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Diagnostic diagrams: Gastroenterology
August
BOOK REVIEWS
1985
old survivor of several arterial bypasses and rebypasses, currently ingesting analgesic drugs for crippling arthritis. Surely the authors would not biopsy an ulcer of the antral greater curve in a patient taking 16 aspirin tablets daily for headache. Despite what I consider occasional departures from optimal medical practice, I believe this book should become the standard text of gastroenterology for medical students, and should be in the possession of all primary physicians. At the price it is a rare bargain. WILLIAMH. BACHRACH,M.D., Ph.D. Washington, DC. Diagnostic Diagrams: Gastroenterology. By A. B. Knapp and P. S. Farkas. 152 pp., $14.95. Williams and Wilkins, Baltimore, Maryland, 1985. Reading this spiral-bound compendium after 40 yr of study of digestive diseases leaves me bewildered and saddened. I am bewildered because I cannot understand the algorithms. As one example, the diagram on diarrhea begins: “History: stool weight normal.” Patients complaining of diarrhea do not present with a history of the weight of their stools. According to this diagram, if the patient reports a normal stool weight, the diagnosis is irritable bowel syndrome. A lengthy text accompanies each diagram, e.g., 7 pages for diarrhea, 6 pages for peptic disease, suggesting that the diagrams need elaborate explanation. This is in contrast to the splendid algorithms in the British Medical Journal in the past year or two, which included specific recommendations for treatment, with an accompanying text of often just 2 pages. I am saddened because there are many statements that cannot be reconciled with good medical practice, such as the following. (a) Giant gastric ulcers in the duodenum are usually resistant to all forms of medical management. On the contrary, Jaszewski et al. (Dig Dis Sci 1983; 28:486-g) and Bianchi Porro et al. (Dig Dis Sci 1984; 29:781-2) have shown that almost all of these ulcers heal with Hz-blocker treatment. (b) Every gastric ulcer should be repeatedly brushed and biopsied before treatment, and if not proven malignant, again after 6 wk of treatment. “Every” anything is poor medical policy; a patient with a gastric ulcer benign by rigid radiologic criteria doesn’t need an endoscopy, much less all this extravagant overkill. (c) Pinpointing the exact cause of malabsorption syndrome can only be achieved by a complete diagnostic evaluation. Overwhelmingly more costeffective is a therapeutic trial of a gluten-free diet or pancreatic enzymes, which may well provide the diagnosis within a week. (d) The Bernstein test consists of intraesophageal drip of water or saline for 5 min followed by HCl for 5 min. There is a limit to how far this test can be foreshortened; such a radical amputation of the Bernstein test as the authors recommend will miss many positives. This digest of gastroenterology requires extensive revision of both text and diagrams to make it helpful to the putative target population-students and residents rotating on a gastroenterology service. WILLIAM
H. BACHRACH,
Rockville, Maryland
M.D., Ph.D.
449
Dysphagia: Diagnosis and Management. Edited by M. E. Groher. 258 pp., $29.95. Butterworth Publishers, Boston, Massachusetts, 1984. A gastroenterologist’s reflex response to the title of this book would be to expect a treatise on esophageal diagnosis and therapy. Not at all-this book might better be entitled “Pitfalls in the Passage of Food and Fluid From the Table to the Stomach.” Problems ranging from inability to hit the mouth with food due to tremor of Huntington’s chorea to neuromuscular incoordination of the esophagus are discussed by neurologists, speech pathologists, nurses, and dietitians. The goal of this book was to bring together information from different disciplines. Certainly this has been done, but the mixture does not always have a homogeneous texture. There does not seem to have been a great deal of editorial coordination. Repitition is the order of the day. The neurologic aspects of swallowing are presented in exhausting detail; the information on esophageal physiology is sparse and a bit dated (a Netter drawing of pressure relationships in the esophagus, circa 1959). Swallowing disorders are classified as being primarily neurologic or mechanical, and therapy is chosen partially on the basis of this division. The section on therapy of swallowing disorders holds the most interest for me. There are reams of practical suggestions. As an investigator, I couldn’t help wondering whether many of these recommendations had ever been subjected to a clinical trial. Such trials could be mounted without difficulty, and the utility of many of the recommendations actually established. Some useful feeding hardware is illustrated, especially items to help those with mechanical problems. The section on surgical approaches to the improvement of swallowing function contains several errors of fact and does not detail the thought processes that go into the selection of one approach over another. In a final excess of nitpicking, I am left wondering whether applesauce is contraindicated (page 115) or to be encouraged (page 241)! Lest all these comments be viewed as negative ones, let me hasten to add that I believe this book will be of value to primary care physicians, geriatricians, and nurses, if not to gastroenterologists. It does draw together several rivers of literature and does have some eminently practical advice in the beginning of the therapeutics section. Its price is reasonable. If it goes into another edition, the contributors should consult with each other before redoing their individual chapters to eliminate duplication and to stress the practical aspects of their contributions. CHARLES
E. POPE II, M.D.
Seattle, Washington
Peptic Ulcer Disease (Contemporary Issues in Gastroenterology, Volume 3). By F. P. Brooks, S. Cohen, and R. D. Soloway. 331 pp., $48.50, Churchill Livingstone, Inc., New York, New York, 1984. If you have a scholarly interest in peptic ulcer (who needs the appended “disease”?) this book is a necessity.
BOOK REVIEWS
1985
old survivor of several arterial bypasses and rebypasses, currently ingesting analgesic drugs for crippling arthritis. Surely the authors would not biopsy an ulcer of the antral greater curve in a patient taking 16 aspirin tablets daily for headache. Despite what I consider occasional departures from optimal medical practice, I believe this book should become the standard text of gastroenterology for medical students, and should be in the possession of all primary physicians. At the price it is a rare bargain. WILLIAMH. BACHRACH,M.D., Ph.D. Washington, DC. Diagnostic Diagrams: Gastroenterology. By A. B. Knapp and P. S. Farkas. 152 pp., $14.95. Williams and Wilkins, Baltimore, Maryland, 1985. Reading this spiral-bound compendium after 40 yr of study of digestive diseases leaves me bewildered and saddened. I am bewildered because I cannot understand the algorithms. As one example, the diagram on diarrhea begins: “History: stool weight normal.” Patients complaining of diarrhea do not present with a history of the weight of their stools. According to this diagram, if the patient reports a normal stool weight, the diagnosis is irritable bowel syndrome. A lengthy text accompanies each diagram, e.g., 7 pages for diarrhea, 6 pages for peptic disease, suggesting that the diagrams need elaborate explanation. This is in contrast to the splendid algorithms in the British Medical Journal in the past year or two, which included specific recommendations for treatment, with an accompanying text of often just 2 pages. I am saddened because there are many statements that cannot be reconciled with good medical practice, such as the following. (a) Giant gastric ulcers in the duodenum are usually resistant to all forms of medical management. On the contrary, Jaszewski et al. (Dig Dis Sci 1983; 28:486-g) and Bianchi Porro et al. (Dig Dis Sci 1984; 29:781-2) have shown that almost all of these ulcers heal with Hz-blocker treatment. (b) Every gastric ulcer should be repeatedly brushed and biopsied before treatment, and if not proven malignant, again after 6 wk of treatment. “Every” anything is poor medical policy; a patient with a gastric ulcer benign by rigid radiologic criteria doesn’t need an endoscopy, much less all this extravagant overkill. (c) Pinpointing the exact cause of malabsorption syndrome can only be achieved by a complete diagnostic evaluation. Overwhelmingly more costeffective is a therapeutic trial of a gluten-free diet or pancreatic enzymes, which may well provide the diagnosis within a week. (d) The Bernstein test consists of intraesophageal drip of water or saline for 5 min followed by HCl for 5 min. There is a limit to how far this test can be foreshortened; such a radical amputation of the Bernstein test as the authors recommend will miss many positives. This digest of gastroenterology requires extensive revision of both text and diagrams to make it helpful to the putative target population-students and residents rotating on a gastroenterology service. WILLIAM
H. BACHRACH,
Rockville, Maryland
M.D., Ph.D.
449
Dysphagia: Diagnosis and Management. Edited by M. E. Groher. 258 pp., $29.95. Butterworth Publishers, Boston, Massachusetts, 1984. A gastroenterologist’s reflex response to the title of this book would be to expect a treatise on esophageal diagnosis and therapy. Not at all-this book might better be entitled “Pitfalls in the Passage of Food and Fluid From the Table to the Stomach.” Problems ranging from inability to hit the mouth with food due to tremor of Huntington’s chorea to neuromuscular incoordination of the esophagus are discussed by neurologists, speech pathologists, nurses, and dietitians. The goal of this book was to bring together information from different disciplines. Certainly this has been done, but the mixture does not always have a homogeneous texture. There does not seem to have been a great deal of editorial coordination. Repitition is the order of the day. The neurologic aspects of swallowing are presented in exhausting detail; the information on esophageal physiology is sparse and a bit dated (a Netter drawing of pressure relationships in the esophagus, circa 1959). Swallowing disorders are classified as being primarily neurologic or mechanical, and therapy is chosen partially on the basis of this division. The section on therapy of swallowing disorders holds the most interest for me. There are reams of practical suggestions. As an investigator, I couldn’t help wondering whether many of these recommendations had ever been subjected to a clinical trial. Such trials could be mounted without difficulty, and the utility of many of the recommendations actually established. Some useful feeding hardware is illustrated, especially items to help those with mechanical problems. The section on surgical approaches to the improvement of swallowing function contains several errors of fact and does not detail the thought processes that go into the selection of one approach over another. In a final excess of nitpicking, I am left wondering whether applesauce is contraindicated (page 115) or to be encouraged (page 241)! Lest all these comments be viewed as negative ones, let me hasten to add that I believe this book will be of value to primary care physicians, geriatricians, and nurses, if not to gastroenterologists. It does draw together several rivers of literature and does have some eminently practical advice in the beginning of the therapeutics section. Its price is reasonable. If it goes into another edition, the contributors should consult with each other before redoing their individual chapters to eliminate duplication and to stress the practical aspects of their contributions. CHARLES
E. POPE II, M.D.
Seattle, Washington
Peptic Ulcer Disease (Contemporary Issues in Gastroenterology, Volume 3). By F. P. Brooks, S. Cohen, and R. D. Soloway. 331 pp., $48.50, Churchill Livingstone, Inc., New York, New York, 1984. If you have a scholarly interest in peptic ulcer (who needs the appended “disease”?) this book is a necessity.