Book Review

Evolving Concepts in Gastrointestinal Motility

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

Article

Evolving Concepts in Gastrointestinal Motility
By Malcolm C. Champion and William C. Orr. 344 pp. Cambridge, Mass., Blackwell Science, 1996. $85. ISBN: 0-86542-944-8

This monograph covers motility in the gastrointestinal tract, from the esophagus to the anus. The authors are among the most active clinical investigators in the field. Each chapter has 50 to 145 references, and some of the clinically oriented chapters contain useful flow diagrams concerning management and treatment. Exception may be taken to some of the steps suggested, but they provide a useful starting point with which to approach common clinical problems.

The chapter entitled “Treatment of Gastroparesis” provides a summary discussion of the prokinetic drugs used to treat motility disorders. This discussion, however, includes many drugs that are not available to physicians practicing in the United States. Many of them, like domperidone, may never reach the American market. Nevertheless, these agents receive almost as much attention here as drugs now available.

Although the title of the monograph is Evolving Concepts in Gastrointestinal Motility, only the chapter entitled “Visceral Sensation and Perception in Functional Bowel Disorders” really lives up to that name. Much of the remainder of the book might more appropriately be called “Contemporary Approaches to Gastrointestinal Motility Disorders.”

I had difficulty identifying the intended audience of the monograph. Some explanations are so simple and basic as to be appropriate for an introductory college physiology textbook. In other places, however, readers will find it difficult to follow the discussions if they are not familiar with the literature cited.

Several topics should have been included in a book that attempts to reflect recent advances in gastrointestinal motility. There is no mention of the interstitial cells of Cajal. Recent studies have established that these cells are the pacemakers governing the motility of the intestine and the colon. It would seem that if we are to understand dysfunction of alimentary tract motility, this cellular network must be recognized and studied. Second, although intraluminal manometry has been the method most widely used to study gastrointestinal motility for the past 40 years, it does not directly measure muscle activity. This point is made in relation to visceral sensation and perception, but it is not mentioned in the discussion of the limitations of clinical measurements of motility. Third, there are problems with motility that are encountered more frequently and that use many more medical resources than chronic idiopathic intestinal pseudo-obstruction. In recent years evaluation and treatment of dysfunction of the sphincter of Oddi have increased enormously. As with other obscure gastrointestinal syndromes presumed to result from disordered motility, treatment has been aimed at the recorded disturbance of motility without attending sufficiently to whether the symptoms are affected by sphincterotomy. Ogilvie's syndrome (massive idiopathic dilatation of the colon) is seen with increasing frequency as the population ages and more people spend the end of their lives in nursing homes. The pathogenesis of this disorder is not understood, and there is little or no agreement on the most effective approach to the care of patients with the syndrome.

This survey of current clinical research and practice relating to gastrointestinal motility has a large and up-to-date bibliography. The clinical flow diagrams should help the generalist develop cost-effective approaches to these motility problems.

Thomas R. Hendrix, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205