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Hepatobiliary Diseases: Pathophysiology and Imaging
  1. S P Olliff

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Professor Okuda sets out the aim of this book which is to describe advances in various imaging modalities to facilitate the use of different techniques and contribute to the understanding of hepatobiliary diseases and pathophysiology. The book is edited by three Japanese professors of medicine and radiology, and one American professor of radiology who is a magnetic resonance imaging (MRI) specialist. The contributing authors are Asian and American with the majority from Japan. The authors include physicians, gastroenterologists, pathologists, endoscopists, and radiologists.

This book celebrates the progress in imaging over the last two decades or so such that gross pathology is now fairly well shown by accurate and non-invasive or minimally invasive imaging methods. Microscopic histological changes are incompletely shown by imaging techniques but there has also been significant progress in characterising various processes, diseases, and tumours by imaging without biopsy.

The first section entitled “progress in imaging” considers computed tomography (CT), MRI, and developments in ultrasound. Modern CT and MR techniques are explained with suitable illustrations. Most impressive are the three dimensional images constructed from CT and MR data.

The chapter on ultrasound introduces all of the new ideas of tissue harmonic imaging (printing error on 33, tissue harmonica imaging!), tissue characterisation, and ultrasound contrast agents. Unfortunately, some of the images in this short chapter are disappointing and the concepts described are not completely clear.

The next section concerns anatomy and gross changes in the liver with illustrations of pathology and imaging examples. These chapters are descriptive down to the level of electron microscopy with a lot of useful diagrams and imaging illustrations. There is a further short chapter describing the relationship and pathology of the diaphragm with the liver.

Longer sections then deal with diffuse hepatic diseases with chapters on acute and chronic viral hepatitis and other causes of chronic hepatitis. There is a chapter on pathology, physical signs, and imaging in cirrhosis and further chapters on fatty liver, alcoholic liver disease, iron overload, and other diffuse changes, including metabolic disease and drug induced liver damage.

The next section deals with vascular disease including portal hypertension, non-cirrhotic portal hypertension, portal vein thrombosis, and Budd-Chiari syndrome. Included in this section is a chapter on haemodynamics. The sometimes complex relationship between the various hepatic circulatory systems are illustrated by CT, arterial portography, and CT hepatic angiography, and also by balloon occlusion of hepatic arteries and veins. Many observational studies of this type have been published in the radiological literature, usually from Japanese centres. This type of work is useful for the understanding of odd lesions or pseudo lesions demonstrated in more conventional CT or MR examinations but they are by no means routine procedures in UK practice.

The chapter on portal hypertension and non-cirrhotic portal hypertension has many fascinating illustrations with a large number of “invasive” studies, including transhepatic portal vein catheterisation and transumbilical portal vein catheterisation. As diagnostic procedures, these would be regarded as somewhat invasive in current UK and European practice when much of this information is obtainable by CT, ultrasound, or MR. We see similar images during procedures such as TIPS but not usually for diagnosis alone.

Naturally, there is considerable discussion of hepatocellular carcinoma, a major problem in Japan and possibly an increasing problem in the western world.

All types of focal liver lesions are described with considerable emphasis on the haemodynamics contributing to contrast enhancement at CT, MRI, and ultrasound. Pathology and imaging of potential premalignant cirrhotic nodules are also reviewed. Later chapters cover other liver disorders including trauma, parasites, and liver transplants followed by extensive discussion of biliary diseases.

This is not an ordinary textbook but a collection of explanations of the pathophysiology illustrated by imaging. This leads to emphasis on CT, hepatic angiography, and arterial portography. In the UK and USA, current emphasis is more on the use of multislice multiphase CT with intravenous contrast and MRI with various, more specific, contrast agents.

Some of the images included are remarkably over the top. For example, a cystic arteriogram is shown in a case of gall bladder carcinoma. Overall, I enjoyed the book, particularly for the imaging minutiae. However, mixed up with this is an attempt to cover all types of liver and biliary disease as well as imaging and pathology. The treatment and management of many conditions are also discussed in a limited way. This gives an overall broad but uneven coverage. Although entirely satisfactory in themselves, I am not certain that it was necessary to include chapters on trauma and liver transplantation with the other material.

This is not a book for every gastroenterologist but will be of more interest to those specialising in liver diseases, particularly if they wish to delve into the complexities of imaging.

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