunochemotherapy is being used.