Mallory-Weiss tears occurring during the course of upper gastrointestinal endoscopy are apparently rare. The present report describes seven cases of iatrogenic gastro-oesophageal tears encountered during 10,000 endoscopic examinations over a period of six years. Five of the seven patients were female and six patients were aged 75 years or older. Six patients had hiatal hernias. The site of the mucosal tear was similar in all patients, extending from a V-shaped breach at the gastro-oesophageal junction inferiorly along the lesser curve for a variable distance of up to 8 cm. Neither retching nor struggling during the procedure contributed to the development of the lesion in any of the patients. One patient suffered from a haematemesis which required transfusion, and in a further patient the tear resulted in a haematemesis and gastric perforation necessitating laparotomy. The study indicates that Mallory-Weiss tears complicating endoscopy occur especially in elderly, female patients with hiatal hernias. The importance of admitting patients with this complication to hospital for overnight observation is recommended in view of the possible development of haemorrhage or perforation.

In a study of 51 male patients with duodenal ulcer, treatment with cimetidine was accompanied by an increase in basal levels of serum testosterone. Treatment with ranitidine, a new histamine H2-receptor antagonist, produced no such effect. It is concluded that cimetidine has antiandrogenic activity in man which is separate from the histamine H2-receptor blocking activity. Sexual dysfunction (Peden et al. 1979a; Wolfe 1979) and lowered sperm counts (Van Thiel et al. 1979) have been reported in man during treatment with cimetidine. Cimetidine has also been shown to exert antiandrogenic effects in animals (Leslie 8c Walker 1977; Winters et al. 1979) but ranitidine, a powerful new histamine H2-receptor antagonist apparently does not (Usadel 1979). We have there¬ fore compared the effects of these two drugs on basal levels of gonadotrophins, prolactin (Prl), tes¬ tosterone and oestradiol-17ß (Oe2) in male patients with duodenal ulcer (DU). Materials and Methods (a) PatientsThree groups were studied.(i) Thirty-three patients (mean age 39.5 years ± 4.5 SEM) with endoscopically proven duodenal ulcer were investigated. Twenty-two patients received cimetidine 1000 mg/day and were studied before and at the end of a 4 week course of treatment. The other 11 patients received cimetidine 800 mg/day in a subsequent double blind therapeutic trial of cimetidine against ranitidine (Peden et al., in press) and were studied before, after 2 weeks and at the end of their 4 week course of treatment.Twenty-eight of these patients achieved ulcer healing and 31 became asymptomatic.(ii) Eighteen patients (mean age 41.3 years ± 3.6 sem) received ranitidine and were studied before, after 2 weeks and at the end of a 4 week course of treatment. Six patients received a dosage of 320 mg/day in the double blind trial mentioned above, while 12 patients received 300 mg/day in a further open evaluation of a twice-daily dosage regime (Peden et al., in press). Sixteen of these patients achieved ulcer healing and all became asymp¬ tomatic.(iii) Nineteen patients who had been treated contin¬ uously with cimetidine 1000 mg/day and 2 patients

During maintenance treatment with nocturnal ranitidine (150 mg) for 1 year, 38% of duodenal ulcers relapsed. Twenty-one patients whose ulcers remained healed after maintenance treatment for 1 year continued to receive ranitidine (150 mg at night) for a further year, while 26 patients with healed ulcers received placebo in a randomized double-blind study. The rate of recurrence of duodenal ulcers during the 2nd year of follow-up study was 18% in ranitidine-treated individuals and 87% in those receiving placebo. The ulcer recurrences of patients receiving ranitidine tended to be asymptomatic and were clinically mild in the rest. Recurrences in patients receiving placebo were usually symptomatic and significantly more likely to be associated with bleeding. We conclude that ulcers that remain healed after 1 year's maintenance treatment with ranitidine tend to remain healed if maintenance treatment is continued. Moreover, this type of continuous treatment of duodenal ulcer is clinically safer than no treatment of the ulcer disease.

No abstract

Thirty-six patients in whom an asymptomatic duodenal ulcer had been detected endoscopically were followed up clinically and endoscopically during the following months. Ten of the patients were receiving either no treatment or placebo, and 26 patients were receiving maintenance treatment with either 150 mg ranitidine or 400 mg cimetidine at night. Treatment remained unchanged during the follow-up period. The cumulative annual rate of spontaneous healing was approximately one quarter, whether or not patients were receiving active maintenance therapy. However, the likelihood of developing symptoms during the year after detection of the asymptomatic ulcer was significantly greater in those patients receiving no treatment or placebo (77%) than in those receiving active maintenance therapy (27%). One patient, receiving no treatment, bled from his ulcer during the follow-up period. We conclude that routine endoscopic reexamination, to detect asymptomatic ulcer recurrences in patients receiving maintenance treatment for duodenal ulceration, is probably unnecessary, since the recurrences rarely cause clinical problems, despite prolonged failure to heal.