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Challenges in Inflammatory Bowel Disease
  1. D Sachar

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This latest entry into the inflammatory bowel disease textbook sweepstakes is intended neither as a comprehensive reference work nor as a guide to everyday management. This demurral is just as well. After all, the former category of texts is already well represented by such heavyweights as Kirsner (WB Saunders), Allan et al (Churchill Livingstone), or Targan and Shanahan (Williams and Wilkins); the latter arena is quite thoroughly covered in works by Gitnick (Igaku-Shoin) and even more notably by Bayless and Hanuaer (BC Decker).

The current volume, rather, adopts a self described “new approach.” It focuses on specific questions ranging from basic science to clinical management, and it seeks to adduce best evidence in addressing controversies in these fields. In taking this particular tack, the editors and publishers have succeeded admirably in at least three respects.

Firstly, they have assembled an all-star cast of contributors. The editors, Derek Jewell, Bryan Warren, and Neil Mortensen—themselves a world class troika of clinician researcher, pathologist, and surgeon—have recruited 38 renowned authors from top centres in six countries besides their own.

Secondly, they have constructed this monograph ingeniously. Each chapter title is phrased as a question, which is then examined critically with scores of references that are pertinent and up to date (at least through to 1999). Six chapters address epidemiological, aetiological, and pathogenetic issues; two deal with diagnosis and assessment; the largest section comprises eight chapters on management, including medical, nutritional, and surgical aspects; four chapters are devoted to cancer surveillance; two pertain to long term complications (in a section subtitled “disease versus therapy” mischievously implying that some treatments are worse than the disease); and a final chapter tackles the subject of prognosis.

As a third defining feature of this ambitious volume, the editors have demanded and received from their authors highly critical analyses of “the most recently available evidence”. The authors analyse and interpret the evidence in ways that allow each chapter to reach reasonably well founded conclusions.

The six chapters on epidemiology and genetics are particularly thorough. If the chapter on inflammatory bowel disease genes is a bit technically dense, it still provides a helpful historical perspective on the accumulation of knowledge over the past decade, and it offers some thoughtful methodological considerations for future research. The chapter on microorganisms covers the topic from putative specific through animal models to therapeutic implications. The chapter on genetics versus environment explores the potential mechanisms of functional interaction between genes and environment.

In the section on diagnosis and assessment, two pathologists take wonderful advantage of the book's format by posing and discussing 18 “controversies in histopathologic diagnosis”, while a second chapter on “new diagnostic tools” deals with advanced imaging techniques but neatly avoids the thorny thicket of serodiagnostics. The eight chapters on management cover the range from specific medical and nutritional therapies to a particular disease presentation (refractory distal colitis) to current surgical controversies. It is especially noteworthy that after a thoughtful review of the conflicting data on the role of mesalazine in Crohn's disease, Hillary Steinhart pointedly reminds us not to forget the often overlooked consideration of patient preferences!

The section on cancer surveillance opens with Karel Geboes's nicely illustrated chapter on how dysplasia is recognised. (Indeed, the only really good illustrations in this book are the photomicrographs; even the pretty looking cover displays only a very poorly reproduced radiograph.) The cancer section then continues with two lively chapters that debate the utility of endoscopic surveillance. The arguments on each side are thoughtful and provocative, even when occasionally slipping into polemic. In any event, it ultimately requires the soothing voice of John Lennard-Jones to provide “a balanced view” that reviews options, presents the arguments pro and con, reaches both pragmatic and general conclusions, and then offers specific recommendations. The issue being so contentious, perhaps he should be forgiven for “hedging” slightly on the problem of low grade dysplasia in flat mucosa: “ . . .unequivocal low-grade dysplasia is thus a reasonable indication for surgery”; but then, one sentence later, “repeat endoscopy within 6 months of a first diagnosis of low-grade dysplasia appears advisable . . ..”.

The final one chapter section on prognosis by Kelly Burak and Lloyd Sutherland effectively comes to grips with the biases that obscure our search for the “natural history” of the inflammatory bowel diseases.

In summary, the audience for this book is best described in the publishers' own words (with my italics added): “An ideal text for [those] who [already] know the tried and tested information, but who now want to know about the areas of controversy in this fast-moving field.”

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