Summary:Four cases of acute proctocolitis associated with non-steroidal anti-inflammatory drug therapy are presented. The drugs implicated were flufenamic acid, mefenamic acid, naproxen and ibuprofen. After resolution of symptoms and signs of proctocolitis three of the four patients were subsequently rechallenged with the implicated drug: in each there was a rapid relapse.

BwR 25MEDICAL JOURNAL abnormal in 8 out of 13 patients. However, the bromsulphthalein excretion and the percentage of esterified serum cholesterol were normal. Since these two tests are more specific, the possibility of misinterpretation of deranged protein metabolism as evidence of liver disease rather than as an integral feature of systemic scleroderma needs no emphasis.The hepatic fibrosis observed at operation in our first patient defies ready explanation, since there was no evidence of malnutrition, previous hepatic or biliary disease, generalized passive venous congestion, small intestinal defect, or ulcerative colitis. Though not subject to proof, it may be a direct manifestation of the viscero-sclerodermatous process. Massimo (1954) Eventual hepatic fibrosis is a recognized sequel to congestive hepatomegaly from cardiac and pulmonary scleroderma and might also be expected to occur in some patients with sclerodermatous haemorrhagic colitis, especially if there were concomitant steatorrhoea as exemplified in our second patient. Her " silver stool " was regarded as a product of these abnormalities. It is, however, equally admitted that the hepatic fibrosis and its complications in our two patients might be independent of the sclerodermatous process.Finally, we suggest that the possibility of the presence of oesophageal varices, as witnessed in both our patients, should be entertained during the standard radiological studies of visceral scleroderma. SummaryTwo illustrative cases, both in women, of scleroderma and hepatic fibrosis are fully reported. In each patient the salient feature was portal hypertension, including oesophageal varices, which led to recurrent haematemesis, an aspect apparently not previously described.The first patient survived a palliative subcardiac portoazygos disconnexion and remained well five years later, with no subsequent haematemesis. The second patient, whose illness was further complicated by a combination of sclerodermatous haemorrhagic colitisandsteatorrhoea to produce the " silver stool " sign, was treated conservatively for repetitive haematemesis. After prolonged invalidism she died in coma, as a result of haemorrhage from an oesophageal varix, some 20 months after her first haematemesis.The scant literature on hepatic fibrosis in systemic scleroderma is reviewed and the causation of such hepatic lesions is briefly discussed in relation to the observations on our two patients.Our thanks are due to Mr. N. C. Tanner for permission ts refer to the operative details in Case 1; to Mr. K. Moore for similar authority in relation to Case

Secondary neoplastic involvement of the heart is not infrequent in routine necropsies of patients dying of malignant disease but cardiac failure as a presenting feature remains uncommon, the cause of the failure often not being diagnosed till necropsy. The importance of its recognition during life, particularly in patients suffering from the reticuloses, is that the failure may benefit from radiotherapy, whereas treatment on conventional lines is often disappointing. The following case is of interest, in that cardiac failure and a lump in the abdomen were the two presenting features, and after three weeks of intractable failure, sudden death occurred from rupture of the heart.A woman of seventy-six was admitted to Putney Hospital in congestive failure. Her story was that she had complained to her doctor of abdominal discomfort and constipation, and a lump was felt in the left iliac fossa. Further questioning revealed, however, that she had been short of breath for two to three months, with swelling of the ankles and abdomen for ten days, and orthopnoea for five days. There was no paroxysmal nocturnal dyspnoea, but cough had been present for some weeks. On examination, she was orthopnoeic with a tinge of cyanosis in the lips and showed uncontrolled auricular fibrillation and signs of congestive heart failure, with a small left pleural effusion. The heart was grossly enlarged, the apex beat being in the anterior axillary line, the impulse weak. There was a presystolic gallop rhythm at the apex and a soft blowing diastolic murmur of aortic incompetence to the left of the sternum. In the abdomen, there was a smooth rounded swelling in the left iliac fossa which from rectal and bimanual examination appeared to be situated in the uterus. The bowels were constipated but flatus passed normally, the urine contained a trace of albumen. Chest X-ray confirmed considerable enlargement of the heart with widening of the mediaastinum, a left plural effusion, and possibly a small pericardial effusion. The electrocardiogram showed normal voltage with a digitalis effect. After a period of slow progress with digitalis and neptal, she died suddenly twenty-three days after admission, having conversed normally five minutes before death.Necropsy by one of us (V.T.) showed the body of a well-covered elderly woman with cedema of the legs and sacrum. The heart was grossly enlarged with extensive involvement by growth of all coats, as shown in Fig. 1 and 2. The pericardium contained a fair quantity of recent blood and there was a small tear through the myocardium, 1 cm. below and lateral to the left posterior aortic cusp. The pericardium was thickened by growth and adherent in places and the myocardium considerably replaced by similar tumours which in parts extended on to the endocardial surface as can be seen in the figure. This feature was particularly marked in the right atrium and there were also small nodular masses on the endocardial surface of the ventricles below the attachment of the atrio-ventricular valves. Histologically, the m...

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