Gastroesophageal reflux (GER) refers to symptoms and events that result from abnormal regurgitation of gastric contents into the esophagus. GER is a common clinical problem that affects large segments of the general population. The spectrum of problems associated with GER is now known to also involve extra-esophageal sites. Respiratory diseases, in particular bronchial asthma, can be exacerbated by multiple triggers, including GER. The relationship between the occurrence of gastroesophageal disorders and changes in respiratory function has been known for over a century, but the mechanism by which intraesophageal acid regurgitation can produce respiratory symptoms is still debated. The reasons for these concurrent pathological events are also not fully understood. Determining, for instance, whether reflux itself initiates or exacerbates asthma, or whether asthma or its treatment primarily causes GER is a matter of current investigation.

Digestive Disease Week-Japan (DDW-Japan) was held successfully in Yokohama April 15-18, 1998, under the management of Prof. Yoshiki Hiki, Chairman of the Steering Committee. DDW-Japan was carried out with the cooperation and participa tion of gastroenterological societies in Japan. Because the participat ing congresses each dealt with topics characteristic of particular fields, all participants could enjoy a rewarding experience and could gather relevant, up-to-date information about a wide variety of subjects in basic and clinical medicine. Prof. Rikiya Fujita, Chairman of the International Relations Com mittee, planned and conducted the International Symposium working together with researchers from foreign countries, thus making DDW Japan in 1998 a great success. The symposium provided a fascinating insight into the global situation, and the papers that were present ed are being published in this monograph, Recent Advances in Gastroenterology. As we all know, the world soon is going to enter the third millen nium. Therefore, treatments and medicines should not be limited to any single country or small area; instead, medical knowledge must be shared as a global resource, without regard to nationality, way of life, or social system. I hope that this monograph will playa useful role in the develop ment of gastroenterology all over the world, and I very much appre ciate the tremendous contribution of all authors for this publication.

In the past several years much progress has been made in understanding the basic mechanisms of pancreatic physiology and the pathogenesis, diagnosis, and treatment of pancreatic disease. A symposium took place in Munich on 18-19 September 1998 that aimed at summarizing current knowledge of the exocrine pancreas and giving di rection to future research. It targeted all practitioners and scientists working in the field of exocrine pancreatic disease. The symposium was also designed to stimulate young persons embarking on a career in this area. It was an exciting meeting for all of us. We wish to extend our thanks to all participants for their prompt submission of manuscripts and to Springer Verlag for speedy publication, providing us with an up-to-date volume on pancreatic research. We would also like to thank G. Beyendorff-Hajda and W. Glockner, as well as D. Kriiger, representatives of Knoll Deutschland GmbH, for their organiza tional assistance and Knoll itself for its generous sponsorship, which enabled colleagues from other countries to participate and made publication of the symposium possible."

Dirk Haller und Gabriele Hörmannsperger geben einen Überblick über die zentrale Rolle des Darms und seiner Bewohner für die Gesundheit und vermitteln zusätzlich einen ersten Eindruck von den komplexen und dynamischen Interaktionen zwischen D+armbakterien und Wirt. Denn Forschungsergebnisse der letzten Jahre weisen darauf hin, dass die lange unbeachteten Darmbakterien (intestinale Mikrobiota) eine unerwartet zentrale Rolle für die Aufrechterhaltung der Gesundheit einnehmen. Die Forschung beschäftigt sich aktuell intensiv damit, die Grundlagen für ein funktionierendes und gesundheitsförderndes mikrobielles Ökosystem zu identifizieren. Dieses Wissen kann zukünftig für die Entwicklung gezielter Maßnahmen zur Prävention und Therapie Mikrobiota-assoziierter Erkrankungen eingesetzt werden.

Practising evidence-based medicine necessarily depends on the clinician having access to the best evidence available, but in a fast-moving field, keeping up to date with the latest developments is a challenging prospect. In this new volume, leading experts focus on the most important clinical issues associated with the management of Lipid Disorders, evaluating and interpreting the evidence available to provide the reader with a reliable summary of our current knowledge. Topics covered include therapeutic strategies for managing hereditary lipid disorders, including familial hypercholesterolaemia, both in adults and children, and familial combined hypercholesterolaemia. The authors also evaluate the evidence for a link between inflammatory disease and cardiovascular risk; the metabolic syndrome and the interconnections between dyslipidaemias and diabetes. They also look at therapeutic challenges such as the management of patients who are statin resistant, and the control of lipid levels in those suffering renal insufficiency. Tables highlight important data, evidence from trial results and expert reports, and each section concludes with a series of Key Points that present a summary of evidence-based recommendations for best practice, graded according to the quality of that evidence. The book provides the busy clinician with a unique analysis of the data supporting current therapies and will help the reader formulate effective strategies for treating their own patients.

This is a histological classification of tumours and tumour-like lesions of the exocrine pancreas which also includes those tu- mours showing a mixture of exocrine and endocrine elements. The classification is based principally on standard microscopic observations, but whenever indicated it incorporates diagnosti- cally valuable immunohistological findings. In addition, the most important immunohistological findings which are helpful in cat- egorizing pancreatic tumours are summarised in Table 1. The major guideline of this classification scheme is the group- ing of the pancreatic exocrine tumours according to their biologi- cal behaviour. Thus, the neoplasms are broadly divided into benign (adenoma) and malignant tumours (carcinoma). How- ever, in recent years we have learned that this division is not a sharp but rather a gradual transition. We therefore added a third group which we call "tumours of uncertain malignant potential" representing a borderline category analogous to that recognized for some ovarian tumours. This group includes mucinous cystic tumour, intraductal papillary-mucinous tumour and solid- pseudopapillary tumour. These neoplasms are defined by the grade of dysplasia and/or potential to become malignant. Mucinous cystic tumours of uncertain malignant potential, for instance, exhibit moderate epithelial dysplasia, but do not show severe dysplasia/carcinoma in situ changes, nor carcinomatous invasion of the cyst wall or the adjacent pancreatic tissue. Solid- pseudopapillary tumour has a benign looking histological ap- pearance, but metastases may occur. Biologically, all these neoplasms are primarily slow-growing lesions and have an excel- lent prognosis when adequately treated by complete resection.

Constipation is a common disorder that is often defined differently by patients and physicians. Clinically, constipation occurs when bowel move ments are difficult or painful. The "normality" of bowel movements, in terms of frequency, varies among individuals; frequency that is thought by one person to be constipation may be reported by another to be usual and thus normal. Often the perceived "need" to have a bowel movement leads to self-treatment with laxatives as these drugs are widely available without a prescription. This situation can raise problems in patient care, because of potential interactions between laxatives and other medications. Furthermore, chronic use (abuse) oflaxatives can cause serious medical consequences, causing patients to visit physicians, and even to be hospitalized for further evaluation and care. This has a financial impact on the patient, and on health care systems. It is essential that pharmacists, physicians and other health care practitioners counsel patients on the causes of constipation and the proper use oflaxatives. A medical work-up by a physician should be done to determine if the constipation is due to a pathological process. Often nor mal bowel function (for an invididual) can be maintained by diet and/or lifestyle. Most laxatives in use today are of botanical origin. Further research on the mechanism of action of these and synthetic laxatives is needed to bet ter define their pharmacology and toxicology."

Recently, rapid developments have occurred in the field of viral gastroenteritis. This book is an update of fundamental and practical aspects of viral gastroenteritis. Among the various agents that cause viral gastroenteritis, group A rotaviruses and caliciviruses are the focus of this volume because of their clinical impact and the significance of new findings about them.

During the years that have intervened since the third volume of the International Life Seiences Institute (ILSI) Monographs on Pathology of Laboratory Animals, Digestive System, was published, new information of interest to pathologists has developed at a rather remarkable pace. Standardized nomenclature has been proposed and gained significant acceptance during the period since the first edition and isbeing utilized on aninternational basis. Thishas resulted in improvement in communi cationof pathologic data to reguiatory agencies and inscientific publica tions worldwide. This monograph series and others sponsored by ILSI have had significant effects on improved communications and the inter national acceptance of standardized nomenclature. In this second edition, new formats have been used in some instances where more appropriate for the subjects to be eovered. The format introduced in the first edition remains useful as it emphasizes the neces sityto reeognize the morphologie features of pathologic lesions to iden tify them precisely. This identifieation is an essential first step toward development of new insightsintopathogenetic meehanismsand their use in decisions eventually applieable to public health. Newinformation is included in thisedition on the nature and variability of preneoplastic lesions in the Iiver of laboratory rodents. Data on the aeeompanying changes in enzyme activity in affeeted Iiver cells are ex panded, and additional information on spongiosis hepatis in the rat and its relation to spongiotic pericytoma is a further feature. In a few in stanees, research on a pathologie entity has been Iimitedbut its recogni tionremains important. Thisjustifiesinclusion of suchentities in the new edition."

Jean-Claude Rambaud The place occupied today in basic and clinical research by intestinal disease related to Clostridium difficile is such that it is hard to remember that this range of disorders was completely identified only in 1977-1978, even though pieces of the puzzle had been identified much earlier. A brief historical review of the discovery of the enteropathogenicity of C. difficile in man might thus be useful. The bacterium was described in 1935 in the stools of infants, using the name Bacillus difficilis [7]. Until 1977, the microorganism, renamed C. difficile, considered to be of endogenous origin, was isolated only in rare cases of abscess or infection, most often unrelated to the digestive tract. Its role in genito-urinary infections [6] was not confirmed. However, the frequency of infant healthy carriers was recognized from the outset [7, 13]. Pseudo-membranous colitis (PMC) was described in 1883 following a gastroenterostomy. Many cases of this condition were published subsequently before the antibiotic era, describing various risk factors [4]. However the disease began to flourish only with the increasingly wide use of antibiotics. Antibiotic associated PMC was first described as an enterocolitis, though with little pathological evidence. It was principally related to the use of chloramphenicol and tetracyclines and attributed to proliferation of Staphylococcus au reus [ 11], a concept strengthened by the spectacular therapeutic action of vancomycin.

This atlas provides a concise yet comprehensive overview of high-resolution manometry, impedance and pH monitoring. Through instructive text and over 130 high-yield images, the atlas describes the basic principles of esophageal, antroduodenal and anorectal high-resolution manometry, reviews both normal and pathologic findings on manometry, covers technical aspects of pH monitoring and impedance, and outlines advances in equipment, software, and diagnostic guidelines. Written by experts in the field, Atlas of High-Resolution Manometry, Impedance, and pH Monitoring is a valuable resource for gastroenterologists and other clinicians and practitioners who work or are interested in the GI motility field.

Biliary tract complications are still the major cause of morbidity following orthotopic liver transplantation. This book deals systematically with the large variety of possible cholangiographic changes. The figures are the results of a review of cholangiograms from more than 280 patients who underwent orthotopic liver transplantation. The etiology, clinical aspects, and treatment of these complications are reviewed on the basis of the authors' experience in radiology, endoscopy, and transplant surgery.

The last volume in the series Fibrin Sealing in Surgical and Nonsurgical Fields discusses various uses of fibrin glue in endoscopic surgery. During the last years fibrin sealant has been established in the treatment of gastrointestinal ulcers and esophageal fistulae.

This volume is a compendium of the lectures, presentations, and workshops of the International Congress entitled "Facing the Pancreatic Dilemma" and of the 17th Meeting of the Italian Association for the Study of the Pancreas, held in Verona on 16 -19 June 1993. Pancreatology is still a relatively young science. Many pathophysiological aspects of pancreatic disease are as yet obscure, and a fair number of the etio pathogenetic mechanisms adduced are no more than hypothetical. We have therefore chosen to compare and contrast in a single volume the various hypo theses and interpretations put forward by leading experts in the field. In view of the swift evolution of this branch of medical science, it is sound policy to bear in mind that yesterday's heresies have become today's orthodoxy, and that todays's heresies may well turn out to be accepted orthodoxy in a not too distant future. The various "pancreatic dilemmas" are addressed systematically in these pages, and we believe that the book will prove an invaluable tool for the special ist and for any physician dealing with pancreatic disease. The book also represents a tribute by the Verona School of Pancreatology to the memory of Prof. L. A. Scuro, founder of the School and one of the outstanding Italian pioneers of pancreatology."

The "Europe against Cancer" programme has, from its inception, emphasised the key role which general practitioners must play in the actions necessary to achieve its aim of reducing the incidence and the mortality from cancer in the European Community. General practitioners, because of their day-to-day direct and continuing contact with patients, playa role not only in primary prevention and education of patients, but also in motivating their patients to accept secondary prevention and screening, some of it carried out by general practitioners themselves. These preventive activities are in addi tion to their traditional role in the care and management of patients with cancer at home, and increasingly, their role in active treatment. In view of the importance of the general practitioner in the "Europe against Cancer" programme, the European Commission, with a view to providing general practitioners with up-to-date useful information, has sponsored the production of this series of publi cations on organbased cancers, especially written for general practitioners. Regis Malbois Advisor in charge of the "Europe against Cancer" programme Commission of the European Communities Brussels Preface Colorectal cancer is the second most common cause of death from malignant disease with a high incidence in many European countries. This book is part of a series of pub lications on major cancer diseases designed for the European family doctor. It is pub lished by the Commission of the European Communities within the context of the Eu rope Against Cancer Programme.

On the subject of stomach and gastric diseases, current cli- nical, morphological, pharmacological, biochemical as well as cellular and molecularbiological aspects will be presen- ted. The articles of the first part of this book will discuss the normal functions of the stomach (such as motility, secre- tion, tissue regeneration etc.). The second part deals with pathophysiological aspects (such as inflammation, ulceration and tumor formation) and modern possibilities of treatment. The authors aim at gaining a deeper knowledge of the sto- mach, its physiology and pathophysiology in order to use this knowledge for the better of their patients.

An experienced pathologist, radiologist and clinician combine forces to review the recent literature on coloproctology and give a precis of the results. Their Highlights in Coloproctology are the ideal source for a clinician or researcher who wants a quick overview of the subject. The book highlights the papers that have had an impact on developments in the field and brings the reader up to date with modern references.

The anastomotic technique plays a predominant role in gastrointestinal surgery. A feared complication is leakage due to the sutures. Such leakage cannot be detected early; consequently, infection spreads locally and systemically. An anastomotic method is generally evaluated according to its rate of leakage, related to the localization, bur real scientific comparisons, i.e., controlled studies, are almost totally lack ing. The criteria of evaluation include the type of suture, the localization, the auxiliary technical tools, practicability, the different forms of wound healing, angiogenesis, and vascularization, among others. The postoperative criteria are complications shortly after surgery, such as bleeding, ruptures, and stenoses of the anastomosis. A standard comparison is made difficult by the variety of cytophysiological and biochemical factors that influence wound healing. In the comparison of larger series one must always take into account differences of auxiliary tools, strategies, and inhomogeneity of patients. A change of one auxiliary tool or of one strategy implies the modification of various target criteria. Often enough, however, one does not sufficiently consider the surgeon's most. important role."

"Updates in Colo-Proctology" covers the proceedings of the Anglo-Swiss Colo-Proctology Meeting held in St Moritz in 1990. The book contains the papers which were presented and dis cussed there by physicians of the various specialties concerned with the care of patients with diseases of the colon, rectum and anus. The authors, each distinguished in a particular field, have contributed across a wide range of subjects and different dis ciplines. The topics covered include surgical and investigative techniques, cancer, inflammatory bowel disease and specific infections. Being familiar with the previous literature, it is clear that little was really new among the themes presented in St Moritz, but few will deny that many of the techniques and methods of treatment described in this book are truly modern. Some contribute an entirely new dimension to the approach to well known colo-proctological conditions, while others may open up new paths for future research. In addition, in colo-proctology as in other disciplines, advances in treatment almost always bring new problems in the complications which attend them. These are the subject of some of the papers. Although it would be invidious to pick out individual contributions when there is so much that is new to talk about and so much that is old to be looked at in a new light, we should like to record how much we have enjoyed reading and collating these chapters. We hope that others will share our enthusiasm and pleasure.

Introducing this monograph by expressing our heartfeIt thanks to all those who have contributed to its success may seem no more than a rhetorical exercise. However, at the same time we feel duty bound to add our sincere apologies, for we know that many of the dis tinguished authors of the various chapters have been hard put to find any relevant information in the existing literature. The plain fact is that very little has been said and written about pancreatic fistulas compared with other aspects of pancreatic disease. Why is this? Essentially, we believe there may be two main reasons: one practical explanation may be their relative rarity, while the other reas on is, as it were, "psychological," i. e., pancreatic fistulas tend almost invariably to be regarded as complications of an imperfectly performed surgical procedure. However useful it might be if we were to do it more often, it goes against the grain to public1y admit one's own mistakes. Ever since I (P. P. ) started practising in medicine, it has been my destiny and privilege to work alongside Professor Dagradi, the pioneer ofpancreatic surgeryin Italy, and to assist him over the years in something like 2000 operations on the pancreatic gland. Clearly, then, any complication due or related to such surgery however rare, has become part and parcel of my practical day-to-day c1inical experience and scientific interests."

There are many diagnostic imaging techniques for the radiological exarmna- tion of the abdomen. Noninvasive methods include supine and upright views of the abdomen (sometimes fluoroscopy and decubitus films); posteroanterior (PA) views of the chest; contrast studies of the alimentary tract; ultrasonogra- phy (US), scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI). Biopsy under fluoroscopic control and angiography are inva- sive techniques. Most of the errors described in this book are related to faulty interpretation; others are due to improper technique. For example, a patient with acute abdominal pain secondary to a perforated hollow viscus may be studied only by supine and upright views of the abdomen that do not include the subdi- aphragmatic regions. A complementary PA view of the chest or a left lateral decubitus film would, however, detect free air in the pentoneal cavity that the incomplete two-film study might have missed. Errors of techmque are due to under- or overexposure, long exammation times or an uncooperative patient (both of which can induce motion artIfacts), improper processing, and failure to perform the proper standard noninvasive or mvaSlVe modalitIes for examining the hollow viscus and the solid organs of the alimentary tract. In order to visualize the diaphragm and the supra- and mfradiaphragmatIc spaces, frontal and lateral chest roentgenograms complement the standard views of the abdomen. Fluoroscopy IS of great value m assessing diaphrag- matic motion as well as being essential when contrast media are utilized.

Gastroenterology is one of the branches of medicine that can profit most from modem technology, whether this involves the advances in diagnostic instrumentation, in data and image processing and management, or in computer applications like expert systems. To evaluate current status of imaging, computerization, and expert systems in gastroenterology, a group of clinical researchers and computer experts met in Bologna, Italy, for several days' discussion. The presentations at this symposium are introduced in this volume, which we believe to be a useful contribution to a specialization of great importance for health care as a whole. Bologna, March 1991 P. R. DAL MONTE Contents Imaging in Gastroenterology A. TORSOLI ......... . 1 Experience with a Hospital-Wide Image Management and Communication System: Is Total Digital Radiology Possible? S.K. MUN (With 1 Figure) ... 3 New Approaches to Endoscopy with the Electronic Videoendoscope M. SCHAPIRO .... ......... . 15 Intraoperative Videocholangioscopy A. MONTORI, L. MASONI, and L. DE ANNA 19 Images and Communication F. VICARI .......... . 22 Didactic Potential of Videoendoscopy F. COSENTINO, E. MORANDI, G. RUBIS PASSONI, F. DI PRISCO, and S. TUCCIMEI ........................... 24 Interactivity Between Image Processing Systems and Videoendoscopy M.A. PISTOIA, S. GUADAGNI, L. LOMBARDI, F. PISTOIA, M. CATARCI, and I. CARBONI. . . . . . . . . . . . 27 Endoscopic Laser Therapy of Colorectal Tumors 30 P. SPINELLI, M. DAL FANTE, and E. MERONI ...

In spite of years of tuition and examination, newly qualified doctors are often left inadequately prepared for real-world clinical practice. The major concern is that 'book knowledge' gleaned at medical school does not always translate to safe and effective practical knowhow.Based on the author's many years of expertise as an educator globally, this book helps final-year students make the difficult transition to first-year doctors. Drawing on the latest evidence-based information, it focuses on aspects important to clinical practice in the areas of gastroenterology, cardiology and respiratory medicine such as differentials, investigations and management with full references provided throughout. Also detailed are examination skills; although not the routine form of how to examine but what to be thinking when asked to examine: what conditions should be prevalent in a doctor's mind? And how can these conclusions be reached before even seeing the patient? Practical knowledge like this defines an effective clinician.Clear, concise and rigorous in its approach, this comprehensive volume is indispensable companions to any new doctor in the above fields.

Dieses Buch pr{sentiert neueste Forschungsergebnisse zur Be- deutung von Pankreasenzymen f}r die normale Verdauung und untersucht die Notwendigkeit der Enzymsubstitution bei Un- terfunktion und Erkrankungen des Pankreas.