Liver and Biliary Diseases

Liver and Biliary Diseases

GASTROENTEROLOGY 1998;115:505–508 PRINT AND MEDIA REVIEWS Lawrence S. Friedman, M.D. Print and Media Review Editor Gastrointestinal Unit, Blake 456D ...

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GASTROENTEROLOGY 1998;115:505–508

PRINT AND MEDIA REVIEWS Lawrence S. Friedman, M.D. Print and Media Review Editor Gastrointestinal Unit, Blake 456D Massachusetts General Hospital Boston, Massachusetts 02114

Liver and Biliary Diseases. 2 ed. Edited by Neil Kaplowitz. 769 pp. $139.00. Baltimore, Maryland, Williams & Wilkins, 1996. ISBN 0-683-04545-8. The increasing prominence of hepatology as a separate discipline within gastroenterology is reflected in the number of excellent textbooks devoted to the liver, ranging from encyclopedic in nature to more general overviews. With the publication of the second edition of Liver and Biliary Diseases, Neil Kaplowitz has assembled more than 70 experts to discuss hepatology and biliary disorders as they relate to clinical practice. The editor states ‘‘the purpose of the Liver and Biliary Diseases is to provide a relatively concise but comprehensive review of the pathophysiology, diagnosis, and treatment of hepatobiliary diseases.’’ The main thrust of the book reflects the premise that the acquisition of knowledge comes best through an understanding of the basic principles. The book is comprehensive, with 44 chapters divided into 7 sections: Structure and Function of the Liver, Pathophysiology, Diagnostic Studies for Liver and Biliary Disease, Acute and Chronic Diseases of the Liver, Other Conditions of the Liver, Complications of Liver Disease: Pathophysiology and Management, and Biliary Diseases. Chapters are arranged in a logical order. They build and expand on information conveyed from previous chapters. The book begins with a strategic emphasis on an understanding of the structure and function of the liver and ends with chapters on the clinical manifestations of liver disease. The approach to biliary disease is similar, ranging from a critical discussion of bilirubin metabolism to the differential diagnosis of jaundice and a discussion of specific biliary disorders. Each chapter in the book is approached in a logical and systematic manner that begins with an overview that gives the reader perspective for the subsequent discussion. The authors address pathophysiology, natural history, diagnosis, and management of each topic. Management strategies are realistic and practical. Without being exhaustive, the authors are concise but descriptive, with key points periodically emphasized by bold font. After the chapter has been read, the bold font allows for quick review. A major strength of the book is its extensive use of illustrations, which are generally easily read and do not duplicate the text. Authors complement their chapters with descriptive figures, simplified algorithms, sharp photographs, and clear tables that add greatly to the reader’s understanding. The chapter on liver and biliary tract imaging, for instance, is enriched with tables describing the appearance of focal and diffuse liver diseases with different radiographic modalities, such as plain radiography, ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI), and angiography. The descriptions of the biliary tree by plain

radiography, cholangiography, ultrasonography, CT, and MRI are equally well done. Magnetic resonance cholangiography is not discussed, given its very recent introduction into hepatology. The references are arranged in an annotated bibliography format. Each chapter has, on average, between 20 and 35 references. The reference lists are, for the most part, not exhaustive but are thorough, and the annotation allows the reader to identify additional resources for further reading. A minor criticism is the relative age of many of these references, with many more than 10 years old. The goal of the book is not to be an exhaustive reference on hepatobiliary disorders. Other larger textbooks serve that purpose well. This book does, however, provide a clear and concise overview of hepatobiliary pathophysiology, diagnosis, and management. Its diagrams and illustrations will allow this book to be referenced over and over again. The fundamentals emphasized give the reader a firm grounding necessary for further study and research. Liver and Biliary Diseases will be a useful addition to the library of any physician who sees patients with liver diseases, including residents, gastroenterology trainees, and gastroenterologists. Bottom Line: This book is well written and nicely illustrated. It provides a solid foundation for an understanding of pathophysiology and extrapolation into the clinical practice of liver and biliary diseases. The book is an excellent starting point for further reading and research in the ever-expanding field of hepatology. SAMMY SAAB, M.D. PAUL MARTIN, M.D. Division of Digestive Diseases UCLA School of Medicine Los Angeles, California

Living with Hepatitis C: A Survivor’s Guide. By Gregory T. Everson and Hedy Weinberg. 220 pp. $14.95. Hatherleigh Press, New York, New York, 1998. ISBN 1-57826-003-5. Living with Hepatitis C has been advertised as ‘‘the book 5 million people need.’’ With hepatitis C at epidemic proportions, there is little doubt that the potential audience for reliable information about this condition is burgeoning. Yet this book, though brimming with information, is unlikely to be helpful to such a broad readership. Dr. Everson, Director of Hepatology at the University of Colorado Health Sciences Center, and Ms. Weinberg, a writer who has been diagnosed with hepatitis C, share the authorship of this volume. Their stated intent is ‘‘to create a useful guide that would take the patient step by step through the process of diagnosis and ongoing care.’’ However, the tutorial path they



have blazed is less than direct. The book begins rationally enough, with a description of hepatitis C, but before page 20, the lay reader is slogging through often incomprehensible descriptions of diagnostic tests. Those who make it through polymerase chain reaction and branched-chain DNA methodologies are rewarded with a good discussion of the routes of infection. After that interlude, the reader risks being mired in 14 pages of ‘‘liver facts,’’ followed by guidelines for nutrition, psychological health, and financial well-being. Only in the closing chapters do the authors address treatment protocols. In short, this isn’t a book that is easily read from cover-to-cover, but one that is better thumbed through in search of answers to the reader’s most urgent questions. The authors do a reasonable job executing another of their avowed purposes: translating medical jargon, anticipating questions, and reducing the fear of the unknown. However, they often fail the reader just when the going is the toughest— for example, in the descriptions of diagnostic tests where complex processes are introduced only to go undefined and poorly explained. To add a human touch, the book is liberally peppered with quotations from people infected with hepatitis C. Unfortunately, these are disembodied voices; we don’t know the speakers’ ages, personal circumstances, or stage of disease, and therefore we cannot identify with any of them. However, we hear from each of the participants more than once, so when we happen upon a quotation from ‘‘Terry,’’ we may find ourselves paging back to his earlier utterances so that we can cobble together a sense of the person, in much the same way a forensic psychologist might. It’s the only way we can tell whether Terry’s experience might have some bearing on ours. Although these anecdotes are occasionally illuminating, in concert they are depressing. The reader wonders whether he or she is destined to share Chris’ esophageal bleed, Tom’s quest for a donor liver, Nadine’s battle for disability benefits, Joe’s headaches, George’s exhaustion, Gary’s petechiae, etc. Most of the optimistic stories appear to be reserved for the nutrition section. As the editor of a medical newsletter, I am always on the lookout for books to recommend to readers who want to delve into a topic in greater depth. I’m still ambivalent about this one. I’d be just as inclined to suggest Chronic Hepatitis C: Current Disease Management from the National Institute of Diabetes and Digestive and Kidney Diseases, even though it would require having a copy of Dorland’s Medical Dictionary ready. Even though it’s written for physicians, it is crisper, more information-rich, and probably less confusing to the motivated lay reader than is Living with Hepatitis. Yet Living with Hepatitis has much to offer. It’s the first popular attempt to make sense of a baffling condition. The information, from etiology to future research, is all there and up-to-date. The book has a good resource list, a comprehensive bibliography, and a helpful index. Still, it would have benefited from another round of editing—to reorder the chapters, pare down the anecdotes, define arcane terms, and perhaps create a


series of algorithmic diagrams to illustrate possible courses of the disease. Bottom Line: Living with Hepatitis is a B2 offering with the potential to be an A. BEVERLY MERZ Editor Harvard Women’s Health Watch Boston, Massachusetts

Vanishing Bile Duct Syndrome: Pathophysiology and Treatment. By D. Alvaro, A. Benedetti, and M. Strazzabosco. In: Modlin, Rozen, and Scarpigriato, eds. Frontiers in Gastrointestinal Research. Volume 24. 272 pp. $123.00. Kluwer Academic Publishers, Dordrecht/Boston/London, 1997. ISBN 0-79238721-X. This book comprises presentations made at an International Falk Symposium workshop in June 1996. The title is somewhat misleading in that a major component of the text deals with the normal anatomy and physiology of the intrahepatic biliary tree. There is then a section on the pathophysiology of cholestasis in general and of the biliary tree in particular. The final section deals with clinical aspects and therapy of the disappearing bile duct syndromes. The first section serves to bring the reader up to date on the enormous advances that have taken place in our understanding of the normal function of the biliary tree, a component part of the liver which, until the 1970s, was regarded simply as a conduit for the excretory product of the hepatocytes. The anatomy and development of the biliary tree are described, and a number of articles deal with experimental models. There is a review of factors that regulate and modify bile secretion as it is transported along the biliary tree. The second section includes extended reviews of the pathophysiology of cholestasis and the biliary tree, together with reviews of the pathogenic mechanisms involved in some of the vanishing bile duct syndromes, notably primary biliary cirrhosis, which is dealt with in an extended and comprehensive way. There is some overlap here in the coverage of the immunologic mechanisms involved in the autoimmune cholangiopathies. In the section on clinical aspects and therapy, liver transplantation for vanishing bile duct syndromes is dealt with together with a review of the pathophysiology of acute and chronic liver allograft rejection, the mechanisms of which shed light on the ‘‘naturally’’ occurring disappearing bile duct syndromes. General medical management is also covered, and the use of ursodeoxycholic acid is dealt with in detail. Like most symposia proceedings, the book is not comprehensive, and inevitably there is variation in style and level of detail. However, such proceedings are of great value in presenting updated reviews by experts who are currently involved in the topic under discussion. This text certainly provides the reader with such updates and by the internationally recognized experts in those areas of bile duct physiology and pathology that I have mentioned.

August 1998

Bottom Line: This book is warmly recommended both to those actively engaged in biliary disease research and to clinicians and pathologists involved in the diagnosis and management of the primary biliary tract diseases. As a value-added bonus there is a fascinating vignette on the foundations and mysteries of Rome provided by Professor Livio Capocaccia, who combines an interest in hepatology with an interest in archeology. R. N. M. MACSWEEN University Department of Pathology Western Infirmary Glasgow, Scotland

Current Trends in Digestive Ultrasonography. Edited by L. Gandolfi and M. Fukuda. 394 pp. $299.00. Karger, Basel, Switzerland, 1997. ISBN 3-8055-6374-4. Current Trends in Digestive Ultrasonography, edited by L. Gandolfi and M. Fukuda, is a multiauthored collection of chapters. Its aim is to describe the current state of the art of ultrasonography as it relates to gastrointestinal disease. Wellorganized into three major sections, the book includes chapters on ultrasound diagnosis, interventional ultrasonography, and recent advances in ultrasonography. Written to appeal to all clinical specialties with an interest in digestive ultrasonography, it has met its objective of providing an overview of international experience and potential applications. Figures are used as needed and are of moderate to good quality throughout. As is always the case in a multiauthored text, writing style is not totally uniform but is very good considering the vast international representation. The final product is an easily read and appealing collection of short topics with a nice overall organization. The first section on ultrasound diagnosis is of necessity quite brief and does not offer the comprehensive coverage of liver and pancreatic sonography provided in many larger ultrasound publications. Nonetheless, considering the very important issue of mass lesions, Cosgrove and Gandolfi et al., in separate chapters, provide a nice overview of the features of benign liver tumors and pancreatic tumors, respectively. The chapter ‘‘Mass Screening for Hepatocellular Carcinoma by Ultrasonography’’ by Hirata and Fukuda of Japan is invaluable and gives an excellent clinical perspective on the question of mass screening for this lethal tumor. This latter chapter on hepatocellular carcinoma is supported by two further excellent chapters in the interventional section that deal with ethanol ablation of hepatocellular carcinoma and a related chapter on echo-guided laser therapy of colorectal metastases. These nonsurgical therapies utilizing ultrasound guidance are current hot topics. Chapters on intraoperative, laparoscopic, and endoscopic ultrasonography describe what are now well-established modifications to standard ultrasound technique. Improved lesion detection and staging information related to the use of highfrequency transducers in close proximity to the area of interest are reported. Sonographic applications in the study of patients



with tropical disease, human immunodeficiency virus infection, and acquired immunodeficiency syndrome round out the clinical experience. Multiple chapters are devoted to Doppler ultrasonography, including a particularly thorough and readable approach to portal hypertension by Bolondi et al. Goldberg et al. also tweak the interest of the reader in future developments in a chapter on ultrasound contrast agents. Bottom Line: The subject matter in this book is up-to-date but does not add new information to the ultrasound field. Rather, in a single publication this book provides a comprehensive overview of the varied applications of ultrasonography as related to gastrointestinal disease. It should be of interest particularly to gastroenterologists and surgeons with an interest in ultrasound. STEPHANIE R. WILSON, M.D., F.R.C.P.C. Department of Medical Imaging The Toronto Hospital Toronto, Ontario Canada

Inflammatory Bowel Disease and Chronic Recurrent Abdominal Pain. Edited by F. Hadziselmovic and B. Herzog. 226 pp. Kluwer Academic Publishers Group, Dordrecht, The Netherlands, 1997. ISBN 0-7923-8722-8. This book represents the proceedings of Falk Symposium 91, which was the Third International Falk Symposium on Pediatric Gastroenterology, held in Basel, Switzerland, in March 1996. The purpose of the meeting was twofold: to discuss epidemiological, immunologic, clinical, and therapeutic aspects of the idiopathic inflammatory bowel diseases (IBD) in children; and to discuss medical and surgical aspects of the puzzling syndrome of chronic recurrent abdominal pain in children. The book is aimed at both basic scientists and clinicians with an interest in these disorders. I believe the book partially meets its stated aims. The title of the book itself is somewhat of a misnomer, in that only one short chapter covers chronic abdominal pain (and only from the surgical perspective), while the remaining 12 chapters deal with IBD. The last 35 pages consist of poster abstracts submitted to the meeting. The chapters are written by multiple authors and, unfortunately, are somewhat uneven in both style and depth of presentation, ranging in length from 1 to 35 pages. As a clinician with an interest in the epidemiology of IBD, I found Andrew Wakefield’s presentation of the Royal Free Hospital IBD Study Group’s hypothesis that IBD represents a small vessel vasculitis triggered by early exposure to measles virus particularly thought-provoking. Several lines of evidence for this still unproven hypothesis are intriguing, and the chapter is worth a read. Several chapters thoroughly cover immunologic aspects of IBD, including humoral and cellular immunity and the role of adhesion molecules in generation of the inflammatory response.



One chapter that nicely reviews pitfalls in the diagnosis and management of pediatric IBD would be of interest to many adult gastroenterologists who occasionally treat a child with IBD. Ernest Seidman emphasizes that growth failure is an often overlooked complication in children and that enteral nutrition and purine analogues should be used more aggressively. A chapter on the pharmacology and efficacy of topical and oral delayed-release budesonide for IBD is well presented. Curiously, there are two chapters devoted to interferon a2a therapy for Crohn’s disease and ulcerative colitis. Short shrift is given to other therapeutic aspects of pediatric IBD. This book, the proceedings from a symposium, does not


attempt to cover all aspects of Crohn’s disease or ulcerative colitis comprehensively. For the practicing gastroenterologist or trainee with a desire to learn more about IBD, there are several excellent IBD textbooks available. Bottom Line: Basic and clinical researchers with an interest in IBD, especially as it pertains to children, may find this book to be of interest. EDWARD V. LOFTUS, Jr., M.D. Inflammatory Bowel Disease Clinic Division of Gastroenterology and Hepatology Mayo Clinic Rochester, Minnesota