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Small and Large Intestine
  1. S J Middleton

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Edited by G Lichtenstein, G Wu. Pennsylvania: Mosby, 2003, £62.99, pp 364. ISBN 0323018955

The Small and Large Intestine, one of four volumes in this series named the Requisites in Gastroenterology edited by Anil Rustgi of the University of Pennsylvania, provides a refreshing readable overview. While successfully avoiding entrenchment in detailed consideration of the scientific literature, it provides a mainstream viewpoint of the major issues. It is presented in a logical and clear manner aimed at achieving an understanding at a basic level which will provide the reader with a good platform to focus on specific areas with more in depth study. In this series, Rustgi moves away from an account of the substantial gastroenterological literature which often includes clinical trials with apparently contradictory conclusions that may lead to controversies unwanted by the novice. Rather than being expected to weigh up the evidence, the student is more usually interested in the general viewpoint of the main body of experts. This series avoids the comprehensive consideration of the literature often found in the larger reference texts and concentrates on the delivery of practical guidance and the acquisition of a general grasp of the subject, particularly for physicians in training and medical students.

Each of the 13 chapters have well defined formats, orientating the reader with a brief initial chapter outline and general introduction to the subject. The majority then discuss the epidemiology and pathophysiology before providing a more detailed account of clinical evaluation and treatment. Considerable attention is given to pragmatic clinical management issues cutting through much of the academic detail to provide practical information, useful to those considering the day to day issues of gastroenterology. For example, in the Crohn’s disease chapter, there are two pages dedicated to pathogenesis, five to clinical assessment and diagnosis, followed by 16 pages on therapy of which only one relates to surgery, and that includes a table (clearly we are heading in the right direction with therapy!). However, nutritional therapy is given very little mention, which may reveal subtle differences in the character of medical gastroenterology between the USA and Europe.

Most chapters stay well within general dogma, including the most important, latest, and robust advances in knowledge; a few have a particular emphasis. The “irritable bowel syndrome” chapter develops the psychosocial/psychiatric approach to patients to a degree that might reflect the chapter author’s own clinical experience as a professor of psychiatry and medicine. It nevertheless addresses the other pathogenic aspects of irritable bowel syndrome, although promotes rather strict Rome criteria to the diagnosis which perhaps does not describe the full range of irritable bowel syndrome patients seen in the average outpatient clinic and is of more value if a well defined group of patients is required, such as for conducting clinical trials. A positive diagnosis based on irritable bowel syndrome symptoms is also recommended. This should be tempered with caution as there are many pitfalls associated with this particular group of patients, particularly for those less experienced in this field of practice who are the target audience for this textbook. The chapters on “intestinal polyposis syndromes and hereditary colorectal cancer” and “colorectal neoplasia”, perhaps by necessity, stray somewhat from the clinical emphasis to include a more detailed account of the pathogensis and epidemiology. They cover the basic genetic aspects in rather more detail than is the trend in other chapters and offer more discussion of the evidence base rather than being confined to expert interpretation and opinion. This perhaps deflects from the needs of the intended target audience towards those more familiar with the subject. Unlike the other chapters, there is also a degree of overlap between these two chapters, which is particularly related to the clinical and genetic criteria for diagnosis of HNPCC and the polyposis syndromes, and the criteria for genetic testing and screening. Both chapters are well written and interesting but it might have been more in keeping with the aims of the book to have combined them and kept to a more clinical approach. The subject matter of the text is augmented by key points in boxes which summarise areas of particular importance covered in each chapter, thus providing a useful at a glance reference. Several chapters contain investigation and treatment algorithms. These are particularly useful in the chapters on diarrhoea, inflammatory bowel disease, and colorectal neoplasia, and would have been a welcomed addition to other areas, particularly the investigation of malabsorption.

There is a strong sense that this text has been prepared with certification and recertification of North American Physicians in mind but it is also well suited to medical students in the broader sense, perhaps revising for finals, MRCP candidates, and medical registrars in training. Although not referenced, each chapter offers a guide to further reading providing a useful introduction to the scientific literature. In this volume, editors Lichtenstein and Wu achieve the aims of the series, as indicated by Anil Rustgi, the editor in chief in his foreword, to provide a user friendly text, imparted with expert knowledge and insights, that together constitute an overview and refresher course aimed at those training in the field of gastroenterology and those in other areas of medicine who want a succinct pragmatic overview.