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Viral Hepatitis
Book Reviews
Entamoeba histolytica is an important test when amebic colitis is considered in the differential of acute mucosal pancolitis, it can sometimes be negative even when the infection is present. An alternative method of diagnosis is colonoscopy with biopsy when the history is suggestive on epidemiologic grounds. Colonoscopy also provides information as to the severity of the colitis in addition to a morphologic and histopathologic diagnosis and can be useful in assessing the response to therapy. Serologic tests at 7 days after the onset of symptoms are positive in more than 95% of cases. 2 However, the value of these tests in diagnosis depends to some extent on whether the disease is endemic. In an area where amebiasis is not endemic, one positive test is predictive; in an area where it is endemic, a negative result is useful in excluding the disease. In our case, colonoscopy was performed on the fifth day after onset of the clinical disease and the findings provided a definitive diagnosis and obviated the need for serologic testing. Ricardo Ebecken, PhD
Chief of Endoscopy Department of U. F. F. Rio de Janerio, Brazil REFERENCES 1. Dunzendorfer T, Kasznica J. Amebic and/or ulcerative colitis. Gastrointest Endosc 1998;48:450-1. 2. Ravdin JI. Diagnosis of invasive amoebiasis-time to end the morphology era. Gut 1994;35:1018-21. doi: 10.1 067 / mge.2000.1 04003 Figure 2. Photomicrograph of colonoscopic biopsies.
A, Inflammatory infiltrate with mononuclear cells and rare polymorphonuclear leukocytes (orig. mag. x250). trophozoites (arrows) (orig. mag. x450).
e,
Free
2 years ago at which 2 sessile adenomas were removed from the ascending colon together with diverticulosis involving the descending colon. Despite her complaint of intense abdominal pain, there was no tenderness on abdominal examination. Hepatosplenomegaly was not also not detected. Laboratory studies revealed leukocytosis and anemia. Entamoeba cysts were not identified in the stool. Colonoscopy performed 48 hours later disclosed severe diffuse pancolitis, the appearance of which suggested a diagnosis of ulcerative colitis (Fig. 1). Four biopsy specimens were obtained from the ascending colon to rectum. On histopathology, there was an ulcerated mucosa with an acute inflammatory infiltrate with free amebic trophozoites (Fig. 2). Treatment was started with metronidazole (750 mg tid) for 10 days to be followed by teclozan (100 mg tid) for 5 days. At 1 month after treatment colonoscopy was repeated and no morphologic or histopathologic alterations were identified. In my experience, this is the first case in 28 years of amebic colitis that thoroughly simulated ulcerative colitis at colonoscopy. Although the stool examination for 642
GASTROINTESTINAL ENDOSCOPY
Viral Hepatitis A. J. Zuckerman, H. C. Thomas 2nd edition, Churchill Livingstone, London, 1998, 635 pp,$195 This is the second edition of a book on viral hepatitis that first appeared in 1993; it has been greatly expanded and updated. The original book was organized into seven sections, with a section each on hepatitis A through E, along with one on diagnosis and one on general clinical aspects. As in the first edition, the contributors constitute an internationally distinguished collection of authors, many writing in the area in which they have done groundbreaking work. The target audience for this second edition remains the same-from clinicians to virologists, and everyone in between. The current text is organized into eight different sections, roughly corresponding to hepatitis A, B, C, D, E, followed by other hepatitis-associated flaviviruses, and lastly, to a general section on clinical aspects ofliver disease. Unlike the first edition, there is no "update" section at the close of each chapter, which allowed each author an opportunity to sandVOLUME 51, NO. 5, 2000
Book Reviews
wich in the latest information before the book went to press. Each of the virus-specific sections is arranged in a similar fashion, with separate chapters describing the molecular virology, along with the epidemiology of each infection. These are followed by chapters on natural history, the diagnosis, and treatment for each particular virus, insofar as each is applicable. The changes in organization inevitably lead to a more virus-specific approach, folding material from generic chapters on natural history and treatment from the first edition now into the virus-specific sections. Overall, however, this probably strengthens the text for clinicians, making it simpler to find relevant information. The downside, of course, for people lucky enough to have time to read it cover to cover, is that the comparative perspective is diminished. The final section includes chapters specifically devoted to hepatitis infections in special populations such as transplant, pediatric, hemophiliac, and HIVinfected populations. In addition, there are chapters related to common manifestations of complications of chronic hepatitis infection, such as the histology of hepatitis infections, the influence of chronic hepatitis infection on the development ofhepatocellular carcinoma, and last, perhaps of special interest to the endoscopy community, a very good overview of the procedures related to sterilization and hepatitis infection. Although some of the chapters have the same authors, most of them are substantially rewritten to reflect the advances occurring over the intervening 5 years. Rarely, one notices scanty changes between editions: for example, the figures and references (oftentimes, much of the text!) in many of the chapters rewritten by the original authors have had only cosmetic changes from the first edition. This is particularly striking in chapters dealing with areas where the pace of discovery has not been as rapid, such as the general introduction, or some of the natural history and structure chapters. This in no way diminishes their readability, as they present a useful overview of these aspects of viral hepatitis; it is simply one of the traps that rewriting engenders. In the new chapters, however (particularly in those dealing with the biology of hepatitis G and other flaviviruses), the text is very current. Invariably, like any multi-authored textbook, there is a fair amount of redundancy. For example, in the hepatitis A section, there is a separate chapter on the epidemiology of the virus, followed, in the next chapter by a fairly prolonged discussion of the same material (complete with graphs of prevalence and incidence). There is also little gained in showing virtually identical electron micrographs of hepatitis VOLUME 51, NO.5, 2000
A virus in different chapters dealing with the same virus. This is particularly true because there are very few illustrations in general throughout the book. Similar complaints can be made for the hepatitis B section, which contains two chapters, both dealing with different aspects of the epidemiology of hepatitis B infection. Both of these are good; one that combines the two would be sufficient. The hepatitis B section has been greatly expanded, with a number of new chapters. To enhance the text's appeal to virologists, there are two new chapters on other nonhuman hepadnaviruses, along with an extremely detailed chapter (re)written by the editors of the book and incorporating a wealth of information on "Molecular variations of hepatitis B." There is also a new chapter on pathogenesis, which presents an understandable and cogent overview of the immunology involved. The chapter on treatment has been greatly expanded to include a discussion of some of the newer therapies available; because of the timing of publication, however, the discussion regarding lamivudine, the most clinically relevant advance, is somewhat meager. Similarly, the hepatitis C section has been expanded, although not always improved. Certain deficiencies are glaringly obvious to most clinicians; for example, there is no discussion on the influence of interferon treatment on the progression of patients with cirrhosis to hepatocellular carcinoma. Likewise, because ofthe timing of publication, there is very little information on the use of combination therapy with interferon and ribavirin for treatment of chronic hepatitis C infection; the same is true for novel interferons, such as consensus interferon. In none of the treatment chapters is there substantial discussion of the mechanisms of action of interferon. Conversely, for most clinicians, there is too much familiarity assumed with some of the molecular biology techniques for them to be completely readable. The chapters in the last section, "Clinical aspects of viral disease" are uniformly good, although some of the material is not necessarily handled with more depth than what is available in standard texts. The rationale for including some of the material is slightly obscure, as well; the chapter on "Management of hepatocellular carcinoma" is interesting but not completely required in a text on viral hepatitis. Overall, I think this text is useful to most physicians seeking an overview of viral hepatitis at a level of detail greater than what can be obtained from a standard textbook ofliver disease. It is impossible for any book to be all things to all readers, and, given the pace of progress in this field, an overview is probably the best that can be hoped. For clinicians, the lag time between writing and publication makes most of GASTROINTESTINAL ENDOSCOPY 643
Book Reviews
the information on therapy outdated. It is a useful stepping off point, though, and those with the time to read through it will emerge with a reasonable synthesis and a more coherent understanding of the biology of hepatitis viruses. Robert O'Shea, MD, MSc
Cleveland, Ohio doi: 10.1067/ mge.2000.1 03576
Diseases of the Liver and Biliary System in Children D. A. Kelly Blackwell Science, London, 1999,356 pp, $165
Diseases of the Liver and Biliary System in Children is a book for clinicians written by clinicians. As such it fulfills the remit Dr. Kelly sets in the Preface. Those readers seeking detailed scientific background and comprehensive research reviews will need to look elsewhere. If, on the other hand, the reader wishes information on the purely clinical approach and management of infants and children with liver disease, they have come to the right place. This book is to be read and not just dipped into for references. Although this text would be useful to anybody in pediatric training, I suspect it will be most useful to the already practicing general pediatrician and the pediatric gastroenterologistlhepatologist in training. With the pressures on the general pediatric trainees, most of them will obtain their hepatologic education from a shorter text. The book is well produced with clear tables and well-drawn figures, and in general the writing is in short paragraphs with clear headings. The photographic plates are all collected together at the end of the book in an "atlas." The reference sections to each chapter were for the most part adequate. There were, however, a few sections throughout the book that were poorly referenced. The structure of the sections and chapters was logical and the information content of the book as a whole was very good. As far as I was concerned every field of clinical importance was covered to some extent. Certain chapters, however, stood out above the rest and reflected the authors' many years of both clinical and research interest in their subjects, namely the chapters on cystic fibrosis, copper metabolism, complications and management of chronic liver disease, and surgical disorders. I particularly enjoyed the chapter on dental care. Dental development and pathology, which is not common knowledge to physicians, was explained at just the required level and clear guidelines were given on the dental management of children before and after liver transplantation. Several chapters were essentially personal practice statements from reputable 644
GASTROINTESTINAL ENDOSCOPY
units such as the chapters on fulminant hepatitis and the two chapters on transplantation. Most of the rest of the chapters gave the impression of diligent literature review but without the personal authority of the best chapters. I was pleased, although far from surprised, at the emphasis on metabolic defects throughout the text. Less satisfactory was the subject ofliver disease associated with intestinal failure and total parenteral nutrition (TPN). This is an increasingly important condition with so many referrals to pediatric gastroenterologists and hepatologists currently from pediatric surgeons and neonatologists in relation to infants with intestinal failure and conjugated hyperbilirubinemia. Although included in at least two chapters, I felt it was inadequately covered, being vague in the explanation of the multifactorial etiology of this condition and poorly referenced. Following on from this is the lack of recommendations for any clear approach to the management of this problem. The only omission was a discussion of granulomatous hepatitis, which although unusual is well described in childhood. This area can often cause both diagnostic and prognostic difficulties for the clinician. Glaring errors in factual content were few. In chapter 2, Alfacalcidol was described as 1,25 dihydroxy vitamin D when it is in fact la-hydroxy cholecalciferol. Also, I was disappointed to see the propagation of a popular myth concerning Factor VIII and its site of production. It has clearly been demonstrated that the hepatocyte is indeed the major Factor VIII-producing cell in the body and not the hepatic endothelium as stated in the chapter on fulminant failure. 1 Clarification of differences between the two sides of the Atlantic in terms of prothrombin times and Nacetylcysteine treatment regimes for paracetamol (acetaminophen) overdose would have been useful as I remember both of these aspects taking me by surprise when I moved from the UK to the USA. The only part of the book which did not impress was the "atlas" section. The concept of an atlas at the back of the book sounded like a very good idea until I realized that this is not a comprehensive atlas of pediatric liver disease but just a series of photographic plates to illustrate points in the text and, thus, as such I think they would have been better among the text. I wonder if this was an economic decision on the part of the publisher to lay the book out in this fashion. Overall, I think this is an admirable textbook, which, as I have mentioned, should be read before placing it on the bookshelf. This book should certainly be part of any pediatric library. Returning to the foreword by Dame Sheila Sherlock: while commending this book she states that it would be "a VOLUME 51, NO. 5, 2000
Entamoeba histolytica is an important test when amebic colitis is considered in the differential of acute mucosal pancolitis, it can sometimes be negative even when the infection is present. An alternative method of diagnosis is colonoscopy with biopsy when the history is suggestive on epidemiologic grounds. Colonoscopy also provides information as to the severity of the colitis in addition to a morphologic and histopathologic diagnosis and can be useful in assessing the response to therapy. Serologic tests at 7 days after the onset of symptoms are positive in more than 95% of cases. 2 However, the value of these tests in diagnosis depends to some extent on whether the disease is endemic. In an area where amebiasis is not endemic, one positive test is predictive; in an area where it is endemic, a negative result is useful in excluding the disease. In our case, colonoscopy was performed on the fifth day after onset of the clinical disease and the findings provided a definitive diagnosis and obviated the need for serologic testing. Ricardo Ebecken, PhD
Chief of Endoscopy Department of U. F. F. Rio de Janerio, Brazil REFERENCES 1. Dunzendorfer T, Kasznica J. Amebic and/or ulcerative colitis. Gastrointest Endosc 1998;48:450-1. 2. Ravdin JI. Diagnosis of invasive amoebiasis-time to end the morphology era. Gut 1994;35:1018-21. doi: 10.1 067 / mge.2000.1 04003 Figure 2. Photomicrograph of colonoscopic biopsies.
A, Inflammatory infiltrate with mononuclear cells and rare polymorphonuclear leukocytes (orig. mag. x250). trophozoites (arrows) (orig. mag. x450).
e,
Free
2 years ago at which 2 sessile adenomas were removed from the ascending colon together with diverticulosis involving the descending colon. Despite her complaint of intense abdominal pain, there was no tenderness on abdominal examination. Hepatosplenomegaly was not also not detected. Laboratory studies revealed leukocytosis and anemia. Entamoeba cysts were not identified in the stool. Colonoscopy performed 48 hours later disclosed severe diffuse pancolitis, the appearance of which suggested a diagnosis of ulcerative colitis (Fig. 1). Four biopsy specimens were obtained from the ascending colon to rectum. On histopathology, there was an ulcerated mucosa with an acute inflammatory infiltrate with free amebic trophozoites (Fig. 2). Treatment was started with metronidazole (750 mg tid) for 10 days to be followed by teclozan (100 mg tid) for 5 days. At 1 month after treatment colonoscopy was repeated and no morphologic or histopathologic alterations were identified. In my experience, this is the first case in 28 years of amebic colitis that thoroughly simulated ulcerative colitis at colonoscopy. Although the stool examination for 642
GASTROINTESTINAL ENDOSCOPY
Viral Hepatitis A. J. Zuckerman, H. C. Thomas 2nd edition, Churchill Livingstone, London, 1998, 635 pp,$195 This is the second edition of a book on viral hepatitis that first appeared in 1993; it has been greatly expanded and updated. The original book was organized into seven sections, with a section each on hepatitis A through E, along with one on diagnosis and one on general clinical aspects. As in the first edition, the contributors constitute an internationally distinguished collection of authors, many writing in the area in which they have done groundbreaking work. The target audience for this second edition remains the same-from clinicians to virologists, and everyone in between. The current text is organized into eight different sections, roughly corresponding to hepatitis A, B, C, D, E, followed by other hepatitis-associated flaviviruses, and lastly, to a general section on clinical aspects ofliver disease. Unlike the first edition, there is no "update" section at the close of each chapter, which allowed each author an opportunity to sandVOLUME 51, NO. 5, 2000
Book Reviews
wich in the latest information before the book went to press. Each of the virus-specific sections is arranged in a similar fashion, with separate chapters describing the molecular virology, along with the epidemiology of each infection. These are followed by chapters on natural history, the diagnosis, and treatment for each particular virus, insofar as each is applicable. The changes in organization inevitably lead to a more virus-specific approach, folding material from generic chapters on natural history and treatment from the first edition now into the virus-specific sections. Overall, however, this probably strengthens the text for clinicians, making it simpler to find relevant information. The downside, of course, for people lucky enough to have time to read it cover to cover, is that the comparative perspective is diminished. The final section includes chapters specifically devoted to hepatitis infections in special populations such as transplant, pediatric, hemophiliac, and HIVinfected populations. In addition, there are chapters related to common manifestations of complications of chronic hepatitis infection, such as the histology of hepatitis infections, the influence of chronic hepatitis infection on the development ofhepatocellular carcinoma, and last, perhaps of special interest to the endoscopy community, a very good overview of the procedures related to sterilization and hepatitis infection. Although some of the chapters have the same authors, most of them are substantially rewritten to reflect the advances occurring over the intervening 5 years. Rarely, one notices scanty changes between editions: for example, the figures and references (oftentimes, much of the text!) in many of the chapters rewritten by the original authors have had only cosmetic changes from the first edition. This is particularly striking in chapters dealing with areas where the pace of discovery has not been as rapid, such as the general introduction, or some of the natural history and structure chapters. This in no way diminishes their readability, as they present a useful overview of these aspects of viral hepatitis; it is simply one of the traps that rewriting engenders. In the new chapters, however (particularly in those dealing with the biology of hepatitis G and other flaviviruses), the text is very current. Invariably, like any multi-authored textbook, there is a fair amount of redundancy. For example, in the hepatitis A section, there is a separate chapter on the epidemiology of the virus, followed, in the next chapter by a fairly prolonged discussion of the same material (complete with graphs of prevalence and incidence). There is also little gained in showing virtually identical electron micrographs of hepatitis VOLUME 51, NO.5, 2000
A virus in different chapters dealing with the same virus. This is particularly true because there are very few illustrations in general throughout the book. Similar complaints can be made for the hepatitis B section, which contains two chapters, both dealing with different aspects of the epidemiology of hepatitis B infection. Both of these are good; one that combines the two would be sufficient. The hepatitis B section has been greatly expanded, with a number of new chapters. To enhance the text's appeal to virologists, there are two new chapters on other nonhuman hepadnaviruses, along with an extremely detailed chapter (re)written by the editors of the book and incorporating a wealth of information on "Molecular variations of hepatitis B." There is also a new chapter on pathogenesis, which presents an understandable and cogent overview of the immunology involved. The chapter on treatment has been greatly expanded to include a discussion of some of the newer therapies available; because of the timing of publication, however, the discussion regarding lamivudine, the most clinically relevant advance, is somewhat meager. Similarly, the hepatitis C section has been expanded, although not always improved. Certain deficiencies are glaringly obvious to most clinicians; for example, there is no discussion on the influence of interferon treatment on the progression of patients with cirrhosis to hepatocellular carcinoma. Likewise, because ofthe timing of publication, there is very little information on the use of combination therapy with interferon and ribavirin for treatment of chronic hepatitis C infection; the same is true for novel interferons, such as consensus interferon. In none of the treatment chapters is there substantial discussion of the mechanisms of action of interferon. Conversely, for most clinicians, there is too much familiarity assumed with some of the molecular biology techniques for them to be completely readable. The chapters in the last section, "Clinical aspects of viral disease" are uniformly good, although some of the material is not necessarily handled with more depth than what is available in standard texts. The rationale for including some of the material is slightly obscure, as well; the chapter on "Management of hepatocellular carcinoma" is interesting but not completely required in a text on viral hepatitis. Overall, I think this text is useful to most physicians seeking an overview of viral hepatitis at a level of detail greater than what can be obtained from a standard textbook ofliver disease. It is impossible for any book to be all things to all readers, and, given the pace of progress in this field, an overview is probably the best that can be hoped. For clinicians, the lag time between writing and publication makes most of GASTROINTESTINAL ENDOSCOPY 643
Book Reviews
the information on therapy outdated. It is a useful stepping off point, though, and those with the time to read through it will emerge with a reasonable synthesis and a more coherent understanding of the biology of hepatitis viruses. Robert O'Shea, MD, MSc
Cleveland, Ohio doi: 10.1067/ mge.2000.1 03576
Diseases of the Liver and Biliary System in Children D. A. Kelly Blackwell Science, London, 1999,356 pp, $165
Diseases of the Liver and Biliary System in Children is a book for clinicians written by clinicians. As such it fulfills the remit Dr. Kelly sets in the Preface. Those readers seeking detailed scientific background and comprehensive research reviews will need to look elsewhere. If, on the other hand, the reader wishes information on the purely clinical approach and management of infants and children with liver disease, they have come to the right place. This book is to be read and not just dipped into for references. Although this text would be useful to anybody in pediatric training, I suspect it will be most useful to the already practicing general pediatrician and the pediatric gastroenterologistlhepatologist in training. With the pressures on the general pediatric trainees, most of them will obtain their hepatologic education from a shorter text. The book is well produced with clear tables and well-drawn figures, and in general the writing is in short paragraphs with clear headings. The photographic plates are all collected together at the end of the book in an "atlas." The reference sections to each chapter were for the most part adequate. There were, however, a few sections throughout the book that were poorly referenced. The structure of the sections and chapters was logical and the information content of the book as a whole was very good. As far as I was concerned every field of clinical importance was covered to some extent. Certain chapters, however, stood out above the rest and reflected the authors' many years of both clinical and research interest in their subjects, namely the chapters on cystic fibrosis, copper metabolism, complications and management of chronic liver disease, and surgical disorders. I particularly enjoyed the chapter on dental care. Dental development and pathology, which is not common knowledge to physicians, was explained at just the required level and clear guidelines were given on the dental management of children before and after liver transplantation. Several chapters were essentially personal practice statements from reputable 644
GASTROINTESTINAL ENDOSCOPY
units such as the chapters on fulminant hepatitis and the two chapters on transplantation. Most of the rest of the chapters gave the impression of diligent literature review but without the personal authority of the best chapters. I was pleased, although far from surprised, at the emphasis on metabolic defects throughout the text. Less satisfactory was the subject ofliver disease associated with intestinal failure and total parenteral nutrition (TPN). This is an increasingly important condition with so many referrals to pediatric gastroenterologists and hepatologists currently from pediatric surgeons and neonatologists in relation to infants with intestinal failure and conjugated hyperbilirubinemia. Although included in at least two chapters, I felt it was inadequately covered, being vague in the explanation of the multifactorial etiology of this condition and poorly referenced. Following on from this is the lack of recommendations for any clear approach to the management of this problem. The only omission was a discussion of granulomatous hepatitis, which although unusual is well described in childhood. This area can often cause both diagnostic and prognostic difficulties for the clinician. Glaring errors in factual content were few. In chapter 2, Alfacalcidol was described as 1,25 dihydroxy vitamin D when it is in fact la-hydroxy cholecalciferol. Also, I was disappointed to see the propagation of a popular myth concerning Factor VIII and its site of production. It has clearly been demonstrated that the hepatocyte is indeed the major Factor VIII-producing cell in the body and not the hepatic endothelium as stated in the chapter on fulminant failure. 1 Clarification of differences between the two sides of the Atlantic in terms of prothrombin times and Nacetylcysteine treatment regimes for paracetamol (acetaminophen) overdose would have been useful as I remember both of these aspects taking me by surprise when I moved from the UK to the USA. The only part of the book which did not impress was the "atlas" section. The concept of an atlas at the back of the book sounded like a very good idea until I realized that this is not a comprehensive atlas of pediatric liver disease but just a series of photographic plates to illustrate points in the text and, thus, as such I think they would have been better among the text. I wonder if this was an economic decision on the part of the publisher to lay the book out in this fashion. Overall, I think this is an admirable textbook, which, as I have mentioned, should be read before placing it on the bookshelf. This book should certainly be part of any pediatric library. Returning to the foreword by Dame Sheila Sherlock: while commending this book she states that it would be "a VOLUME 51, NO. 5, 2000