Twenty patients with bronchial asthma who also had gastro-oesophageal reflux were investigated. The severity of their reflux was graded using symptom score of heartburn and regurgitation and by the following investigations: barium swallow and meal, fibreoptic endoscopy and biopsy, manometry and pH monitoring of the distal oesophagus, and an acid infusion test. Full lung function studies were performed and patients were entered into a double-blind crossover study using cimetidine to control their reflux in order to assess beneficial effects with respect to their respiratory problems. Eighteen patients completed the study. Significant improvements were seen in reflux and night time asthmatic symptoms, both these indices being measured on a scoring system. Home monitoring of peak flow values showed a statistical improvement for the last peak flow reading of the day. Fourteen patients felt that their chest symptoms had significantly improved during the cimetidine period.Gastro-oesophageal reflux commonly produces symptoms in subjects of all ages. The dominant complaints are usually related to the upper gastrointestinal tract and include heartburn, regurgitation, and occasionally dysphagia. Patients with re'lux are also liable to respiratory complications leading to severe, progressive, and disabling pulmonary damage.' More recently attention has been drawn to an association between reflux and exacerbations of bronchial asthma,23 and there have been several studies suggesting subjective improvement in such patients after surgical correction of hiatus hernia. [3][4][5] In this study we have attempted to demonstrate a measurable improvement in symptoms and respiratory function in a group of asthmatic patients, who also had well-documented reflux, by controlling their reflux with cimetidine in a double-blind, crossover trial. MethodsInformed consent for study was obtained from 20 patients, 13 men and seven women, whose ages ranged from 30-65 years (mean 54 years). All patients had bronchial asthma and were attending

Expectant treatment can be recommended in this group of patients. Those who do present with further biliary symptoms do so soon after ERCP. Therefore, we recommend follow-up for 12 months after ERCP, prior to discharge.

SUMMARYThe changes produced by the Nissen fundoplication were measured in 12 patients, who required surgery to control their reflux oesophagitis. The gastro-oesophageal junction of each patient was studied before and three months after operation by station pullthrough manometry and prolonged pH monitoring of the distal oesophagus. All patients were free from reflux symptoms post-operatively. The Nissen fundoplication resulted in a significant increase in the pressure, but not the length, of the lower oesophageal high pressure zone. A greater proportion of this zone was situated in the abdomen postoperatively. Prolonged pH monitoring showed a significant improvement in all the measured indices of acid reflux. Nissen fundoplication restores competence to the gastro-oesophageal junction as judged by manometry and pH monitoring. This kind of study should be performed to document the efficiency of other anti-reflux procedures.Although the precise nature of the mechanism which prevents abnormal reflux of gastric contents into the lower oesophagus is not clearly defined and may be dependent upon more than one factor,l 23 it is now well recognised that failure of this mechanism may occur independently of the anatomical abnormality of a sliding hiatal hernia.45 Consequent upon this understanding of the pathophysiology of gastro-oesophageal reflux has come the reappraisal of the aim of surgery in the treatment of those patients whose symptoms and oesophagitis are unresponsive to conservative therapy.When the cause of the symptoms of heartburn and regurgitation were correctly attributed to gastrooesophageal reflux," it was assumed that this reflux was made possible by the presence of a sliding hiatal hernia. It was further assumed that, if this hernia were repaired according to the general principles of hernia repair, then the abnormal reflux would be prevented and the patient cured. Unfortunately, anatomical repair of the hiatus frequently did not prevent further reflux, however meticulously the operation was carried out and by whatever method it was performed.7 8

The results are presented of two studies of the station pullthrough technique for lower oesophageal manometry. The first part of the work is an assessment of the reproducibility of this technique using both an infused tube system and a system of subminiature, intraluminal strain gauge transducers. The second part of this report describes a study into the effect that the position of the recording hole on the probe may have in relation to the measured pressure for the lower oesophageal sphincter.

This study of 73 patients with the clinical diagnosis of thromboembolism has shown that the pulse rate, respiratory rate, and arterial partial pressure of carbon dioxide have discriminatory value in identifying the group of acutely ill patients who are most likely to have pulmonary embolism. In contrast, the clinical diagnosis of deep venous thrombosis, PaO2 chest radiography and electrocardiography which are all essential to patient management have no such value. In this series, only 29% of the patients had a pulmonary arteriogram positive for thromboembolism, but the mortality rate in this group was 33%. Pulmonary perfusion scanning has been shown to be a useful and accurate screening investigation and should be routinely employed prior to pulmonary angiography if the patient is stable hemodynamically.