Book Review

Clinical Challenges in Gastroenterology

N Engl J Med 1997; 336:1844-1845June 19, 1997

Article

Clinical Challenges in Gastroenterology
Edited by Michael J.G. Farthing. 214 pp. St. Louis, Mosby, 1997. $75. ISBN: 1-85317-252-9

Don't be misled by the title. This book is not a series of difficult clinical cases complete with discussions and expert solutions. Rather, it is a collection of reviews that tackle “common and difficult problems that face gastroenterologists and hepatologists on a daily basis.” The problems range from treating Helicobacter pylori infection, the irritable bowel syndrome, and hepatitis C to palliating esophageal cancer and managing difficult bile-duct stones. The management strategies aim to integrate the best evidence available with clinical judgment in order to be truly evidence-based. The book only partly fulfills its ambitious goals, however.

The chapters are generally well written and remarkably easy to read (in part because of the large print and excellent layout). There are a few black-and-white photographs and a reasonable number of good diagrams, and the paper feels and looks nice. All the contributors are from the United Kingdom, but the views reflect practice on both sides of the Atlantic (and even the Pacific). Each chapter ends with a novel section entitled “What would I do if I had . . .”; though brief, these personalized overviews are particularly enjoyable and insightful.

A common problem with multiauthored books is that the contributions are patchy (unless the editor rewrites most of them, as some do). This book is no exception. Some contributions are really outstanding, such as those on screening tests for celiac disease, the role of surveillance and surgery in Barrett's esophagus, and intestinal failure. But others tend to skim the surface of large topics, such as the treatment of refractory diarrhea in AIDS and the management of refractory Crohn's disease. Of course, no book can keep pace with the ever-expanding literature; most of the references here predate 1994. This limitation particularly affects rapidly evolving areas, such as combination therapies for H. pylori (which seem to change constantly) and the use of injections of botulinum toxin to treat achalasia (whose long-term value now looks questionable). It is also unfortunate that the authors do not give their strategies of searching the literature, so as to reassure the reader that a balanced view is being presented (although for the most part the chapters do seem appropriately based on evidence).

Who should purchase the book? Despite shortcomings, it contains some truly valuable messages for practicing clinicians. However, the selection of topics (14 in all) is arbitrary and far from comprehensive. Problems such as the management of unexplained chronic abdominal pain, chronic constipation, fecal incontinence, and portal hypertensive gastropathy — to name just a few difficult areas of practice — are not discussed. On the other hand, a few topics, such as nutritional support as the primary therapy for Crohn's disease, are arguably of lesser interest and could have been omitted. Moreover, there is not quite enough detail for fellows in training, and like all books, this one is not current enough for practitioners, who will still have to conduct appropriate literature searches. I enjoyed the book's approach, but in its current form the appeal to gastroenterologists and hepatologists will be limited.

Nicholas J. Talley, M.D., Ph.D.
University of Sydney, Penrith NSW 2751, Australia