Book Review

Clinical Practice of Gastroenterology

N Engl J Med 2000; 342:1533-1534May 18, 2000

Article

Clinical Practice of Gastroenterology
Edited by Lawrence J. Brandt, with nine others. 1793 pp. in two volumes, illustrated. Philadelphia, Current Medicine, 1999. (Distributed by Churchill Livingstone, New York.) $235. ISBN: 0-443-06520-9

The stated purpose of this book is “to offer the latest clinical information in an easy-to-read-format, thereby aiding the busy practitioner to care for his or her patients.” The editors have tried to accomplish this by limiting “chapter content to the essentials of patient care.” This ambitious endeavor, however, cannot accommodate all styles of clinical practice. Some clinicians comfortably rely on empiricism, but others prefer the state of the art, even if it is rudimentary or uncertain. Whereas many editors would err on the side of completeness and allow the reader to decide what is germane, the editors of this book have attempted to establish the appropriate canon of ideas. This is an impossible task, well illustrated by the three chapters on inflammatory bowel disease, which pay scant attention to epidemiology, causes, and pathophysiology. Such an approach is unrewarding to those who think in mechanistic terms and is in definite contrast to that in other chapters.

Interestingly, the attempt to include only the essentials of patient care seems overly restrictive for the large survey chapters, yet it allows specialized subjects to be treated in detail. For example, chronic viral hepatitis is allotted 10 pages, whereas gastric infection receives 12 pages, even though there are also two chapters devoted to Helicobacter pylori. Another topic covered in depth is “pill-induced esophagitis,” which is discussed in a comprehensive, six-page chapter that reviews all 828 reported cases of injury, including new cases reported in this chapter. Although such depth makes the chapter comprehensive, the level of detail is inappropriate in relation to that provided for other subjects and is in contrast to the stated aim of the editors.

This two-volume book is organized, according to anatomy, into sections on the esophagus, stomach and duodenum, small bowel, colon, liver, gallbladder and biliary tract, and pancreas. There is also an extensive, 245-page section on pediatric gastroenterology and hepatology as well as a section on special topics. I found the book's organization to be problematic. A book designed to help busy clinicians might best be organized according to clinical syndrome or presentation rather than according to organ. Some chapters discuss symptoms, syndromes, and presentations, but these chapters are included in the section on the most relevant organ. Thus, the chapters entitled “Abdominal Pain” and “Nausea and Vomiting” are included in the section on the stomach and duodenum, “The Acute Abdomen” and “Infectious Diarrhea” in the section on the small bowel, and “Secretory Diarrhea” and “Gas and Flatulence” in the section on the colon.

In addition to making it difficult to search for information on a specific symptom, this approach to organization leads to overlap and repetition among some chapters. The chapter on infectious diarrhea is comprehensive, whereas the chapter on infectious colitis, in the section on the colon, deals only with infection relative to this organ. Careful study of overlapping material did not reveal substantial disagreement among the chapters. However, the chapters entitled “Gallstones,” “Cholelithiasis and Cholecystitis,” and “Laparoscopic Cholecystectomy” all list indications for prophylactic cholecystectomy, and each of these lists is different from the others.

The design and presentation of information in this book are pleasing and clear. There are numerous charts, graphs, radiographs, endoscopic photographs, intraoperative photographs, photomicrographs, tables, and algorithms. The figures are in shades of green, black, and white, a combination that is easy on the eyes. When a photograph would benefit from color presentation, it is reproduced in black and white within the chapter, with a reference to its color plate at the end of the volume. Although it would be preferable to see color photographs in the body of the chapters, I find this arrangement a cost-effective compromise. In general, the text and figures are complementary; scanning the figures usually provides a good sense of the material that is presented in the text.

The liberal use of diagnostic and therapeutic algorithms is a valuable feature. Although one might quibble about the evidentiary basis for these algorithms, they allow the reader to benefit from the judgment and experience of experts in their discipline. A few of the authors simply discuss the efficacy and side effects of various therapeutic options, but most commendably stick out their necks by presenting explicit algorithms. I found one instance in which a diagnostic algorithm is misleading. The chapter on gas and flatulence contains a very reasoned and thoughtful discussion of the workup based mainly on historical clues, but the accompanying algorithm makes it seem that the first step after ruling out aerophagia (by asking the patient about belching) is to analyze a sample of rectal gas by gas chromatography.

The editor-in-chief and the section editors have done a superb job of recruiting national and international authorities to discuss their areas of expertise. Other strong points of this book are its liberal use of diagnostic and therapeutic algorithms and its eye-pleasing format. The inconsistency in the presentation of pathophysiologic mechanisms, the varying depth with which subjects are treated, and the strict organ-based organization are weaknesses. This book may be useful for empiricists who do not have a strong interest in the mechanisms of disease or for internists who prefer to avoid the expense of more complete textbooks of hepatology and gastrointestinal disease.

Peter Ells, M.D.
State University of New York at Stony Brook, Stony Brook, NY 11794-8173