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J G Kingham

Publications and source records attributed to J G Kingham.

At least 19 recordsLinked to original sources
PubMed2001

Enteric-release glyceryl trinitrate in active Crohn's disease: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Mucosal ischaemia may contribute to the pathogenesis of Crohn's disease. Microvascular abnormalities have been found in colonic resection specimens, and mucosal levels of constitutive nitric oxide synthase are reduced. AIM: To assess the efficacy of a novel, enteric-release formulation of the nitric oxide donor, glyceryl trinitrate, aimed at increasing the mucosal circulation and relaxing smooth muscle in the affected bowel. METHODS: The trial was randomized, double-blind and placebo-controlled. Baseline disease activity was assessed by a structured symptom diary, with blood tests and a quality of life assessment. Patients with a Crohn's disease activity index of > or = 150 and < 450 were randomized to receive 12 weeks of either glyceryl trinitrate (initially 6 mg twice daily, increasing to 9 mg twice daily after 6 weeks) or an identical placebo. Assessments were repeated at 6 and 12 weeks. RESULTS: Seventy patients (22 male) entered the study; 34 were given glyceryl trinitrate and 36 placebo. At 12 weeks, there were no differences between the treatment groups in terms of Crohn's disease activity index, pain, stool frequency, inflammatory markers or quality of life scores. CONCLUSIONS: Enteric-release glyceryl trinitrate did not benefit patients with mild to moderately active Crohn's disease. Whilst ischaemia may contribute to the pathogenesis of Crohn's disease, our results fail to provide supportive evidence for this hypothesis.

Administration, Oral↗
PubMed2001

Scoring systems and risk assessment for upper gastrointestinal bleeding.

Mortality associated with acute upper gastrointestinal bleeding remains high despite advances in diagnosis and therapy. This was emphasized by the findings of the seminal English National Audit of acute gastrointestinal haemorrhage undertaken by Rockall and associates in the mid-1990s. The apparent lack of progress is largely due to less selective reporting in an ageing population with greater co-morbidity. Thus some deaths will be unavoidable even with exemplary treatment. Managing high risk patients in a dedicated area with close cooperation between medical and surgical gastroenterologists has been shown to improve outcome. The challenge is to select those patients who have most to gain from such a scarce and expensive resource so that their treatment can be optimized. Various risk factors have been identified to help achieve this end. Rockall's national audit data suggest that avoidable deaths remain a problem in most district general hospitals. A simple numerical score was derived from these audit data (Rockall score) to predict rebleeding and mortality. The score is based on five variables: age, shock, co-morbidity, endoscopic diagnosis and stigmata of recent haemorrhage. It has the advantage that pre-endoscopic assessment can be made by inexperienced medical or nursing staff. The system was validated internally in a second audit by Rockall and co-workers, and subsequent external validation has come from New Zealand and the Netherlands. The score is less reliable at predicting rebleeding than death and so is, as yet, an imperfect instrument. The scoring system has also proven valuable in selecting low risk patients for early discharge (resulting in health care economies) and for comparing outcome data from different hospitals or populations. Endoscopic treatment has recently been shown to reduce rebleeding rates and perhaps mortality. These advances in therapy are becoming more widely adopted and may influence the predictive ability of the Rockall score. The study from Edinburgh, in this issue, although small and with wide confidence intervals, supports the ability of the Rockall score to identify high risk cases amongst those given endoscopic treatment. It also suggests that an adjustment of the score may be required in these circumstances to prevent overcalling the risk of rebleeding and death.

Endoscopy, Gastrointestinal↗
PubMed2001

The causes of obvious jaundice in South West Wales: perceptions versus reality.

AIMS: (1) A prospective analysis of clinically obvious jaundice (bilirubin >120 micromol/l) in South Wales to determine accuracy of diagnosis, referral pattern, treatment, and outcome. (2) To compare British gastroenterologists' and local general practitioners' perceptions of common causes of jaundice with our study findings. METHODS: Over a seven month period all patients with bilirubin >120 micromol/l (excluding neonates with physiological jaundice) were identified by a biochemistry laboratory serving three general hospitals and the community. Clinical data were recorded prospectively. Sixty nine consultant gastroenterologists and 67 local general practitioners (GPs) were asked to cite the commonest causes of bilirubin >120 micromol/l in their experience. RESULTS: A total of 121 patients were identified of whom 95 were admitted to hospital because of jaundice, 22 developed jaundice while in hospital, and four remained in the community. Causes of jaundice were: malignancy 42, sepsis/shock 27, cirrhosis 25, gall stones 16, drugs 7, autoimmune hepatitis 2, and viral hepatitis 2. One in five was wrongly diagnosed, often as viral hepatitis. Although 30% were under surgical care only 4% required surgery. Overall mortality was high (31%) and greatest in sepsis/shock (51%). Gastroenterologists and GPs both perceived malignancy and gall stones to be the commonest causes of marked jaundice followed by viral hepatitis and cirrhosis; sepsis/shock was hardly mentioned. CONCLUSIONS: There are important discrepancies between gastroenterologists' and GPs' perceptions of likely causes of jaundice and the actual causes we have shown. In particular, sepsis/shock is common in hospital practice but is overlooked whereas viral hepatitis is rare but perceived as common and overdiagnosed. Gall stones usually cause mild jaundice with bilirubin levels less than 120 micromol/l. Many patients are referred to surgical services for historical reasons yet rarely require surgery and are usually treated by physicians or endoscopists.

Adolescent↗
PubMed1999

A prospective study of the causes of notably raised aspartate aminotransferase of liver origin.

BACKGROUND AND AIMS: To ascertain the causes of raised aspartate aminotransferase (AST) presumed to be of hepatic origin in two hospitals and the local community served by a centralised biochemistry laboratory. METHODS: From June 1996 to February 1997 all patients with AST greater than 400 U/l were identified by the biochemistry laboratory; the patients' clinical records were studied to determine the diagnosis, the clinical outcome, and whether the raised AST and its significance had been noted. RESULTS: A total of 137 patients with a hepatic cause for the raised AST were found. The cause of the raised AST was hepatic ischaemia/hypoxia in 68, pancreatobiliary disease in 33, primary hepatocellular disease in 23, hepatic malignancy in five, and hepatic haematoma in one. In seven patients the diagnosis was unclear. The overall mortality was high (22%) with the highest mortality in the hepatic ischaemia group (37%). The recording and interpretation of the causes of raised AST was poor with only 48% having the correct diagnosis. In 38% the raised AST was apparently not noticed by the attending clinicians. CONCLUSIONS: The commonest cause of a hepatitis like biochemical picture was hepatic hypoxia (50%) followed by pancreatobiliary disease (24%). Drug induced hepatic necrosis (8.8%) was uncommon and viral hepatitis was rare (3.6%). AST concentrations returned towards normal most rapidly in patients with hepatic hypoxia and calculous biliary obstruction. Hepatitis, viral or otherwise, is an uncommon cause of a typical hepatitic biochemical result in this community.

Adult↗
PubMed1998

Metachronous small-bowel adenocarcinoma in coeliac disease: gluten-free diet is not protective.

Coeliac disease is associated with an increased risk of certain gastrointestinal malignancies, especially of the small bowel. Metachronous malignancies are well established in the colon, where adenocarcinoma is common, but are exceptional in the small intestine. We describe a young woman with a long history of malabsorption who was shown to have coeliac disease complicated by a small-bowel adenocarcinoma. The cancer was resected, and the coeliac disease went into complete remission on a strict gluten-free diet. Fifteen years later she developed iron deficiency anaemia. Investigations showed a metachronous small-bowel adenocarcinoma but continuing remission of the coeliac disease. The case provides strong evidence against a causative role for the enteropathy of active coeliac disease in small-bowel adenocarcinoma and against a protective effect of a gluten-free diet in tumour development. Predisposition to adenocarcinoma in coeliac disease is probably genetic.

Adenocarcinoma↗
PubMed1998

The association between primary biliary cirrhosis and coeliac disease: a study of relative prevalences.

BACKGROUND: Coexistent primary biliary cirrhosis (PBC) and coeliac disease has been recorded but the association has not been systematically studied. AIMS: To determine relative prevalences of PBC and coeliac disease in a defined population over a 12 year period. PATIENTS AND METHODS: All patients with PBC or coeliac disease in a stable population of 250,000 in South Wales were identified from a clinical register and laboratory records. RESULTS: Sixty seven patients with PBC and 143 patients with coeliac disease have been diagnosed and followed over a median of 86 (4-135) months; point prevalences in 1996 were 20 per 100,000 for PBC and 54 per 100,000 for coeliac disease. PBC in patients with coeliac disease was sought by investigating abnormal liver function tests. Ten (7%) had persistent abnormalities and three had PBC. Coeliac disease in patients with PBC was sought by investigating malabsorption, haematinic deficiency, positive antigliadin antibody, or coeliac disease family history. Eleven patients underwent duodenal biopsy revealing one further coeliac disease case. Four patients (three women have both conditions giving a point prevalence for patients with both conditions of 1.6 per 100,000 (95% confidence limits 0.44 to 4.1 per 100,000). Prevalence of PBC in patients with coeliac disease was 3% and of coeliac disease in patients with PBC was 6%. CONCLUSION: A 12 year study of a stable 250,000 population revealed a relative prevalence of PBC in 3% of 143 patients with coeliac disease and of coeliac disease in 6% of 67 patients with PBC. PBC and coeliac disease are therefore associated. Screening for PBC in patients with coeliac disease using antimitochondrial antibody testing and screening for coeliac disease in patients with PBC with antigliadin antibody testing or duodenal biopsy are recommended.

Adult↗
PubMed1997

Type I autoimmune hepatitis is primarily a disease of later life.

Previous studies of type I autoimmune hepatitis (AIH) have been based on selected populations attending specialist liver units. We describe 41 patients with type I AIH from a stable population in South Wales sequentially diagnosed over an 11-year period. All were Caucasian; 32 women, nine men; median follow-up 4 years. All cases conformed with International AIH Group criteria. Median age at diagnosis was 62 years. At presentation, only five patients were under 40 years old, 23 were over 60. This was very different from the classical age distribution. The commonest presentation was acute icteric hepatitis (29/41); median duration of illness 3 months. Co-existing acute arthralgia was common (10/41), as were other autoimmune diseases. Liver biopsy revealed piecemeal necrosis or interface hepatitis in 30; others showed non-diagnostic acute hepatitis. Fourteen also had cirrhosis. Median AsT fell from 508 (73-2385) to 32 (13-607) U/I after immunosuppression, representing complete remission in 28, partial remission in eight, and two treatment failures. Three patients were not treated, because of either quiescent disease or spontaneous remission. To date, there have been eight deaths (median age 64, range 37-86); five due to liver failure, one to variceal haemorrhage, one to acute myocardial infarction and one to upper gastrointestinal haemorrhage caused by acute idiopathic thrombocytopenia. Contrary to previous descriptions, type 1 AIH is a disease of later life in this stable, unselected population; peak incidence was in the seventh decade, and few cases occurred before the fifth decade. Presentation was usually as painless acute icteric hepatitis. Immunosuppression was effective and safe in most cases; 5-year survival rates were 61% (> 60 years at diagnosis), 66% (< 60) and 64% (overall).

Adolescent↗
PubMed1986

Collagenous colitis.

Clinical and pathological aspects of six patients with collagenous colitis are presented. These patients have been observed for between four and 15 years and the evolution of the condition is documented in three (cases 1, 3 and 5). Management and possible pathogenetic mechanisms of this enigmatic condition are discussed.

Adult↗
PubMed1985

Origin of chronic right upper quadrant pain.

We have studied 22 consecutive patients referred for investigation of severe chronic right upper quadrant pain. The majority were women whose symptoms had been present for many years. All had undergone repeated investigations of the pancreatico-biliary, gastro-intestinal, urinary, and even gynaecological systems without a satisfactory diagnosis. Most had undergone at least one abdominal operation in an unsuccessful attempt to cure their pain. In 21 of 22 patients the customary pain was completely and reproducibly mimicked by balloon distension of the small or large intestine in at least one site. The trigger sites were jejunum (15), ileum (12), right colon (nine), and duodenum (six). In 12 more than one trigger site was found. Close questioning revealed features of the irritable bowel syndrome in the majority and depression in many though the symptoms were not spontaneously volunteered. Reproduction of pain has provided a convincing demonstration to this difficult group of patients that they have a sensitive gut and allows appropriate management.

Abdomen↗
PubMed1984

Jejunal motility in patients with functional abdominal pain.

A radiotelemetric system using dual pressure pills was used to record the jejunal motility in man. Prolonged recordings were made under relatively physiological conditions. Six patients with functional abdominal pain and six age/sex matched normal subjects were studied. Motility patterns varied markedly both within and between subjects. No differences were detected between the two groups. In particular, the occurrence of characteristic pain in the patients bore no relation to the recorded motor activity. The wide range of jejunal motility patterns in normal subjects needs to be appreciated before conclusions can be drawn about possible abnormalities in gut diseases or disorders.

Adult↗