Alcohol (ethanol) is a drug, and health professionals should know something of its physiological and pathological effects and its handling by the body. It is a small, water soluble molecule that is relatively slowly absorbed from the stomach, more rapidly absorbed from the small intestine, and freely distributed throughout the body. Alcoholic drinks are a major source of energy-for example, six pints of beer contain about 500 kcal and half a litre of whisky contains 1650 kcal. The daily energy requirement for a moderately active man is 3000 kcal and for a woman 2200 kcal.

had developed a duodenal ulcer, one a gastric ulcer, one a combined duodenal and gastric ulcer, and one was found to have radiological evidence of achalasia of the cardia. These patients were referred for surgical treatment, with excellent results in all except the patient with achalasia. Of the four remaining patients, further radiological investigation had shown renal disease in -two, but with no evidence of gastrointestinal disease, and two were again found to have no abnormality.When the radiological diagnosis for the 1964 barium-meal study was compared with the follow-up diagnosis six years later it changed in eight cases. Six, as indicated above, developed upper gastointestinal lesions, and two were found to have renal disease. None of these patients experienced gastrointestinal haemorrhage or perforation during the period of follow-up. Six had died, but in none was the recorded cause of death attributable to a lesion in the upper gastrointestinal tract. DiscussionAn increasing number of patients with dyspepsia are referred for radiological investigations by their general practitioners because a peptic ulcer is suspected. In this series few (3 5%) of those patients with a normal finding on barium-meal examination in 1964 were later found to have a peptic ulcer. Most showed appreciable symptomatic improvement, 65 (76%) claiming to have little or no dyspepsia when questioned in 1970. Fifteen patients claimed there had been no change in their symptoms. The five patients shown by the questionnaire to have deteriorated symptomatically were reinvestigated, and in two a positive diagnosis was obtained.Similar groups of patients studied over an extended period have shown a much higher incidence of peptic ulceration in follow-up. In a group of 174 hospital patients who were followed for 27 years, 40 % were shown to have a peptic ulcer at subsequent investigations (Krag, 1965). Brummer and Hakkinen (1959) followed 102 patients over a six-year period and found that 12 had developed a peptic ulcer. Barfred (1959) followed 235 patients over a 10-year period, and 30% developed a peptic ulcer during this time.The lower incidence of peptic ulcer in our study may be related to two factors. Firstly, all of the present patients were referred directly from general practitioners, whereas the reports referred to above all dealt with a hospital population. Secondly, a longer follow-up period would possibly have given a higher incidence of the subsequent development of peptic ulceration. We believe that this would be unlikely as 76% of the present patients were virtually symptomless six years later.If we assume that "x-ray-negative dyspepsia" represents a separate disease entity then its prognosis is more favourable than for peptic ulcer, most patients showing appreciable improvement with time. If further investigations are reserved only for those patients who show a deterioration symptomatically then the burden of repeated reinvestigations both for the radiological services and the patients will be eased, so reducing unnecessa...

SummaryCirculating levels of renin, angiotensin I, and angiotensin II were increased in six patients with chronic renal failure and hypertension uncontrolled by dialysis and hypotensive drugs. Lower and often normal levels were found in 10 patients whose blood pressure was controlled by dialysis treatment. For a variety of reasons all patients were subjected to bilateral nephrectomy. The logarithm of the decrease in plasma concentrations of renin and angiotensin II was significantly related to the fall of blood pressure after operation. Plasma renin concentration correlated significantly with blood angiotensin I concentration and with plasma angiotensin H in samples taken before and after nephrectomy. Renin, angiotensin I, and angiotensin II were measurable in samples ofblood taken 48 hours or more after the operation.

The syndrome of portapulmonary hypertension is well recognised but the cause of the association is obscure. We describe the history of a 24-year-old man who developed this syndrome, and in whom the findings at necropsy included the hitherto unreported association of adenomatous hyperplasia of the liver. Case reportA 24-year-old Indian man died in 1977 after a long illness that began in 1961 (aged 8 years) with a severe gastrointestinal haemorrhage. Laparotomy showed large oesophageal varices that were oversewn. The spleen was enlarged but the liver looked normal. After a further gastrointestinal bleed in 1966 he underwent splenic venography, which showed a small, poorly opacifying portal vein and extensive oesophageal varices. Splenectomy and lienorenal anastomosis were performed. Chest radiography was normal.He remained well until 1972 when he developed pneumonia. Cardiac catheterisation at this time showed a mean pulmonary arterial pressure of 64 mmHg, a mean wedge pressure of 5 mmHg, and a pulmonary vascular resistance of 826 dyne s cm-5. Pulmonary angiography showed aneurysmal dilatation of the pulmonary trunk and pruning of the peripheral vessels but no sign of thromboembolism. Hepatic wedge pressure was 3 mmHg. Results of spirometry, liver function tests, and a liver biopsy were normal. He was treated with anticoagulants but his exercise tolerance gradually decreased, and in 1976 he developed signs of right heart failure from which he died in July 1977. PATHOLOGICAL FINDINGSPost-mortem examination showed gross right ventricular and right atrial hypertrophy. Total heart weight was 502 g, right ventricle 290 g, left ventricle and septum 121 g (ratio L: R 0-41), atria 91 g. The cardiac valves were structurally normal, and there were no septal defects. Histological examination of the right ventricular myocardium showed hypertrophy of the muscle fibres with boxlike nuclei. The pulmonary trunk was greatly dilated and showed extensive areas of cystic medial degeneration in which there were small tears, indicative of early dissection. Histologically, the media had a "moth-eaten" appearance with numerous areas where the elastic lamina had been lost, being replaced by acid mucopolysaccharide. There was severe intimal fibrosis.The elastic pulmonary arteries were thick and atheromatous. The muscular pulmonary arteries (those between 100 and 1000 ,um in diameter) were dilated and many were occluded by intimal fibroelastosis of "onion-skin" type. Their media appeared thinned, distended, and infiltrated by intimal fibroelastic tissue. Many branches were extremely thin and dilated, and clustered around parent vessels (fig 1) or in the lung parenchyma. Some branches contained plexiform arrangements of cells which appeared to have arisen either from the intima or in continuity with cellular components of the media. Such appearances constitute

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