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Clinician's Manual on Managing Dyspepsia. G Holtmann, NJ Talley (Pp 96; £7.75). London: Science Press, 2000. ISBN 1-85873-376-6.
Picture the scene. An international conference on gastroenterology, delegates flown in from the four corners of the earth, a nice hotel near the sea and golf courses, and one of those keypad voting systems. Dyspepsia? Easy! Dish out a PPI and lets get on to the really interesting stuff like fucosyltransferases and Ki-ras gene point mutations.
But wait! The audience has been asked what it would do with a 43 year old man with an 18 month history of vague upper abdominal pain, a stressful life, and a variable response to OTCH2 blockers. The voting screen reveals an astonishing divergence of opinion about management. A Helicobacter pylori test followed by endoscopy if positive? Plenty of PPI and symptomatic review in a couple of months? Urgent or once in a lifetime endoscopy? The Austrian delegation are muttering about psychotherapy and a shady group of surgeons in the corner are all for an exploratory laparotomy.
This is why people keep writing books about dyspepsia and why this book by Gerald Holtmann and Nick Talley is particularly welcome. It succeeds in combing Germanic thoroughness and a degree of didacticism with clarity of thought and a healthy scepticism about what passes for the “literature”. The book has clearly been sponsored by Byk Gulden who make pantoprazole because one of their staff has written the preface. However, the authors are scrupulous and objective about their references to individual drugs, and there is nowhere a hint of commercial bias.
The arrangement of the material is traditional but contains some little gems. The section on the definition and clinical presentation of abdominal syndromes includes very helpful information about subgroups of dyspepsia categories and ways of distinguishing between functional dyspepsia and irritable bowel syndrome. The epidemiology is, as you would expect, thorough, and the chapter on the pathophysiology of functional dyspepsia, supported by almost 100 references, is a mine of information with implications for research as well as clinical practice. There is a good section on psychosomatic factors, once again well referenced and reasonably up to date. The chapters on diagnosis and management also cover most of the recent publications but although the cisapride problem is acknowledged, the recent work on aHelicobacter pylori test and treat strategy from Bytzer's group did not quite get in. There is a terrifying looking algorithm on the management of dyspepsia which, on closer inspection, turns out to be perfectly sensible. Two randomised controlled trials of herbal medicines in the treatment of dyspepsia are referenced. The section on psychological treatment is short but contains an invaluable table describing the basis of the therapeutic relationship between patient and physician.
There is something here for everyone. The family physician will have to be selective but will find useful guidance on diagnostic and management approaches. Trainees in gastroenterology will find the book stimulating and might well start asking some new research questions about dyspepsia. Established gastroenterologists will need to read this book on the plane when they are next subjected to scrutiny on the Costa del Golf.
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