SUMMARY When rectal biopsies from 65 patients with ulcerative colitis and 20 patients with Crohn's disease were stained for mucins, an abnormal pattern (excess of sialomucins) was seen in about half of them. This is in contrast with 65 cases of non-specific proctitis where the mucin pattern of rectal biopsies was normal in all except one case. The abnormal mucin secretion in patients with ulcerative colitis was apparently related to the activity, duration, and extent of the disease. All biopsies with dysplasia showed predominant sialomucin staining except one. All biopsies showing sialomucins during remission also had dysplasia, while during active disease a number of biopsies had increased sialomucins without the evidence of dysplasia. It is not known if such cases will subsequently develop morphological atypia.Alterations in the composition of mucous secretion have been described in the gastrointestinal tract in association with malignancy.16 In the colon these changes are characterised by an increased proportion of sialomucins in contrast with normal biopsies where sulphomucins predominate. The findings of these abnormal mucin patterns in solitary ulcer syndrome,7 however, raised the question whether such changes were non-specific and simply related to inflammation.We, therefore, decided to study mucous secretion patterns of other inflammatory bowel diseases. We were particularly interested to see if alteration in mucin composition was related to the histological severity, extent, and duration of the inflammation or the presence of dysplasia and whether such changes can be used to distinguish ulcerative colitis, Crohn's disease, and non-specific proctitis. Methods PATIENTSA total of 240 rectal biopsies were examined from 65 cases of ulcerative colitis, 20 of definite colonic Crohn's disease, and 65 of non-specified proctitis collected over a four-year period . Cases of ulcerative colitis complicated with carcinoma or

SUMMARY Over a four-year period 21 cases of solitary ulcer syndrome (SUS) were studied for their clinical, histological, and mucus secretion patterns and compared with histological and mucus secretion patterns of 78 cases of non-specific proctitis collected over the same period. Normal mucus composition was found in non-specific proctitis while abnormalities of mucins with predominance of sialomucins were associated with SUS. Although histology remains the most important investigation in the diagnosis of SUS, mucin changes provide valuable additional evidence.Solitary ulcer syndrome (SUS) and non-specific proctitis both present with symptoms which are common to most anorectal diseases.'-3 The sigmoidoscopic appearance and particularly the histological features of the rectal mucosa are used to differentiate these two conditions. We investigated the mucin-staining patterns in the rectal biopsies of patients with these diseases to see if this provided useful additional information. Patients and methodsThe clinical features were studied closely and the histology of the rectal mucosa and the mucin secretion patterns were compared, in 78 patients with non-specific proctitis and 21 cases of SUS, seen over a four-year period (1975-9 either an ulcer without other evidence of inflammation or a localised area of hyperaemia with abnormal perineal descent or prolapse of the rectal mucosa.All rectal biopsies were routinely fixed in 10% formol saline and paraffin sections were stained with haematoxylin and eosin and van Gieson's stain. To assess the amount and types of mucins the following techniques were used: periodic acid-Schiff (PAS)4 and high iron-diamine-alcian blue (HID-AB)5 which distinguish between neutral, sulpho-and sialomucins. The histological criteria for SUS' were based on the presence of mucosal ulceration, increased fibroblasts in the lamina propria with minimal inflammation and thickened muscularis mucosae with tendency of individual fibres to point toward the lumen. Distorted crypts, hyperplasia and mucus depletion were seen in some cases.

Background: Results of 24-hour Holter monitoring in elderly patients are often unhelpful, since the prevalence of asymptomatic arrhythmias increases and their prognostic significance is unclear. We investigated the value of the resting electrocardiogram (ECG) in predicting significant findings on 24-hour Holter recordings in those suspected of having cardiac syncope. Objective: To see whether the resting 12-lead ECG can be used as a screening tool to select elderly patients suspected of having cardiac syncope for 24-hour ECG monitoring. Method: Comparison of resting 12-lead ECGs and 24-hour Holter tapes in 145 consecutive elderly outpatients suspected of having a cardiac cause for falls, dizziness, or syncope. Results: Four of 30 normal ECGs (13%) showed an abnormality on Holter monitoring as compared with 55 of the 115 abnormal ECGs (47.8%; chi = 11.7143, p < 0.005). In the ‘normal’ group the 4 abnormal Holter recordings all showed short runs of supraventricular tachycardia, and no intervention resulted. The 115 abnormal resting ECGs showed either ischaemia (n = 27), dysrhythmia (n = 28), sinus bradycardia (n = 22), or conduction defects (n = 38). The 55 of these which showed abnormalities on Holter recordings occurred mostly where the resting ECG showed dysrhythmia (n = 14/28; 50%), bradycardia (n = 19/22; 86.4%), and conduction defect (n = 17/38; 44.7%). Seven patients had complete heart block on Holter, and all had conduction defects on resting ECG (p < 0.0004). Fifteen patients had pauses of longer than 3 s on Holter; all had conduction defect, bradycardia, or dysrhythmias on resting ECG (p < 0.0045). Sixteen patients were paced because of complete heart block or pauses on Holter recordings, and all had either bradycardia or conduction defects on resting ECG, resulting in complete resolution of their symptoms. Conclusions: Patients with suspected cardiac syncope and normal resting ECGs are unlikely to reveal significant abnormalities on single 24-hour Holter monitoring. Cardiac event recorder or prolonged Holter monitoring may be required in patients with strong clinical history. Those with abnormal ECGs, in particular sinus bradycardia and conduction defects, are highly likely to have significant abnormalities on 24-hour ECG monitoring.

The clinical notes and histology of 374 patients treated by colectomy and ileo-rectal anastomosis for ulcerative colitis were reviewed. Only those with definite diagnosis of ulcerative colitis and follow-up rectal biopsies were included (171 cases). Morphology and patterns of mucin secretion were investigated to assess whether abnormal mucin with predominance of sialomucins is a useful indicator of malignancy-risk. Carcinoma has developed in six patients and 'precancer' in seven. The results show coexistence of dysplasia and sialomucin even in the absence of inflammation in all but three biopsies; in contrast the presence of both dysplasia and normal mucin profile was found in less than 1%. A significant correlation was noted between an inflamed mucosa and the development of cancer or precancer, the presence of sialomucins and the appearance of dysplasia. Sialomucins showed a greater sensitivity in detecting cancer than dysplasia (75% versus 30%). However, dysplasia was notably more specific (94% compared with 50%), hence its greater predictive value as indicator of malignancy (50% as against 15% for a positive sialomucin result). Mucin stains on routine fixed paraffin-embedded tissue provide a simple screening method to sharpen the assessment of dysplasia and cancer-risk in patients with ulcerative colitis despite the limitations referred to above. The lack of definite evidence of dysplasia in four patients who developed malignancy without premalignant changes in the rectal biopsies emphasises the need for frequent multiple biopsies in patients with an ileo-rectal anastomosis for ulcerative colitis.

The present study concerns eight patients with ulcerative colitis treated by total colectomy and ileorectal anastomosis and subjected to follow-up rectal biopsies who later developed precancer (two cases) or carcinoma in the retained rectum. We report the results of the biopsies and the detailed mapping of lesions in the resected rectal stump to highlight certain features which may lead to increased detection rate of early malignancy. Two groups of patients emerged. Group A: in all four cases the follow-up biopsies showed increasing severity of dysplasia; altered mucin secretion with predominance of sialomucins was seen in the biopsies even in the absence of inflammation or dysplasia; the biopsy findings (morphological and secretory) mirrored those observed in the rectal stump; in three, the lesions were villous polypoid growths, of which two were invasive carcinomas. Group B: in none of the cases was dysplasia seen in the biopsies and mucus secretion was normal; similar features were seen in the rectal stump; all had invasive carcinoma of which three were flat ulcerated lesions. The different behaviour of carcinoma in the two groups almost certainly reflects the different tumour phenotype characteristics and this is a matter for further study. From the practical point of view we emphasize the risk of relying on biopsy evidence of dysplasia alone as an indicator of malignancy and the need for additional immunological or histochemical tests to assess the individual risk of cancer in colitis.