1225

Mebeverine-induced perforated colon in distal intestinal syndrome of cystic fibrosis SIR,-Dr Mulherin and Professor Fitzgerald (March 3, p 552) an exacerbation of the distal intestinal syndrome (DIS;

report

meconium ileus equivalent) caused by nebulised ipratropium bromide (’Atrovent’, Boehringer Ingelheim), presumably attributable to the antispasmodic effect of this anticholinergic drug. We would emphasise the dangers of antispasmodic drugs in cystic fibrosis.

children below the third centile, and who decides and on what criteria? There will always be short normal children in a society whose height is increasing. Some hGH-treated short children presumably have genetic short stature and will probably themselves produce short children. Does a limitless supply of hGH require an endless demand for its use? The lines of J. K. Bangs seem pertinent: I met a little elfman once, Down where the lillies blow. I asked why he was so small, And why he did not grow. He slightly frowned and with his eyes, He looked me through and through, "I’m quite as big enough for me", he said, "As you are big for you".

We report a 24-year-old man in whom cystic fibrosis was diagnosed 5 years ago. His regular medication included pancreatic enzyme supplements, flucloxacillin, and inhaled beclomethasone

and salbutamol for his coincidental asthma. He was admitted with severe lower abdominal pain for 18 h. He gave a history of severe constipation and lower abdominal pain for ten days, for which his general practitioner had prescribed mebeverine hydrochloride (’Colofac’, Duphar). On examination he was dehydrated, pyrexial, and had a tachycardia. There were signs of generalised peritonitis. He had very high neutrophil leucocytosis. Chest radiography showed gas under the diaphragm. Initial management was conservative with rehydration and intravenous cefuroxime and metronidazole. He deteriorated over the next 24 h. Laparotomy revealed a large pelvic abscess full of thick pus, and the rest of the peritoneal cavity contained thin watery pus. The descending and sigmoid colon were loaded with faeces and there was a perforated stercoral ulcer in the mid-sigmoid colon. The whole of the left side of the colon was resected, the splenic flexure was anastomosed to the rectum, and a defunctioning colostomy was done in the right hypochondrium. The appendix was also removed. Pus showed a heavy growth of Escherichia coli. Histological examination revealed stercoral ulceration of the large bowel with peritonitis. The appendix showed peritonitis but no evidence of acute mucosal inflammation. He made a slow but uneventful recovery and was discharged from hospital a month later, after revision of the colostomy. Two months after operation his bowel habit has almost returned to normal. This case further emphasises the dangers of antispasmodic drugs in cystic fibrosis. Although mebeverine is not anticholinergic, it causes relaxation of colonic smooth muscle thereby decreasing intestinal motility. The patient’s initial abdominal colic obviously resulted from DIS and it is reasonable to assume that mebeverine produced colonic stasis, which in turn led to stercoral ulceration and perforation. The accepted treatment for severe obstructive DIS includes rehydration and meglumine diatrizoate (’Gastrografm’, Schering) or acetylcysteine. Surgery is usually contraindicated but in our case it was essential because of colonic perforation and

generalised peritonitis. Active management of DIS is imperative in cystic fibrosis. Symptomatic treatment with antispasmodic agents such as mebeverine delays proper management of this condition and may result in intestinal perforation. Department of Respiratory Medicine, Sunderland Royal Infirmary, Sunderland SR2 7JE, UK

Department of Paediatrics, Royal College of Surgeons

in

Ireland,

DENIS GILL

Dublin 2, Ireland

Plasma cotinine,

smoking, and lung

cancer

in China a SIR,-In comprehensive epidemiological survey in China we investigated the smoking habits of 260 groups of male and female inhabitants randomly selected in sixty-five rural counties. Each group included 25 adults aged 35-64 years. The counties were chosen from 24 provinces in such a way as to represent the whole range of mortality rates from seven major cancer sites, including lung.l Plasma cotinine was measured on plasma pools rather than individual samples.2 None of the 130 groups of men (25 per group) had a mean plasma cotinine lower than 49 mg/ml, while the mean was 150 (54) mg/ml for men (range 49-314 mg/ml) and 20 (30) mg/ml for women (range 0-134 mg/ml). Plasma cotinine, the indicative metabolite of nicotine, correlated significantly with current daily consumption of tobacco, especially other-than-manufactured cigarettes, and with current smoking of home-made cigarettes (table i) but negatively with smoking of manufactured cigarettes. The negative correlation of cotinine with manufactured cigarettes is due to the low consumption of home-made cigarettes in areas where manufactured cigarettes are used. Home-made cigarettes may contain much more nicotine, though this was not measured. Home-made cigarettes are consumed predominantly in the more agricultural counties, whereas western-type manufactured cigarettes are characteristic of the more industrialised counties. This may explain the positive correlation of plasma cotinine with chronic pulmonary and cardiac diseases such as (r=0’41, pneumonia

Growth hormone for short children.

1225 Mebeverine-induced perforated colon in distal intestinal syndrome of cystic fibrosis SIR,-Dr Mulherin and Professor Fitzgerald (March 3, p 552)...
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