Imaging in Liver Disease

GASTROENTEROLOGY 1998;114:415–418

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

Current Clinical Topics in Gastrointestinal Pharmacology. Edited by James H. Lewis and Andre Dubois. 342 pp. £60.00. Blackwell Science Inc., Malden, Massachusetts, 1997. ISBN 0-865425213. This book is the inaugural volume in a proposed series of monographs dealing with drug therapy in the field of gastroenterology and hepatology. The editors have recruited an impressive cadre of leaders in the field of gastroenterology and hepatology to review a potpourri of timely and sometimes controversial areas of interest. This group is involved currently with both clinical and research activities that put them at the leading edge of the field. The authors have been challenged to produce chapters that are both timely and relevant to the practice of clinical gastroenterology. The chapters have been organized by either pharmaceutical class or disease process. Of particular interest to practicing gastroenterologists are two chapters on potentially controversial aspects of procedural gastroenterology, namely, antibiotic prophylaxis and conscious sedation. The book reviews areas essential to the practice of gastroenterology. For example, the review of antimicrobial therapy for the acquired immunodeficiency syndrome (AIDS) is useful in its focus on systemic and topical agents for fungal diseases of the gastrointestinal tract, as well as viral and antimicrobial agents useful for treatment of gastrointestinal manifestations of AIDS. In another chapter, prevention of viral hepatitis is emphasized repeatedly and appropriately. Specific problems such as management of nonresponders to hepatitis B vaccination and side effects of interferon therapy are addressed skillfully. The present and future use of peptide therapy is reviewed in extraordinary detail. The reader can only be impressed by the explosion of research in the area of peptide therapy. The author translates the results of research into analyses of clinical uses of these agents extraordinarily well. The figures, tables, and legends throughout this chapter render a complex subject understandable. The intended audience of the book is clinicians, pharmacologists, and students of gastrointestinal pharmacology and therapeutics. Although much of what is presented in this monograph is available in clinical and research journals, the text pulls together in one area not only the results of research activity but also the appropriate application of this information to clinical practice. Each reader will likely find sections of the book useful and on target but, in all candor, will also find some areas outside his or her area of interest or daily practice. The chapters do vary in structure and length, not unusual in texts of this sort that examine a number of related but conceptually different areas of practice. Whereas one chapter

extended to 80 pages with more than 500 references, the majority of chapters were digestible in one sitting with bibliographies numbering less than 100. All editors of texts of this type face a difficult compromise between achieving uniformity of style, presentations similar in quality and quantity of data, and timeliness. The editors are to be congratulated for refraining from excessive reworking of chapters, which may have inadvertently but, of necessity, blunted the authors’ insights and achievement. I anticipate with pleasure the publication of the next installment planned by the editors but would suggest that the series title be changed from ‘‘Current Clinical Topics in Gastrointestinal Pharmacology’’ to ‘‘Current Topics in Clinical Gastrointestinal Pharmacology’’ to reflect more clearly the editors’ stated audience. Bottom Line: I recommend this text highly for advanced students of gastrointestinal pharmacology. Those gastroenterology fellows who have mastered the standard texts on clinical practice and clinical pharmacology will be challenged by the wealth and depth of material presented here. MICHAEL M. VAN NESS, M.D. Canton, Ohio

Acute Liver Failure. Edited by William M. Lee and Roger Williams. 304 pp. $100.00. Cambridge University Press, New York, New York, 1997. ISBN 0-521-55381-4. The coeditors of this monograph explain their decision to participate in this worthy project by pointing to the lack of a definitive text on the topic. While not disputing the accuracy of this statement, it does bring into focus the appropriateness of publishing a book about a topic that customarily merits no more than a chapter in most hepatology textbooks. The answer, as the coeditors themselves reasonably conclude, lies in the relevance of acute liver failure to the many hospital groups who now participate in the care of these patients. No longer are patients with acute liver failure the luckless objects of whispers in intensive care units and recipients of such wonderful treatments as high-dose corticosteroids, pig liver perfusion, total body washout, etc. They have become high-priority candidates for liver transplantation, which in no time at all has transformed a clinical condition with survival rates of 20% or less to one in which survival can be expected in 80% of patients or better; hence, the timeliness of this monograph. The coeditors of Acute Liver Failure are joined by 38 other nationally acclaimed experts from the United States, Canada, United Kingdom, and continental Europe in a multiauthored venture with an international flavor. Topics selected for presentation are mostly well considered, although one might disagree with some of the monograph’s organization. For

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example, why place a chapter titled ‘‘Pathology of Acute Liver Failure’’ in the section headed ‘‘Mechanisms of Disease and Multisystem Involvement,’’ and why discuss artificial and bioartificial liver devices after rather than before liver transplantation? The monograph begins with an opening chapter on classification of acute liver failure, after which follow chapters on various causes of liver failure, a chapter titled ‘‘Mechanisms of Disease and Multisystem Involvement’’ (hard to fathom what led to that heading), and chapters on intensive care management (which are among the most attractive features of the monograph), liver transplantation, artificial liver devices, and a hodgepodge of other topics under the general heading of ‘‘Other Applications.’’ Several issues are given short shrift, including the coagulation system in fulminant liver failure and impaired renal function in this setting, but for the most part, the work does touch all bases. Discussion of complex and controversial areas is often relatively perfunctory (when do you consider liver transplantation in Budd–Chiari syndrome?), and the bibliography is rather sparse. The result is that the final product is most likely to be appreciated by physicians, scientists, nurses, pharmacists, laboratory technicians, and others who are on the fringe of the area and need a text to fill in the many voids that they may have. Experts more directly involved with the field might be disappointed by the lack of depth in most areas, although the monograph clearly addresses a currently unmet need in the medical literature. On balance, the positive features considerably outweigh the negative ones. The book will command a position in my office library and will doubtless be used endlessly by trainees, nurses, and social workers. Bottom Line: This monograph fills a previously unmet need. For all professionals who work with patients with acute liver failure, this book provides the necessary insights into their optimal management. MARTIN BLACK, M.D. Gastroenterology Section Temple University School of Medicine Philadelphia, Pennsylvania

Imaging in Liver Disease. By Kenichi Takayasu and Kunio Okuda. 562 pp. $275.00. Oxford University Press, Inc., New York, New York, 1997. ISBN 0-19-262634-5. The authors of this text are noted authorities in liver imaging, particularly concerning hepatocellular carcinoma (HCC). They have translated years of experience in imaging liver diseases into a concise text that allows the reader to visualize, through case presentations, the nuances of liver tumor imaging. According to the preface, this is an update and expansion of a prior text published in Japanese in 1991. The English translation is excellent, and the book reads easily. The authors are successful in meeting their aim of providing a source for physicians to learn about the early diagnosis and treatment of HCC. It is evident that the authors’ expertise has

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been in imaging HCC, as reflected in the emphasis and extent of pages devoted to HCC. The first part of the book details liver anatomy and the computerized tomography (CT), magnetic resonance imaging (MRI), ultrasound, angiography, and venography counterparts. Extensive imaging illustrations are combined with beautifully designed drawings that present key anatomic points schematically. This combination provides an unmatched learning tool and reference for understanding liver anatomy, as both an overview and for exquisitely fine detail of subtle hepatic vasculature. The concepts of liver segmental anatomy are well described with use of color charts that easily define various schemas and with excellent imaging correlation. These pages provide one of the best descriptions of the relevant anatomy for radiologists, hepatologists, or surgeons dealing with imaging liver disease that I have ever encountered. Chapters 2–12 deal with diagnosis. The mainstay of this section are the 100 pages discussing HCC. The cases presented and the illustrative imaging/pathological correlation represent a broad spectrum of appearances of HCC. The extensive pathological correlation aids in understanding the imaging findings. The extensive use of diagnostic angiography, rarely used in the United States, provides an excellent tool for understanding the contrast-enhanced imaging appearances of these tumors. Such a compendium of the total range of imaging appearances of HCC in one book provides a helpful tool for those learning about HCC and a useful reference source for difficult cases. Liver tumors other than HCC are adequately presented. Some of the tumors have better presentations and illustrations than others, presumably based on the authors’ experience. Even rare tumors such as epithelioid hemangioendothelioma and biliary cystadenocarcinoma, however, are presented with excellent imaging/angiographic/pathological correlation. This provides an excellent review and reference for unusual liver tumors encountered in clinical practice. Although not truly liver disease, bile duct tumors and gallbladder carcinoma receive a discussion of moderate length, but other bile duct and gallbladder tumors are not discussed. The areas of the text dealing with nonneoplastic diseases (vascular disorders, cirrhosis, fatty infiltration, and others) are discussed too briefly, particularly in proportion to the remainder of the text dealing with neoplasms of the liver. Chapters 13–19 deal with imaging examination techniques. This is the weakest section of the book. The discussions are too remote from the purpose of the book and include basic physics and image processing for the digital modalities and discussions on hepatic arteriography technique that are too brief for the serious angiographer and probably not of interest to the nonangiographer. As would be expected of a 1991 publication translated into English, the techniques section is already outdated; for example, there is no substantial discussion of optimizing contrast administration for helical CT. The discussion of MRI is too brief, and I question its value. Chapters 19–25 deal with therapy of primary liver tumors. The section on chemoembolization is the longest and reflects

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the authors’ extensive experience. The case material is again prolific and well illustrated. Other treatments discussed briefly include surgical therapy, alcohol ablation, and systemic chemotherapy. Absent are discussions on cryotherapy and laser ablation therapy. The limitations of this book lie in the outdatedness of much of the material. The CT images are based predominantly on older technology, and helical CT imaging is lacking. Limited MR images are presented. References are also outdated and limited in many instances. Those for hemangioma are representative: the 1979 article on CT of hemangiomas by Freeny et al. is referenced, but their classic 1986 article is not, nor are any of the articles from the 1990s concerning state-of-the-art CT characterization. The extensive discussion concerning atypical adenomatous hyperplasia, early HCC, and early advanced HCC uses outdated terminology not widely used in the United States. Bottom Line: This book is most impressive for the extensive pathological correlations and illustrative drawings and charts, particularly for discussions of normal anatomy and hepatocellular carcinoma; there are no other books that present this material so well. Its role will be as a teaching guide for advanced anatomy and as a reference source for imaging of hepatocellular carcinoma. As such, I highly recommend this book for any physician dealing with such imaging issues. RICHARD L. BARON, M.D. Department of Radiology University of Pittsburgh Medical Center Pittsburgh, Pennsylvania

Hepatobiliary and Pancreatic Surgery. Edited by O. James Garden. 411 pp. $89.00. W.B. Saunders, Philadelphia, Pennsylvania, 1997. ISBN 0-7020-2142-3. This fine book is one in a series designed to serve as companions to specialist surgical practice and to provide affordable texts with up-to-date information. Six other titles in the series deal with other aspects of general surgery, ranging from critical care to transplantation surgery. This book, edited by O. James Garden, Professor of Hepatobiliary Surgery at The Royal Infirmary in Edinburgh, Scotland, covers the major topics in hepatobiliary and pancreatic surgery, including both benign and malignant disease. Chapters are written by various contributors, all of whom are internationally known Europeanbased surgeons and many of whom have made major contributions to their specific areas. It has been the intention to write the volumes in a short time frame and produce them quickly so that the information is as current as possible. Overall, the text is easy to read, and many chapters give nice summary tables reviewing current treatment algorithms and outcomes. In general, the quality of radiographic images is excellent. A very minor criticism is that the method of headings and subheadings makes following the text a bit more difficult than usual. Also, although the approach given for most diseases is quite rational and appropriate, there is certainly a bit of a European flavor to some of the treatments.

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This provides a more broad world view than is available in some purely American texts. As with any text, it is possible to find some things that are quite well done and others with which I would quibble. For example, the initial chapter of the book describing the investigation of hepatobiliary and pancreatic malignancy is quite nicely done, presenting various evaluation algorithms and discussing the pros and cons of various investigational tests fairly. Also well done is a chapter on primary tumors of the liver, focusing largely on the current management of hepatocellular carcinoma. Yes, there are some areas of minor disagreement. The discussion of hepatic abscess is quite simple, lacking the broad perspective related to differing etiologies and treatment options. The discussion of cryotherapy for intrahepatic metastases is quite short, without adequate description of this newly emerging technology. The discussion of laparoscopic cholecystectomy likely overstates the success rate of laparoscopic cholecystectomy at 95%. The surgical mangement of localized gallbladder carcinoma is stated to include cholecystectomy and resection of the gallbladder bed, without mention of portal lymphadenectomy. A discussion of pancreatic pseudocysts mentions that mature pseudocysts should not be allowed to persist, despite several reports validating selective observation of patients with stable uncomplicated pseudocysts. The pancreaticoduodenal resection illustrated for patients with chronic pancreatitis is a classic Whipple procedure (that includes a distal gastrectomy), whereas most surgeons would favor a pylorus-preserving resection in such a setting. The discussion of the epidemiology and etiology of pancreatic cancer fails to mention the molecular genetics of the tumor, including recent information regarding K-ras oncogene activation and loss of tumor suppressor genes such as p53, p16, and DPC4. The treatment of advanced pancreatic cancer makes no mention of the drug gemcitabine, the chemotherapeutic agent of choice in the United States for patients with advanced disease. Bottom Line: I found this text to be well done, nicely presented, and expertly written and edited. It reaches its intended audience and it is appropriate for general surgical residents in training, residents in advanced surgical training (such as surgical oncology and advanced alimentary tract surgery), and surgeons in practice who see patients with a broad range of hepatobiliary and pancreatic diseases. CHARLES J. YEO, M.D. Department of Surgery and Oncology Johns Hopkins Hospital Baltimore, Maryland

MRI of the Abdomen and Pelvis: A Text-Atlas. By Richard C. Semelka, Susan M. Archer, and Caroline Reinhold. 171 pp. $125.00. Wiley-Liss, Inc., New York, New York, 1997. ISBN 0-471161640. The purpose of this book is to illustrate ‘‘a complete set of diseases of the abdomen and pelvis’’ by applying the principles of magnetic resonance imaging (MRI). The authors have

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compiled an excellent text. Perhaps the most remarkable aspect of the work is the uniformly high quality of the images. These show the true potential of body MRI. However it is important to note that the images shown were obtained on specially equipped high-field MRI scanners, which may not be widely available. Coverage of diseases of the abdomen and pelvis is thorough. It is quite noteworthy that this was possible with only a handful of authors. Indeed, having Dr. Semelka as a coauthor of 12 of 15 chapters provided a uniformity of style often lacking in multiauthor texts. The chapters are extensively referenced, which adds to the utility of the book. Another attractive feature of the text is that the MRI techniques have been described in great detail, thereby allowing radiologists to replicate image quality. However, this advantage may be short-lived, because body MRI techniques have not matured and continue to evolve at a rapid pace. The principal limitation is that the book is limited to imaging diseases with MRI. This does not allow the reader to compare imaging features of diseases with other imaging techniques, such as computerized tomography (CT) and ultrasonography. As a result, the text will be most useful to

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radiologists who wish to supplement their CT-ultrasound experience. Admittedly the authors are ‘‘MR zealots’’ and have pioneered many applications of body MRI, such as Dr. Reinhold’s work on MR cholangiography. As a result, the authors often overstate the clinical potential of MRI. For example, it is claimed that MRI may be more sensitive than CT for evaluation of acute pancreatitis (page 222). Occasionally the reader may also be irritated when multi-image examples are spread over two pages, requiring the reader to flip back-andforth while reading the legend. Bottom Line: The major contribution of this text is a succinct compilation of high-quality MRI of the abdomen and pelvis. This will be most useful to experienced radiologists. Nonradiologists interested in the role of imaging for abdominal and pelvic diseases will find alternative textbooks that illustrate disease processes with CT, MRI, and ultrasonography to be more useful. SANJAY SAINI, M.D. Department of Radiology Massachusetts General Hospital Boston, Massachusetts