Viral Hepatitis: Diagnosis, Treatment and Prevention

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

Clinician’s Manual on Helicobacter pylori. Edited by George J. J. Misiewicz and Adam Harris. 45 pp. £7.25. Science Press Ltd., London, England, 1997. ISBN 1-85873-239-5. This is a pocket-sized manual reviewing the pathophysiology, diagnosis, and treatment of Helicobacter pylori infection in the upper gastrointestinal tract. In view of the rapid growth in information on H. pylori infection, the authors aim to provide the reader with an up-to-date review of current knowledge about this organism. In the first chapter, there is a concise review of the pathophysiology of H. pylori infection in the gastrointestinal system. Initially, the epidemiology of H. pylori infection is described, and the link with socioeconomic standing is noted. It is postulated that infection probably occurs through direct contact, although this remains to be proven. The different patterns of gastritis that may occur with H. pylori are described, and how gastritis may predispose to either duodenal or gastric ulceration is expanded. In addition, the importance of virulence factors such as vacuolating cytotoxin, cytotoxin-associated gene, and urease activity are mentioned. How host responses aid in the development of disease is described in detail, with figures that elucidate the necessary points. This detail could leave the reader muddled; however, the authors explain these concepts clearly. The myriad of tests available to diagnose H. pylori infection are divided into hospital and primary care investigations. There is a brief description of each test, including its sensitivity and specificity. There are some minor errors in the text, for example, the implication that H&E stains have the same sensitivity and specificity as the Warthin–Starry and Giemsa stains. The histological micrographs are of excellent quality, as is the figure explaining how the urea breath test works. The treatment section compares the advantages of various antibiotic combinations, specifically double, triple, and quadruple therapy, and covers the various drawbacks, including antibiotic resistance, compliance, and side effect profiles. In view of the large number of regimens, this is an excellent, concise summary and imparts information without confusing the reader. The tables are easy to read and provide a rapid source to return to when a clinical scenario arises in the office. The last section covers the indications for eradicating H. pylori, including follow-up investigations and retreatment regimens for those who do not respond to treatment. The recommendations for therapy of clear-cut indications such as peptic ulcer disease are clearly written with good algorithms provided on how to manage patients with either duodenal or gastric ulcer. The thorny issue of whether to treat patients with nonulcer dyspepsia, gastroesophageal reflux disease, or those at risk of gastric cancer is also addressed.

Overall, this is a well-written manual on the current investigation and therapy of H. pylori–associated gastrointestinal diseases. The algorithms and tables add to the text and allow quick reference for a busy practitioner. Some tables are superfluous and could easily have been combined with no loss of clarity, for example, Figures 1.10 and 1.11, 1.12 and 1.14, and 1.13 and 1.15. The photomicrographs would have benefited from arrows showing the bacteria (Figures 1.7 and 2.1) and metaplasia (Figure 1.8). Naming the histological stains used on the figure legends would help the reader to recognize the different stains used in identifying this organism. The references are limited and a large number of abstracts are included. These are relatively minor faults and do not detract from the value of the pamphlet. This is a convenient reference for primary care physicians and house staff. For many gastroenterologists, this pamphlet may be somewhat superficial and basic, but for a compact, easy to carry book, it manages to address the main clinical associations of H. pylori and outlines the appropriate management. The summary on therapy is particularly well written and is easy to follow for the busy clinician. Its target audience seems to be primary care physicians, trainees, and medical students, and for these groups, I would recommend this as a quick primer on this topic. Bottom Line: Drs. Misiewicz and Harris have done an admirable job of summarizing in a concise and readable format the role of H. pylori in gastrointestinal disease. The target audience of this primer are primary care physicians, trainees, and medical students. ROBERT D. J. HENIHAN, M.B. Gastrointestinal Unit Massachusetts General Hospital Boston, Massachusetts

Therapeutic Endoscopy: Color Atlas of Operative Techniques for Gastrointestinal Tract. Edited by Nib Soehendra, Kenneth F. Binmoeller, Hans Seifert, and Hans Wilhelm Scheiber. 214 pp. $159.00. Thieme, New York, New York, 1998. ISBN 0-86577638-5. As stated in the preface, this books aims to ‘‘portray the realistic therapeutic capabilities of endoscopy in its day-to-day practice,’’ and it succeeds in its mission. This atlas uses very high-quality original anatomic and endoscopic view drawings to illustrate therapeutic techniques of endoscopic procedures. The text is concise without compromising the important details pertinent to the specific procedure, the legends to the figures are highly detailed, and the index is complete. The atlas is easy to view and read and can be thoroughly reviewed in an evening. There is no bibliography.

June 1998

There are 17 chapters, with 40% of the content related to the upper gastrointestinal tract, 50% related to endoscopic retrograde cholangiopancreatography (ERCP) and associated pancreatobiliary techniques, and 10% devoted to the colon. The atlas reflects the experience and viewpoints of a single expert European center. Viewpoints are therefore a reflection of that center and some controversial approaches are presented as ‘‘the best way’’ without balancing the discussion (e.g., esophageal strictures should be dilated only to size 42F, and type III biliary hilar tumors should not be treated endoscopically). The American audience will find the atlas interesting for showing a variety of techniques not commonly used or available in the United States, such as use of cyanoacrylate tissue adhesive for varices and closure of fistulae and hemoclips for hemostasis and closure of perforations. Although the text is remarkably generic in its presentation, a few of the tubes and products mentioned are not available in the United States. Placement of plastic stents in the esophagus and pancreatobiliary trees are nicely presented. Notably absent, however, are illustrations of metal stent placement in the esophagus, duodenum, biliary tree, and colon. Hemorrhoid therapies are omitted, and common hemostasis techniques of injection and thermal therapies are not portrayed. The pancreatobiliary sections contain many tips, such as saline injection at the edge of a duodenal diverticulum to aid pancreatobiliary cannulation. The artwork has excellent potential for teaching. Hopefully, the atlas will become available in slide form or optical disk for large screen projection. The authors appropriately caution the reader that these techniques should only be performed by persons with adequate clinical experience and training, because the drawings might tempt the novice to try the new technique. Bottom Line: The authors and their artists have assembled an excellent set of life-like illustrations. This atlas is a must buy for teaching centers and therapeutic endoscopy enthusiasts. EMAD RAHMANI, M.D. GLEN A. LEHMAN, M.D. Indiana University Medical Center Indianapolis, Indiana

Gastrointestinal Diseases. Risk Factors and Prevention. Edited by John F. Johanson. 296 pp. $79.00. Lippincott-Raven Publishers, Philadelphia, Pennsylvania, 1997. ISBN 0-397-58781-3. Numerous studies have shown that preventable illnesses comprise a significant proportion of total health care costs. The focus in our health care delivery systems has begun to shift from one based almost solely on disease treatment to one that emphasizes disease prevention through dietary and lifestyle changes, risk-factor identification and reduction, screening, early disease therapy, and reduction in environmental toxins. In the new health care system, even greater clinical and research resources will be allocated to these efforts. Whereas studies of the risk factors for cardiovascular disorders have led to large-scale primary, secondary, and tertiary prevention programs that have dramatically reduced morbidity and mortality,

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programs targeted at the prevention of gastroenterological diseases have lagged far behind. The field of gastroenterology must now move forward into disease prevention. The goal of this book is to discuss the epidemiology and risk factors of common gastroenterological disorders and to provide guidelines for the prevention, screening, and early detection of these disorders. The chapters are written by various eminent gastroenterologists, most of whom have contributed heavily to our understanding of gastrointestinal epidemiology and to the development of current prevention guidelines. The opening three chapters of the book provide an introduction, a brief review of the methodology of epidemiological studies, and a discussion of screening and surveillance. Each of the remaining chapters deals with a specific gastroenterological disorder, including gastroesophageal reflux disease (GERD), peptic ulcer disease, irritable bowel syndrome, constipation, chronic pancreatitis, chronic liver disease, and various gastrointestinal malignancies (esophageal, gastric, colorectal, pancreatic, and hepatocellular). Each of these chapters follows a similar format, first discussing the disease definition, clinical epidemiology, and risk factors before reviewing prevention strategies and screening guidelines. Overall, the book is well organized, highly informative, and a delight to read. As with any text, some chapters are stronger than others. Although the chapter on epidemiological methods should be a cornerstone of the book, it is a cursory, superficial review that detracts from an otherwise strong book. After an initial overview of general principles and criteria for screening tests, the chapter on screening and surveillance focuses largely on colorectal cancer, ulcerative colitis, and Barrett’s esophagus, specific topics more appropriately covered in subsequent chapters. Most of the disease-specific chapters are excellent; however, the chapters on GERD, peptic ulcer disease, inflammatory bowel disease, chronic liver disease, gastric cancer, colorectal cancer, and hepatocellular cancer deserve particular praise for their clarity and scholarly review. Some of the topics chosen are of dubious merit. Two chapters devoted to the epidemiology of fecal incontinence and hemorrhoids (although very well written) seem excessive; prevention programs are unlikely to impact on the former, and the latter could be subsumed under the chapter on constipation. Likewise, the chapter on gallstones, one of the best in the text, seems almost superfluous in the era of laparoscopic cholecystectomy. The chapter on irritable bowel syndrome is superficial and does not do justice to the extensive epidemiological research performed in this area. Despite its many strengths, it is not clear to what audience this text will be most helpful. The editor states that the book is aimed at primary care physicians, gastroenterologists, and surgeons and may aid managed care organizations in their development of disease-prevention guidelines. Nonetheless, the book does not strike me as being particularly useful to practicing gastroenterologists. Most of the information on disease epidemiology is not new and may be found in the major gastroenterology textbooks. The book does provide useful, current recommendations for screening and surveillance; how-

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ever, similar guidelines have been published in numerous journal articles over the past few years and have been presented at national meetings. Academic gastroenterologists engaged in epidemiological research and teaching will find this to be a useful overview and handy quick reference. Although this would be appropriate reading for primary care physicians, I am skeptical that it will achieve much penetration of this market. Bottom Line: The text is written, organized, and edited well. It is a useful compendium that may be recommended to academic gastroenterologists interested in epidemiology and disease prevention and to clinical gastroenterologists who want a quick, easy-to-read reference for screening and surveillance guidelines. KENNETH R. MCQUAID, M.D. San Francisco VA Medical Center Gastroenterology Section University of California San Francisco San Francisco, California

Viral Hepatitis: Diagnosis, Treatment and Prevention. Edited by Richard A. Willson. 552 pp. $175.00. Marcel Dekker, Inc., New York, New York, 1997. ISBN 0-8247-9416-8. The study of viral hepatitis has accelerated over the past decade. Research has advanced our understanding of the molecular virology, epidemiology, pathogenesis, and clinical management of viral hepatitis. The aim of this textbook is to highlight recent developments in research on viral hepatitis, placing this information in a clinical context that is pertinent to and easily understood by the clinician with a limited laboratory background. This would seem to be a formidable challenge; however, the contributors to this textbook have succeeded in creating a text that is comprehensive and thorough but also very readable, understandable, and useful to clinicians interested in viral hepatitis. This textbook is not encyclopedic, nor was it intended to be; nevertheless, there are no large gaps in the information presented. The text is divided into 16 chapters, each focusing on an important area of study in viral hepatitis. The first chapter focuses on molecular diagnostic testing for viral hepatitis and is an excellent summary of the techniques used currently to diagnose, characterize, and quantitate the hepatitis viruses. The following seven chapters are devoted to the hepatitis viruses, A through G, as well as other hepatitis viruses. The organization of these chapters is not uniform, which would have been very helpful, but each virus-specific chapter includes some information about the molecular biology and virology, epidemiology, pathogenesis of infection, clinical features, diagnostic methods, and treatment of acute and/or chronic disease. Hepatitis C is presented in one long chapter that would have been better organized into two chapters, one

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that focused on the molecular biology and virology of hepatitis C and a second that addressed the epidemiology, pathogenesis, prognosis, and treatment of hepatitis C. Hepatitis B is the focus of two chapters: Chapter 3 focuses on the molecular and immunopathologic features of the hepatitis B virus, whereas chapter 4 addresses the clinical syndromes associated with hepatitis B infection, immunoprophylaxis, and antiviral therapy of chronic infection. These chapters are well written and complementary and give the reader a good understanding of hepatitis B from both a virological and clinical point of view. In all the virus-specific chapters, graphs, tables, and figures enhance the text and provide a visual representation of the most pertinent information contained in each chapter. Some information is outdated, however. For instance, there is little information about the use of nucleoside analogues, including lamivudine, for treatment of hepatitis B, and chapter 8 on non–A-E hepatitis viruses includes information that reflects our early and erroneous understanding of hepatitis G and another putative hepatitis agent, sometimes called hepatitis F. Such errors are unavoidable given the lag time between when a chapter is written and when it is published, and this limitation does not impact significantly on the relevance of the text. The seven virus-specific chapters provide the clinician with an excellent overview of our current understanding of the molecular and clinical characteristics of these viruses. The last eight chapters of the book are topical in nature and provide a clinical context for the molecular and virological information presented in the virus-specific chapters. The topics covered include hepatocellular carcinoma and viral hepatitis; liver transplantation and viral hepatitis; viral hepatitis in marrow and stem-cell transplantation; extrahepatic manifestations of viral hepatitis; overlap syndromes; viral hepatitis and the immunocompromised host; and the role of iron in chronic viral hepatitis. Although this is not a comprehensive list of topics pertinent to the clinician, the information presented is concise, easy to understand, well referenced, and clinically relevant. The tables, figures, and illustrations are well designed and nicely appointed throughout the text and enhance the flow of the book. Bottom Line: This is a well-written, comprehensive text that should have great relevance to clinicians interested in viral hepatitis. Readers will be pleased with the book’s compact size, excellent bibliographies, detailed index, and ease with which the text can be read. This book will be a welcome addition to the library of any clinician who treats patients with viral liver disease. ANDREA E. REID, M.D. Gastrointestinal Unit Massachusetts General Hospital Boston, Massachusetts