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SUMMARY We report a series of 10 elderly patients with large bile duct calculi refractory to standard endoscopic extraction techniques who were treated by gall stone dissolution using methyl tertiary butyl ether (MTBE) instilled through a nasobiliary catheter. In eight patients complete bile duct clearance was achieved after an average of eight hours MTBE instillation. In two patients gall stone size did not change. Both underwent operative gall stone removal and subsequent stone analysis showed low cholesterol content, which is unlikely to respond to MTBE. Apart from occasional transient nausea and drowsiness, no adverse reactions were noted. Methyl tertiary butyl ether appears to be a powerful in vivo gall stone dissolution agent which, from preliminary studies, is not associated with serious toxicity.Endoscopic sphincterotomy (ES) has revolutionised the management of gall stones in the extrahepatic bile duct. The present success rate of bile duct stone clearance using endoscopic techniques based on ES varies from 77% to 90%.1-3 The most common reason for failure to achieve bile duct clearance is related to stone size and is encountered when large calculi cannot be delivered through a complete sphincterotomy. Mechanical and ultrasound lithotripsy have not yet been fully developed for use in the bile duct4 and therefore in most centres surgery is the only treatment option remaining after failed endoscopic stone extraction. Choledochotomy in the elderly, however, may carry a high morbidity and mortality,5 a fact which may well have been the main reason for referring a patient for endoscopic management in the first place. In addition, surgical bile duct exploration does not always result in complete clearance of gall stones.2Gall stone dissolution has been considered a potential solution to this problem but despite nearly 100 years of research neither the ideal chemical nor delivery route has been found. Many of the dis-

Thirteen cases of ascites following the insertion of a ventriculo-peritonea1 (VP) shunt have been reviewed recently'. We report a case in which ascites was treated successfully by a Hakim-Cordis shunt used in series with the pre-existing VP drainage system. Ascites in our patient was probably due to 'sclerosing' peritonitis. Case reportA 26-year-old woman first presented in 1972 with raised intracranial pressure. A right temporal fibrillary astrocytoma was surgically removed and the area was then irradiated. A VP shunt was inserted three years later because of recurring episodes of raised intracranial pressure.In 1981 she complained of increasing anorexia, weight loss and intermittent abdominal pain and distension. Radiological studies suggested a narrowed area in the ileum. Crohn's disease was considered, but steroids had no effect on the patient's deteriorating clinical condition. In addition, ascites was now clinically elicited. At laparotomy, the abdominal viscera were normal. Intestinal biopsies failed to confirm Crohn's disease. The ascitic fluid was of an exudative nature (protein 43 g/litre versus serum protein 76 @re) and cultures including those for tuberculosis were negative.The patient, although reasonably well, had refractory ascites which required paracentesis every 3 4 weeks, yielding 1.5-3.5 litres on each occasion. In 1983 she started complaining of abdominal pain. Table I illustrates her haemotological and biochemical findings. Radiological studies of the entire gastrointestinal tract were unremarkable. Liver ultrasound and biopsy were normal. Laparoscopy showed generalized thickening and granularity of the visceral and parietal peritoneum.Ascitic fluid cytology showed large numbers of white cells which were predominantly neutrophils; there were also large macrophages with vacuolated cytoplasm. No malignant cells were seen.Histology of the peritoneal biopsies showed a non-specific inflammatory reaction containing a fibrous exudate and eosinophils. Areas of black pigmented material with doubly refractible particles were present but no foreign body giant cells were evident.One of the real difficulties in management was the necessity to relieve discomfort by repeated paracentesis. We therefore employed a Hakim-Cordis (peritoneo-venous) shunt in series with the pre-existing VP shunt. The procedure resulted in a rapid disappearance of the ascites. The patient remained asymptomatic for 14 months when infection of her ventriculo-peritonea1 shunt with Staphylococcus albus necessitated replacing both systems with a ventriculo-caval one. At the last review, the patient remains well. DiscussionIn the presence of a V P shunt, the peritoneal cavity plays a predominant role in CSF absorption. Absorption of water and Several factors, such as repeated abdominal operations3 and certain CSF secreting brain tumours4 have been implicated in the development of CSF ascites. Neither of these mechanisms were operative in our patient.The very high ascitic .protein levels (40 g/litre) make it unlikely that the ascitic fl...

A case of familial polyposis coli in association with hepatocellular and gastric carcinoma is reported. No similar case has ever been documented in the world literature. This may be surprising as it is well known that familial polyposis has a potent oncogenicity not only in the colon but also in extracolonic organs.