Despite significant progress in modern gastroenterology, the aetiology of inflammatory bowel disease as well as coeliac disease is still to a great extent unknown and poorly understood. The principles of treatment - particularly of IBD - emphasize the importance of a combined medical and surgical approach. This book is the proceedings of an international symposium that brought together workers from many disciplines involved in the treatment of IBD and coeliac disease, and is a useful update on recent advances in paediatric and paediatric-surgical gastroenterology. F. Hadziselimovic, B. Herzog, A. Biirgin-Wolff vii List of Principal Contributors M. BUROELSKI F. HAOZISELIMOVIC Kinderklinik Department of Gastroenterology Medizinische Hochschule Hannover Basler Kinderspital Postfach 61 01 80 Rbmergasse 8 CH-4005 Basel 0-3000 Hannover 61 Switzerland FRG H. K. HARMS A. BURGIN-WOLFF Dr. V. Hauner'sches Kinderspital Basler Kinderspital Lindwurmstrasse 4 Rbmergasse 8 0-8000 Munich 2 CH-4005 Basel FRG Switzerland A. H. CO LOONY W. T. J. HEKKENS Department of Physiology Harvard Medical School Faculty of Medicine Division of Urology The Children's Hospital University of Leiden 300 Longwood Avenue Wassenaarseweg 62 Boston, MA 02115 PO Box 9604 NL-2300 RC Leiden USA The Netherlands C. P. FLIEGEL Department of Radiology B. HERZOG Basler Kinderspital Pediatric Surgery Rbmergasse 8 Basler Kinderspital CH-4005 Basel Rbmergasse 8 Switzerland CH-4005 Basel Switzerland J. -O. GEBBERS Institute of Pathology B. S. KIRSCHNER Kantonsspital Wyler Children's Hospital CH-6000 Luzern 16 5825 S. Maryland Avenue Switzerland Chicago, IL 60637 USA A. M. GRIFFITHS Division of Gastroenterology M. L.

This classification is based primarily on the microscopic characteris- tics of tumours. It is therefore concemed with the identification of cell types and histological pattems as seen by conventional light mi- croscopy. In general, time-honoured terms have been retained. Syn- onyms are listed only if they have been widely used, or if they are considered to be important for understanding the disease process. In such cases the preferred term is given first, followed by the synonym in parentheses. The individuality of the tumour manifests itself principally in its histological appearance and the extent of spread at the time of diag- nosis. This volume is concemed only with the histological classifica- tion of tumours. Anatomieal extent or staging is covered in the TNM 1 Classification. The histological classification of a tumour depends on two main parameters, typing and grading, and a number of additional parame- ters which may apply to selected examples.

Despite the fact that the incidence of gastric cancer is declining in the Western world, it remains a significant problem with respect to accurate diagnosis and treatment since it has a high mortality rate. In June 1989 an International Conference was held at the University of Rome "La Sapienza" entitled "New Trends in Gastric Cancer: Background and videosurgery." During this meeting background information on the aetiopathogenesis of gastric cancer was presented together with talks and video presentations on the latest advances in the treatment of gastric carcinoma, both from the European and Japanese experience. Because of the poor prognosis of gastric carcinoma there is increasing pressure for early detection. Some of the problems in the early detection of gastric carcinoma are discussed together with methods of surveillance of high-risk subjects. It is generally accepted that the surgical approach to gastric carcinoma should take into account the site and extent of the lesion and there are chapters on new methods for pre and intraoperative staging of the disease which allow a more logical approach to surgery. A comparison between Japanese and Western rule and results was attempted and reasons for the differences were investigated. Since the field is still evolving not all aspects could be covered, and those angles not approached in this book will be addressed in a second International Conference to be held in Rome in June 1990.

The Third International Symposium on Inflammatory Bowel Diseases was held in Jerusalem during September 10-13, 1989. Four hundred physicians and scientists from 25 countries attended the meeting. The symposium was organized into five panels devoted to state of the art reviews of the latest findings and approaches on the etiology, pathogenesis, metabolic implications, clinical assessment of disease activity and the medical management of IBD. Several issues were discussed in debate form. The last panel was dedicated to discussion of three patients with computer assisted active participation of all the attendants. In addition, 03 abstracts were presented as posters, all of which were published in the Book of Abstracts. The organizing committee gratefully acknowledges the contributors who presented their work in clear and concise manner and the participants, whose active part in the discussions contributed to the success of the meeting. The Jerusalem International symposium on Inflammatory Bowel Diseases has become a tradition that will continue with the Fourth Symposium to be convened in September 1993. Joseph Zimmerman, M.D. Daniel Rachmi1ewitz, M.D. LIST OF FIRST AUTHORS Theodore M. Bayless, Michael J. Langman, Johns Hopkins University Department of Medicine, School of Medicine, Queen Elizabeth Hospital, Baltimore, Maryland. Birmingham, England. Michael D. Blackstone, J.E. Lennard-Jones, University of Chicago, St. Mark's Hospital, Chicago, Illinois. City Road, London, England. Charles O. Elson, Division of Gastroenterology, James Lee Madara, The University of Alabama Department of Pathology, at Birmingham, Brigham and Women's Hospital, Birmingham, Alabama. Boston, Massachusetts.

The nonsurgical management of gallstone disease has drawn widespread clinical interest during the last decade as ultrasound surveys have indicated that cholelithiasis is predom inantly an asymptomatic condition and much more prevalent than previously thought. This book presents an overview of the pathophysiologic and pathobiochemical principles of gallstone formation and the consequences for clinical therapeutic regimens. New information concerning the balance between vesicular and micellar transport of choles terol, early cholesterol nucleation, and the influence of inhibiting and promoting com pounds for cholesterol nucleation as well as information concerning the effects of changes in gallbladder motility and gallbladder mucosal function is reviewed. In order to make further progress in developing treatments which facilitate gallstone dissolution and in preventing disease, it is necessary to integrate this new data into our thinking. Methods of treatment such as systemic litholysis of cholesterol gallbladder stones with bile acid preparations and mechanical fragmentation of stones either by extracorpo ral shock waves or intracorporal laser systems are carefully described and separate discussions of direct contact litholysis of cholesterol stones with ether preparations and the local litholytic treatment of calcified pigment stones are included. New therapeutic applications of HMG-CoA-reductase inhibitors and nonsteroidal anti-inflammatory drugs are also critically reviewed. Finally, for the interested reader an evaluation of prophylactic treatment against stone recurrence after successful conservative treatment and an appraisal of alternative management strategies supplement the information on the conservative treatment of gallstones.

Jeder fA1/4nfte Deutsche leidet unter Reizdarmbeschwerden. Vielleicht auch Sie? Dieses Buch verspricht Linderung bei Durchfall oder Verstopfungen, BlAhungen und Schmerzen. Der Internist und ErnAhrungsmediziner Dr. Matthias Robert beschreibt, was sich hinter dem Reizdarmsyndrom verbirgt, welche so gar nicht reizenden Symptome es mit sich bringt und welche Untersuchungen Ihr Arzt bei Ihnen durchfA1/4hrt, um die Diagnose stellen und andere Erkrankungen ausschlieA en zu kAnnen. Er erklArt, wie das komplexe Organ Darm funktioniert, wie eng Bauch und Hirn verbunden sind und warum deshalb Psyche und Stress eine so groA e Rolle beim Reizdarmsyndrom spielen. Vor allem aber setzt er sich mit den verschiedenen MAglichkeiten der Therapie auseinander und stellt eine ganze Reihe von MAglichkeiten vor, wie Sie Ihre Beschwerden lindern kAnnen: ErnAhrungsumstellung und Entspannung, Medikamente und alternative Heilmethoden. Damit endlich Ruhe in Ihrem Bauch einkehrt.

Total parenteral nutrition (TPN) is now an everyday occur rence in most general hospitals. Over the last two decades this therapeutic modality has been made so simple that it is no longer the province of the specialized surgeon or physician. Indeed, as with the management of chronic renal failure so now with short bowel disease, home parenteral nutrition has become a reality, though this still requires a specialist team dedicated to its management. Furthermore, as more patients will become suitable for home TPN treatment (either long term or short term) so better rationalization of (a) cost, (b) delivery systems and (c) patient training will be necessary. Lessons can be learnt from the somewhat diverse development of regular dialysis treatment in the early 1960s compared with the situation today. Here is a golden opportunity, with the UK National Registry, to rationalize on home TPN costs and to make sure the treatment is simplified and available to all those who may require this treatment. This book is not designed to be an overall comprehensive review of parenteral nutrition. It is meant to set out simple guidelines and the requirements for effective TPN both in hospital and at home. It is aimed at doctors in training, interested physicians and surgeons, nurses, dietitians and pharmacists. The purpose is to stimulate interest and aware ness, rather than to provide detailed 'small-print' information. For the person seeking greater knowledge, there are several excellent monographs on the subject.

Inflammatory bowel disease - i.e. ulcerative colitis and Crohn's disease - not only creates significant patient morbidity but also imposes a diagnostic and therapeutic challenge to the physician in charge of these patients. Since the development of sulphasalazine by Dr Nanna Svartz in Sweden half a century ago, important improvements in the prognosis of ulcerative colitis and Crohn's disease have been achieved. This book makes an attempt to present and discuss some of the most recent advances in diagnostic procedures and therapeutic approaches to inflammatory bowel disease with special respect to Crohn's disease. Although the fmal diagnosis of ulcerative colitis and Crohn's disease is generally based on endoscopic, histological or X-ray examinations, nuclear medicine and its imaging procedures have established their place in certain aspects of inflammatory bowel disease. One chapter of this book is dedicated accordingly to the indications of nuclear diagnostic procedures in the clinical setting. Sulphasalazine has been the mainstay of medical therapy in ulcerative colitis and Crohn's disease of the colon. Recently 5-aminosalicylic acid has been discovered to be its active compound and sulphapyridine was found to be the component responsible for most of the adverse effects of sulpha salazine. It is not surprising that many studies have investigated 5-amino salicylic acid as a single therapeutic agent in inflammatory bowel disease."

It is easy to make anecdotal claims for the efficacy of new forms of treatment based on the short term results in a small number of patients. Many authors have done this for endoscopic laser therapy in the gastrointestinal tract. It is very much more difficult to carry out a comprehensive assessment of the short and long term effects of new techniques and to compare these with the results of alternative treatments for the same diseases. This book, from one of the world's leading departments of gastroenterology, describes and analyses the largest series of patients yet reported from one centre treated endoscopically with the NdYAG laser for gastrointestinal disease. The follow up extends over 8 years and the results are impressive. Some of the early claims for laser therapy have been validated, others have not, but the real value of the book is that we now have a large amount of well organised data on which to judge the merits of laser therapy. Medical laser techniques are in their infancy and the potential for future develop ment is enormous, but ideas on current applications have been consolidated and that is essential before the next concepts evolve. This book has taught us how to walk. The world is now ready to learn to run! S. G. Bown, Director National Medical Laser Centre London Contents INTRODUCTION 3 Introduction and purpose of the study 5 1 General aspects of laser 6 1. 1.

Safe surgery is founded upon careful dissection and clear identification of vital structures. Knowledge of the appropriate anatomy and anatomical relations is therefore essential, not only during surgical training, but as the cornerstone of surgical practice. The aim of this book is to describe the essential anatomical basis of a range of common procedures in general and vascular surgery. The large-format multi-volume texts on operative surgery, despite their undoubted excellence, are now too expensive for individual purchase. Single-volume books on operative surgery have been unable to devote sufficient attention to anatomical detail and the surgeon is left ploughing through anatomy texts, often failing to find illustrations which demonstrate clearly the features that are important in an operative dissection. The present text highlights features of the operations which are important anatomically while not attempting to give a complete description of the operative procedure. A combination of line diagrams and cross sections has been used to provide the topographical detail. The volume is aimed mainly at surgeons in training, to help them on a day-to day basis and to provide a text which will be useful in revising for post graduate examinations in surgery. It is also hoped that the book will be of use to practising surgeons, providing an easy means of highlighting important anatomical aspects of the procedures they perform relatively infrequently. 1989 S.J.S."

How best to deal with such benign problems as the irritable bowel syndrome, diverticula, heartburn, non-ulcer dyspepsia, and gas, among other ailments. For a general audience.

Gastric Carcinoma/Classification, Diagnosis, and Therapy presents the most current perspective on gastric carcinoma, with particular emphasis on the surgical and chemotherapeutic modalities that offer hope for future treatment. The book discusses epidemiology, pathogenesis, and precancerous and clinical stage classification of the disease and provides valid practical guidelines for stage-specific diagnosis, therapy, and patient guidance. Topics explored include endoscopic criteria for premalignant lesions and early gastric carcinoma; clinical staging of gastric cancer by ultrasound, computerized tomography, and magnetic resonance tomography; surgical treatment of carcinomas of the gastroesophageal junction; possibilities for palliative treatment in surgical practice for advanced tumors; adjuvant treatment of gastric cancer; and chemotherapy of advanced gastric carcinomas in elderly and high-risk patients.

Fibrin plays a central role in wound healing. It has a hemostatic effect by forming a temporary wound closure and assists in neovascularization and fibroblast prolifera- tion. It therefore makes the repair of injured or severed parts of the human body by simple glueing possible, a notion that men have dreamed of since ancient times. The first modern attempts in this direction, using clotting substances derived from human blood to achieve hemostasis, were reported by Bergel (in 1909), Grey (in 1915), and Harvey (in 1916), who used fibrin powder or fibrin patches to control bleeding from parenchymatous organs. Two decades later Young and Medawar (1940) and Cronkite (1944) used blood plasma or fibrin solutions, adding thrombin to seal nerve anastomoses and to fix skin grafts in humans. Due to the poor adhesive strength of the fibrinogen the results were unsatisfactory. In 1972 a new era in fibrin sealing was initiated by Matras. By using highly concentrated fibrinogen in combination with factor XIII (fibrin-stabilizing factor) and by delaying fibrinolysis with a fibrinolysis inhibitor (aprotinin), a method was developed which after satisfactory results in animals, soon began to be applied in humans.

International Congress for Infectious Diseases, Rio de Janeiro - April 17-21, 1988. F.-A. Waldvogel, President

Die Endoskopie vermochte bisher Gewebsformationen zu dehnen, zu durchtrennen, abzutragen und zu zerstoren. Gewebedefekte auszufullen, miteinander zu vereinigen und zu heilen, war bislang endoskopisch nicht moglich. Die Einfuhrung von Fibrinklebern eroffnete neue Anwendungsbereiche. Der Kleber kann, in seine Komponenten getrennt, uber doppellumige Sonden uber beliebig weite Strecken an den vorgesehenen Einsatzort unter Sicht des Endoskopes transportiert werden. Die Klebung von Fisteln, Rupturen oder Leckagen an Bronchusstumpfen, im Lungenparenchym oder an gastrointestinalen Anastomosen kann heute komplizierte Heilungsverlaufe und riskante operative Re-Interventionen ersetzen. Die spezielle Technik der endoskopischen Fistelklebung wird in diesem Buch erstmals zusammenfassend und interdisziplinar erortert. Daneben werden neue Moglichkeiten zur Stillung gastrointestinaler Blutungen mit Fibrin durch intramurale Injektion oder oberflachlichem Spray besprochen. Grundlegende Untersuchungen zeigen, dass im Vergleich zu anderen Substanzen, die Fibrinapplikation in das Gewebe zu deutlich geringerer Traumatisation und zu geringeren entzundlichen Reaktionen bei gleichem Hamostaseeffekt fuhrt. Ziel des vorliegenden Buches ist, verstreute Einzelbeobachtung zu sammeln, zu ordnen und zu vergleichen, um dem interessierten Leser die neue Technologie der Verklebung von Defekten und der Hamostase mit biologischen Substanzen zu vermitteln.

This book is a completely up-to-date review of the basic tests available in gastroenterology. It is based on a detailed critical analysis of recently described procedures and the review of more traditional methods; each is as signed its correct place in the modern management of patients. Emphasis is placed on those techniques with which the authors have practical experience. The most useful investigations are indicated in the table of contents by heavy type. Comprehensive references are included to provide information about the selection, performance and interpretation of tests. The book is designed for trainees and clinicians without special expertise in gastroenterology, as well as being a shelf manual for the gastroenterologist and the staff of gastrointestinal investigation units. Special thanks are due to the nursing staff of the Day Ward, Bishop Auck land General Hospital; Mr P. Grencis, Medical Photographer; Dr S. Desai, Radiologist; and Amanda Gallagher who typed the manuscript. Malcolm C. Bateson Ian A. D. Bouchier 1988 xu CHAPTER 1 Intubation The passage of various forms of nasogastric, duodenal and intestinal tubes is basic to many of the diagnostic procedures performed in the gastrointestinal system. Method Whenever possible the patient's fullest co-operation should be obtained. If the patient is taking any drugs which might influence the test to be under taken these should be discontinued."

These exercises are meant for students and practitioners who wish to familiarize themselves with the normal and pathologieal computerized tomographie radioanatomy of the abdomen. The iconography is suffieiently characteristic to be read without the help of clinical or biological data. It comprises both normal and pathologie findings. Analysis of scans is comprised of two steps. The first part consists of the detailed study of normal scans, whieh serve as a reference. For this, eight main slice levels have been considered necessary and sufficient: neces sary since a certain number of slices are indispensable for the exploration of the abdomen; sufficient because a larger number of slices would risk rendering memorization difficult. The second part involves a study of the pathologie findings, organ by organ. Acknowledgements. Appreciation is extended to all those who have helped in realizing this study and, more particularly, to our friends and colleagues, J. L. DIETEMANN, C. Roy, J. L. BURGUET, M. VOUGE, and J. W. SOUITER. We would also like to thank Dr. J. WIECZOREK for his friendly assistance and advice in the planning and presentation of figures and schemata. 1 Technical Note Computerized tomography of the abdomen begins with an initial image called "scout view". This numbered radio graph of the abdomen is an analogous representation of the information and allows the location of the eight selected slice levels; these are represented by horizontallines. The slices are 10 mm thick and are taken at intervals of 2.5 cm.

Transcutaneous ultrasonography is an established procedure for diagnosis and therapy in gastroenterology. However, ultrasonic images can often be hampered by pulmonary and intestinal gas and by bony and adipose tissue. In 1956 Wild and Reid reported the first results of transrectal ultrasound of the prostate [1]. In 1976 Lutz introduced an A-mode ultrasonic probe which could be introduced via the biopsy channel of an endoscope [2]. In 1978 and 1980 Hisanaga performed echocardiography using an ultrasonic transducer attached to the tip of a flexible instrument [3, 4]. In animal studies and later on in humans Di Magno has used an echoendoscope in which a small transducer was attached at the tip of a fiberoptic endoscope [5, 6]. The purpose was to overcome the limitations of transcutaneous ultrasonography by directly approaching target lesions with a high-frequency ultrasound source via the gastroin testinallumen. SJlbsequently, the first series of endoscopic ultrasonography (EUS) examinations were reported during the European congress in Stockholm [7]. The purpose of this book is: 1. To evaluate the technique and the equipment for endoscopic ultrasonography 2. To evaluate in detail the endosonographic pattern of the normal and abnormal wall structure 3. To analyze a large consecutive series of various gastrointestinal malignancies in order to determine the usefulness and accuracy of EUS in the detection, staging, and therapy of malignant diseases 4. To compare EUS with other imaging techniques References 1.

In OCtober 1986, recognized authorities from a variety of disciplines met in Lisbon, Portugal, to review recent knowledge on eicosanoids - i. e., prostaglandins, throm boxane A , and leukotrienes - and their role in gastrointestinal diseases. 2 Briefly, in the stomach endogenous as well as exogenous prostaglandins may mediate cytoprotective actions in that they stimulate gastric mucus production, bicar bonate secretion and cellular regeneration while providing adequate mucosal blood flow. In contrast, thromboxane A2 by vasoconstriction may act as an ulcerogenic substance. Diarrheal states may be associated with prostaglandins of types E and F as they are capable to enhance intestinal water and electrolyte secretions. In chronic in flammatory bowel disease, mucosal synthesis of leukotrienes was found to be increased more markedly than that of prostaglandins suggesting that leukotrienes may have a major part in the pathogenesis of that disease. In this volume, which is an elaborated collection of the papers given on occasion of the above-mentioned symposium, the facts and problems associated with prostanoid substances are dealt with in four sections on 1. biochemistry, biology and pharmacology of eicosanoids, 2. physiologic and pathophysiologic aspects, 3. established therapeutic implications, and 4. treatment perspectives. We believe that the publication of these contributions by leading workers in the given fields provides a comprehensive and up-to-date appraisal of the role of eicosanoids in gastrointestinal diseases, and it is hoped that this volume will be of value to both basic scientists and practicing clinicians.

Das Spektrum der in den westlichen Industrienationen filhren- den Krankheiten und der darauf basierenden Thdesursachen hat sich in den letzten J ahrzehnten gewandelt. Wahrend frliher die Infektionskrankheiten und speziell die Thberkulose den hochsten Todeszoll forderten, sind in den Jahrzehnten nach dem zweiten Weltkrieg mit steigendem Wohlstand die Herz- und GefaBkrankheiten an die erste Stelle gerlickt. Trotz gewis- ser Erfolge in der Pravention in einigen Uindern wie z. B. in den USA, Kanada, Australien; aber auch in einigen Gebieten West- europas, in denen die Zahl der tOdlichen Hirnschlage und Herzinfarkte inzwischen wieder rlicklaufig ist, wird die Spit- zenposition in der Todesursachenstatistik hier auch weiterhin von diesen Krankheiten eingenommen. In anderen Uindern wie z. B. in Osteuropanehmen die Erkrankungsraten weiter zu. Wenn man sich fragt, was getan werden kann, urn weitere Er- fqlge auf diesem Gebiet zu erzielen, dann ist ein Blick in die Lander des Fernen Ostens hilfreich. In der Volksrepublik Chi- na undin J apanliegt die Sterblichkeit an koronarer Herzkrank- heit bzw. an Herzinfarkten flinf- bis zehnmal niedriger als in der Bundesrepublik Deutschland. Arteriosklerotische Durch- blutungsstorungen der unteren Extremitaten, auch diabeti- sche GefaBerkrankungen kommen dort kaum vor. Vergleicht man die Lebensweise der Bevolkerung in diesen Uindern mit den Verhaltnissen in den westlichen Industriena- tionen, so fallenerhebliche Unterschiedeinder Ernahrungauf. Wahrend in China Fleisch und Molkereiprodukte in deutlich geringeren Mengen als bei uns verzehrt werden, besteht der Hauptanteil der Ernahrung aus einer an pflanzlichem EiweiB und Schlackenstoffen reichen Kost.

This book, the seventh in the series Exercises in Radiological Diagnosis, deals with sonography, an imaging procedure in which the ability of the radiologist plays an exceptionally important role. The author, Catherine Roy, has very extensive experience in the clinical use of sonography. She has selected the images, which are of excellent quality, with great care to illustrate a wide range of conditions and has supplemented them by commentaries and discussions which are easy to comprehend. The systematic use of schematic drawings to interpret the images makes it possible for the reader to follow the author's approach without any difficulty. Schematic drawings are par ticularly important in sonography because the relationship be tween the details in the images and the anatomy may be very weak. Images, schematic drawings, and text (both commentaries and interpretations) are three didactic elements which Cathe rine Roy has skill-fully combined in these exercises into an excellent whole. A. WACKENHEIM v Contents Introduction . . . . . . . . . . . . . . . . . . 1 Iconography, Commentary with Corresponding Schemata. . 2 Subject Index 203 VII Introduction Ultrasound imaging of the abdomen has now become a routine investi gation. It has brought about changes in the procedure of additional investigations and even rendered part of conventional radiology redun dant, particularly that concerning the bile ducts. These exercises are meant for students or physicians who already have basic knowledge of ultrasound diagnosis. It has not been possible to cover the entire spectrum of abdominal pathology, especially trauma, with 114 cases.

Get the essential tools you need to make an accurate diagnosis with Gastrointestinal Imaging, 4th Edition! Edited by Giles W. Boland, MD, this popular volume in The Requisites Series delivers the conceptual, factual, and interpretive information you need for effective clinical practice in gastrointestinal imaging. Master core knowledge the easy and affordable way with clear, concise text; new, high-quality images, and coverage of the latest modalities. Efficiently and affordably prepare for the written board exam and for clinical practice with focused, high-yield, richly illustrated coverage of the most essential concepts in gastrointestinal imaging. Make optimal use of the latest gastrointestinal imaging techniques with a significant new emphasis on CT and MR, including multi-slice CT, MR enterography, Diffusion-weighted MRI, hepatobiliary contrast agents for liver lesion detection and characterization, plus many other essential updates. See how gastrointestinal conditions present with a wealth of new multi-modal, high-quality digital images that mirror the findings you're likely to encounter in practice and on exams. Access the complete, fully searchable text and downloadable images online at www.expertconsult.com.

N. Rietbrock Wachsendes Qualitatsbewusstsein beschrankt sich nicht nur auf die Guter des taglichen Bedarfs, sondern gilt auch fur die im Krankheitsfall zu verordnenden Arzneimittel. Die Qualitat ist vom pharmazeutischen Hersteller im Zulassungsverfahren nachzuwei- sen. So schreibt der im zweiten Gesetz zur Anderung des Arzneimittelgesetzes vom 16. August 1986 neu eingefugte 11a bindend vor, dass in der Fachinformation "die pharma- kologischen und toxikologischen Eigenschaften und Angaben uber die Pharmakokinetik und Bioverfugbarkeit, soweit diese Angaben fur die therapeutische Anwendung erfor- derlich sind ..." enthalten sein mussen. Damit schrankt der Gesetzgeber aber auch bewusst die Angaben zur Pharmakokinetik und Bioverfugbarkeit auf therapeutisch relevante Arzneigruppen ein. Folglich bleibt die Erbringung der Daten praktikabel. Es liegt nicht im Sinne des Gesetzgebers noch in dem des Herstellers in Anbetracht der limitierten Zahl der medizinischen Institute mit ent- sprechender Ausrichtung, des relativ grossen Zeitaufwandes und der nicht unerheblichen Kosten fur alle Arzneimittel eine generelle Regelung zu treffen. Pharmakokinetik und Bioverfugbarkeit sind fur die therapeutische Anwendung erforder- lich unter anderem bei Arzneimitteln, die bei Uberdosierungen zu gravierenden unerwunschten Wirkun- gen fuhren konnen; bei Arzneimitteln, die vorwiegend renal eliminiert werden und bei denen die Gefahr einer verstarkten Kumulation bei eingeschrankter Nierenfunktion besteht; bei Arzneimitteln mit einem "first pass" Effekt; bei allen Arzneimitteln mit geringer therapeutischer Breite. Damit wird aber auch der Zweck solcher Studien klar: Qualitat ist ein relatives Merkmal eines Arzneimittels. Die Validitat dieses Merkmals ist immer im Zusammenhang mit dem klinischen Krankheitsbild zu sehen.

This book is an extraordinary achievement by Jonathan Halevy. To condense the material of three major gastrointestinal textbooks would be triumph enough, but to add a distillate of the contents of ten journals, from 1980 to 1985, requires Herculean vigor. To reorganize all the material under headings which extract concise "facts" from wheat and chaff requires a passionate interest in pa tients together with an understanding of physiology. Fortunately, Jonathan Halevy has just the right combination of clinical and lab oratory interest for him to select the details of what is important. Such compulsive dedication has now made it possible for the prac ticing phYSician, gastroenterologist, or house officer, interested in preparing for board examinations or simply browsing in the field, to have at his fingertips a series of definitions and to put in his pocket the key facts for diagnosis and therapy. Of course, facts by themselves are something of which to be a little wary. Scientists first, doctors regard facts the way farmers look at sheep-to be sheared for their utility. Medicine too often is only a fact-gathering occupation (some lectures send me to wool gathering), in which having the facts sometimes clouds clinical judgment about what is important for the individual patient. - vii viii FOREWORD tionalism and romanticism lie at the two poles of medical practice, but rationalism rules in the 1980s."