Book Review

The Functional Gastrointestinal Disorders: Diagnosis, pathophysiology, and treatment — a multinational consensus

N Engl J Med 1995; 332:1657June 15, 1995

Article

The Functional Gastrointestinal Disorders: Diagnosis, pathophysiology, and treatment — a multinational consensus
Edited by Douglas A. Drossman, with Joel E. Richter, Nicholas J. Talley, W. Grant Thompson, Enrico Corazziari, and William E. Whitehead. 370 pp., illustrated. Boston, Little, Brown, 1994. $87.50. ISBN: 0-316-19342-9

Functional gastrointestinal disorders are frequent but poorly understood and often prove frustrating to patients and physicians. Amid the uncertainty stemming from limited clinical trials in this area, patients are often subjected to extensive (and expensive) tests in search of an elusive “organic” illness. The clear and thorough exposition on this topic presented in The Functional Gastrointestinal Disorders, edited by Drossman et al., is therefore a welcome addition to medical libraries.

Much of the book derives from a series of consensus-committee reports presented at the International Congress of Gastroenterology held in Rome in 1988 and subsequently published in Gastroenterology International. The authors represent a panel of experts who together have contributed much of the primary data available on functional gastrointestinal disease. They provide an international perspective on this group of disorders, which are highly prevalent throughout the developed world.

The authors tackle the broad spectrum of disorders that fit this classification, generally grouping them according to anatomical site. They cover esophageal, gastroduodenal, and bowel disorders (along with functional abdominal pain), as well as functional biliary disease and disorders involving the anus and rectum. In addition, there is a chapter on the optimal design of therapeutic trials of functional gastrointestinal disease and a section with detailed data on prevalence.

Each chapter adheres to a common format, which includes the definition, epidemiology, diagnostic criteria, clinical evaluation, physiologic features, psychological features, and approach to treatment of the given disorder. This approach results in some redundancy (for instance, in terms of the psychological factors involved in functional gastrointestinal disorders), but each chapter is complete and can serve as an independent resource on its topic. Though the book generally maintains a practical focus, its usefulness to clinicians might have been enhanced by the inclusion of illustrative cases. More extensive comment about natural history and prognosis would also have been helpful.

The book is clear, reasonably concise, and well referenced. It presents a complete discussion of a difficult topic, making explicit what is known and unknown and addressing areas of overlap between these related disorders. Dominant theories of pathophysiology are presented, fortunately without the excess of motility tracings and other primary data that make many sources on this topic unreadable. The inclusion of consensus-derived, symptom-based diagnostic criteria, as developed and widely accepted for rheumatic diseases and for psychiatric symptoms, represents a major contribution of this book, not readily available elsewhere.

Finally, clinicians will welcome the authors' concrete approach to therapy, offered despite the remaining uncertainty in this area. The literature lacks clear and consistent entry criteria and objective measures of severity or improvement. The placebo-response rate is strikingly high. Therefore, where treatment trials are difficult to perform and interpret, the authors rely on their considerable personal experience to fill in gaps and expand their discussion beyond the available literature.

This book is likely to attract a loyal (though not large) audience. Although even practicing gastroenterologists may not be able to envision themselves curling up with a 370-page book on functional gastrointestinal disease, this book is one that primary care physicians and gastrointestinal specialists will frequently pull off the shelf as a useful reference on the care of these challenging cases. Moreover, it should prove invaluable to those planning clinical studies. I hope we will see updates of this textbook in coming years, since there is such rapid expansion of new knowledge in the field.

Debra F. Weinstein, M.D.
Massachusetts General Hospital, Boston, MA 02114