Susan E. Clamp

Short-term course and prognosis of Crohn's disease

An analysis is presented of the course and outcome of the initial referred attack in a group of 332 patients with Crohns disease treated at the General Infirmary at Leeds from 1939 to 1968 inclusive. A further 50 cases were excluded on the basis of insufficient diagnostic evidence: usually such patients had acute terminal ileitis. Only 5% of patients achieved full remission on conservative management, and most eventually came to surgery. The overall fatality rate was some 3·3% and this was affected chiefly by the severity of attack and the age of the patient. The severity of attack was classified as mild, moderate, or severe according to a system which took into account factors such as bowel habit, rectal bleeding, abdominal pain, pulse rate, temperature, haemoglobin, and weight. In attacks graded as `mild, no deaths occurred; in those graded `severe the fatality rate was 8·8%. Similarly, whilst no patient under 20 years of age died, the fatality rate in the over 60s was some 14·8%. Further comparison between the present group of 332 patients and an earlier series of 204 patients suffering from ulcerative colitis (Watts, de Dombal, Watkinson, and Goligher, 1966a) shows considerable differences in the course and prognosis of the two diseases. In particular 70% of patients with ulcerative colitis achieved remission on conservative management alone whereas only 5% of Crohns disease patients did so. These differences, and in particular the poor response to conservative therapy, are discussed, together with their implications for management.

Ocular disorders in a series of 332 patients with Crohn's disease.

Ocular disorders arising in association with Crohns disease are apparently something of a rarity, since there is very little reference in the literature to such a combination of complaints. This is something of a paradox, since it was Crohn (I925) who described the simultaneous occurrence of corneal inflammatory disorders, conjunctivitis, and uveitis in two patients suffering from ulcerative colitis. Since that time, a few reports have noted that such a combination of eye and bowel disorders may exist in respect of Crohns disease (Korelitz and Coles, I967; Lennard-Jones, I968; Macoul, 1970; Truelove, 197I; Sherman, Swanson, Fleisher, Woolley, and Weitzman, I972; Evans and Eustace, 1973), but these have chiefly consisted of reports of isolated cases, and there has been little in the way of systematic investigation of the two conditions. The present paper describes in detail a series of eye lesions which were found amongst a group of 332 patients suffering from Crohns disease. An analysis is presented of the types of eye lesion found and an attempt is made to assess the development of ocular complaints in relation to the clinical course of the inflammatory bowel disease.

The British Society of Gastroenterology early gastric cancer/dysplasia survey: an interim report.

This presentation describes interim findings in a series of 319 patients referred from 41 hospitals on the basis of histopathological findings of early gastric cancer, dysplasia, or worrying mucosal appearances. Data were recorded using a predefined proforma, and histopathological material circulated amongst a panel of three further pathologists. After this process, 132 patients were classified as having early gastric cancer and 63 as dysplasia. There was good agreement between pathologists as to whether the cases had cancer or dysplasia - but 39 cases said by referring pathologists to have early gastric cancer were classified by the panel as having more extensive disease. Most early gastric cancer cases were diagnosed only after histopathological examination. Cancer or possible cancer was only mentioned after 36% of the radiological investigations and 40.5% of the endoscopies. Computer aided analysis of the patients symptoms placed 91.3% of the early gastric cancer cases into a high risk group - but was unable to distinguish between early gastric cancer and dysplasia. The five year survival rate of the cases agreed to be early gastric cancer by the panel was well over 90%, but the four year survival rate of cases registered as early gastric cancer but said by the panel to have more advanced disease was under 75%. These findings may account for some of the differences between series, and emphasise the need for precise, widely agreed criteria for the diagnosis of early gastric cancer and gastric dysplasia.

Geographical Variation in Disease Presentation Does it Constitute a Problem and Can Information Science Help

This paper assesses the extent and importance of geographical variation in disease presentation in relation to automated systems for clinical decision making. Reference is made to studies carried out by the World Organization of Gastroenterology involving 1,500 patients with inflammatory bowel disease, 6,000 patients with acute abdominal pain, and 1,300 patients with upper GI bleeding. These studies indicate that geographical variation in disease presentation (both regarding prior probability of disease and conditional probability of symptoms in each disease) is so great as to constitute a considerable potential threat to the widespread introduction of any automated decision-making system. It is suggested that there is an urgent need for the creation of large-scale multinational case series where diseases and symptoms are adequately and reproducibly defined in advance. Reference to studies previously mentioned is used to adduce evidence of the benefits of such large-scale data bases.

Diagnosis of inflammatory bowel disease: an international multicentre scoring system.

Inflammatory bowel disease is being studied by the World Organisation of Gastroenterology (OMGE) Research Committee in a survey (currently) affecting 1696 patients presenting to 30 hospitals in 16 countries. A computer-aided diagnostic prediction system (when tested in 1056 patients) showed an accuracy of match between computer prediction and clinical diagnosis in 94% of these patients. Most centres, however, do not possess appropriate computing facilities. A simple diagnostic scoring system, based on likelihood ratios, has therefore been developed, using a series of numbers set out on a single sheet of paper. The overall accuracy of the simple scoring system in the same 1056 patients was equivalent (93%) to the computer-aided system. In a further series of 510 new patients from eight fresh centres the diagnostic scoring system made a firm prediction in 490 cases (96%). Where made, the accuracy of match between the scoring system prediction and clinical diagnosis was 96%. It is suggested that this simple system, which requires no analytical resource and could be used by any gastroenterologist, might be of some value in clinical research and clinical practice.

Observer variation in assessment of results of surgery for peptic ulceration.

The results of surgery for peptic ulcer may be assessed in many ways. For instance, an assessment may focus on such factors as mortality and morbidity immediately after operation. Early postoperative mortality is, however, low-whatever the operation-and most workers have therefore concentrated on the medium and long-term results of surgery and have dealt with the presence or absence of symptoms attributable to recurrent ulceration or the operative procedure itself, together with the severity of these symptoms. The patients overall status has usually also been graded, the most popular grading system being that devised by Visick.1 As little has been done to assess the reproducibility of these methods of assessment we carried out observer variation studies in a series of 170 patients seen at gastric follow-up clinics in York. We report here our findings.

Computer-Aided Diagnosis of Lower Gastrointestinal Tract Disorders

This paper reports a survey of human and computer-aided diagnosis in a prospective consecutive series of 301 patients admitted to the hospital with lower gastrointestinal tract disease. At initial outpatient contact (at which time endoscopy was customarily performed), the clinicians diagnostic accuracy was 64.5%. After biopsy, radiology, and other investigative procedures, the clinicians preoperative diagnostic accuracy rose t0 82.7%. When data from the house surgeons case notes were fed into the computer, its diagnostic prediction proved accurate in 77% of the 301 patients, and when details of the outpatient endoscopy were added to the house surgeons case notes, the computers diagnostic accuracy rose to 84.7%. It is suggested that computer-aided analysis may have a limited part to play in discriminating between the common causes of lower gastrointestinal disorders in routine clinical practice.

Prediction of Individual Patient Prognosis Value of Computer-aided systems

Physicians take both diagnosis and prognosis into account when allocating treatment. How ever, by prognosis physicians usually imply a somewhat vague impression concerning large groups of patients. One possible task for decision support studies is to design and construct systems that accurately predict individual patient prognoses. The authors con structed and tested such systems in three areas of medicine (inflammatory bowel disease, upper gastrointestinal tract hemorrhage, and acute chest pain). In each area, the individual patients symptoms were compared with a computer-held database of information via a Bayesian analysis, prior and conditional probabilities being derived from large-scale real-life surveys. Prospective trials designed to test these predictive systems by reference to test series comprising over 4,000 patients indicate that a firm prognostic prediction can generally be made; where made, the accuracy of prediction is over 90%. Ways in which this type of prediction may be of clinical value are discussed. Key words: chest pain; computers; en doscopy ; hematemesis; inflammatory bowel disease; prognosis. (Med Decis Making 6:18- 22, 1986)

A Comparison of Barium Sulphate Preparations Used for the Double Contrast Barium Meal

Radiologists opinions of the properties of six barium suspensions with their recommended gas-producing agents designed for upper gastrointestinal use were assessed, using a linear analogue scale. Five radiologists independently assessed mucosal coating of stomach and duodenum, areae gastricae, gaseous distension and bubble formation in a total of 258 patient examinations. Preparation 1 (EZHD) was judged to give best overall results, coating stomach and duodenum particularly well. Preparation 2 (X-Opaque) gave good distension and also coated mucosa fairly well, as did preparations 3 and 4 (Medebar XAC and Field 2C). The latter two preparations produced good distension at the expense of bubble formation. Preparations 5 and 6 (Micropaque DC and Baritop G) were judged, by comparison, to have performed poorly as regards mucosal coating. None of the preparations delineated areae gastricae well, even in the presence of good, bubble-free gastric distension.