Objective To compare the efficacy of non-invasive testing for Helicobacter pylori with that of endoscopy (plus H pylori testing) in the management of patients referred for endoscopic investigation of upper gastrointestinal symptoms. Design Randomised controlled trial with follow up at 12 months. Setting Hospital gastroenterology unit. Participants 708 patients aged under 55 referred for endoscopic investigation of dyspepsia, randomised to non-invasive breath test for H pylori or endoscopy plus H pylori testing. Main outcome measure Glasgow dyspepsia severity score at one year. Use of medical resources, patient oriented outcomes, and safety were also assessed. Results In 586 patients followed up at 12 months the mean change in dyspepsia score was 4.8 in the non-invasive H pylori test group and 4.6 in the endoscopy group (95% confidence interval for difference -0.7 to 0.5, P=0.69). Only 8.2% of patients followed up who were randomised to breath test alone were referred for subsequent endoscopy. The use of non-endoscopic resources was similar in the two groups. Reassurance value, concern about missed pathology, overall patient satisfaction, and quality of life were similar in the two groups. The patients found the non-invasive breath test procedure less uncomfortable and distressing than endoscopy with or without sedation. No potentially serious pathology requiring treatment other than eradication of H pylori was missed.

Three patients were treated after they had deliberately ingested domestic agents containing formic acid. The major complications included the local effects on the oropharynx, oesophagus and stomach, metabolic acidosis, derangement of clotting mechanisms with haemorrhage and shock, widespread intravascular haemolysis, disseminated intravascular coagulation and the acute onset of respiratory and renal failure. All 3 patients died between 2 and 14 days after admission. It is the authors’ belief that intensive therapy from the outset to include exchange transfusion, infusion of clotting factors, high dose steroids, ventilatory support and peritoneal or haemodialysis with parenteral nutrition may perhaps offer a better chance for survival.

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Pica is the compulsive eating of non-food substances over a sustained period of time. It remains an intriguing, little understood occurrence, with a potential for both positive and negative outcomes. In this review information is given on the history of the phenomenon, its prevalence among children and women, and its relation to iron and zinc deficiency. A number of examples of pica practice are reported from Africa.