With collaboration of Consulting Editor, Dr. Alan Buchman, Guest Editors Drs. Gerard Mullen and Berkeley Limketkai have created a practical and current issue covering the breadth of topics in nutrition and gastrointestinal disease. Articles are specifically devoted to the following topics: Nutrition in the Management of Inflammatory Bowel Diseases; Irritable Bowel Syndrome: Food as a Friend or Foe; Treatment of Obesity: Beyond the Diet; Nutritional Management of Acute Pancreatitis; Nutritional Care in Patients with Intestinal Failure; The Life-long Role of Nutrition on the Gut Microbiome and Gastrointestinal Disease; Nutritional Strategies for Esophageal Disorders; Precision Medicine in Obesity; Gastrointestinal Food Allergies and Intolerances; All Things Gluten; Fish Oil for Inflammatory Bowel Disease: Panacea or Placebo; Nutrition Tools for the Practicing Gastroenterologist; Colorectal Cancer and Diet: Is Diet an Intervention; Non-Alcoholic Fatty Liver Disease: Nutritional Considerations; and Nutritional Considerations in the Hospital Setting. Readers will come away with current clinical information that they can employ in the clinical setting to improve outcomes in patients with gastrointestinal diseases.

The Second International Symposium on Inflammatory Bowel Diseases was held in Jerusalem from September 8-11, 1985, under the auspices of the Israel Academy of Sciences, the Israel Gastroenterological Society and the Hebrew University-Hadassah Medical School. Five hundred physicians and researchers from 26 countries attended. The symposium was organized into six panels devoted to state of the art reviews and presentations of the latest findings and approaches on etiology, pathogenesis, medical and surgical management of IBD and clini cal assessment of disease. In addition, 89 abstracts were presented as posters during the symposium, all of which were published in the book of abstracts. The concluding panel outlined new directions for future re search on IBD. The organizing committee gratefully acknowledges all the contributors who presented their work in a clear and concise manner, and to all the participants whose active role in the discussions contributed to the suc cess of the meeting. In view of the great interest in the symposium and the tradition es tablished following the first, in 1981, it was decided to convene a third international symposium on IBD in Jerusalem in September 1989."

Cell surface receptors are multifunctional proteins with binding sites towards the external environment and effector sites which mediate intracellular events. The purpose of this symposium was to bring together investigators who have a com mon interest in those receptors which are located in the liver, and who have studied endocytic mechanisms for various macromolecules like insulin, lipoproteins, epi dermal growth factor and others. Experiments in this particular field of research date back to the early 60-ies but have only recently led to new and important in sight in the molecular basis of receptor mediated uptake in the liver. The structural features which control these mechanisms are currently under intense investigation in many laboratories. Though this symposium largely emphasizes lipoprotein up take and catabolism by the liver, it was the particular intention of the organizers to discuss methodology and results with investigators who are also interested in he patic uptake of macromolecules. This might then eventually lead to new and com mon concepts for both receptor-ligand interaction and internalization processes in the liver. Biochemists, pathologists and gastroenterologists met for two and a half days and discussed their latest data in this so rapidly developing field of basic rese arch. This conference is part of a series on current topics in gastroenterology and hepatology arranged regularly by the Departments of Medicine and Surgery at the University Hospital Eppendorf. If is our hope, that such exchange of information between the different disciplines in medicine will continue. i. k."

Gastroenterologists require detailed knowledge regarding the anatomy of the GI system in order to understand the disturbances caused by diseases they diagnose and treat. Gastrointestinal Anatomy and Physiology will bring together the world s leading names to present a comprehensive overview of the anatomical and physiological features of the gastrointestinal tract. Full colour and with excellent anatomical and clinical figures throughout, it will provide succinct, authoritative and didactic anatomic and physiologic information on all the key areas, including GI motility, hepatic structure, GI hormones, gastric secretion and absorption of nutrients. GI trainees will enjoy the self-assessment MCQs, written to the level they will encounter during their Board exams, and the seasoned gastroenterologist will value it as a handy reference book and refresher for re-certification exams

In this age of specialization most patients with diseases of the hind gut and anus are still managed by general physicians or surgeons. The speciality of coloproctology has grown from the art of 'anology', a study of conditions limited to that distance from the anal verge that could be inspected easily by torch- or candlelight or with the aid of a simple speculum. Two centuries ago many proctological ills were often treated by itinerant quacks, partly because the physician considered himself rather too grand to meddle around the anus and the medical profession in general tended to look down on those who studied anal disease. Today, in certain countries, coloproctology has become a speciality every bit as exclusive as urology or orthopaedic surgery, with its own training programme and examinations, usually undertaken after the end of general surgical training. Such super-specialization has undeniable advantages with rapidly advancing technology and therapeutic possibilities. There is no doubt that for the patient suffering from a low rectal carcinoma or severe inflammatory bowel disease there are advantages in being treated by surgeons who are dealing with several cases in a year rather than by a general surgeon who sees such problems relatively rarely. Such specialized colorectal surgery units makes good sense medically and economically in large centres of population with good communications.

Toby K. Eisenstein Symposium Committee Chairperson Temple University School of Medicine Philadelphia, Pennsylvania 19140 This symposium is the thirteenth biennial clinical microbiology program sponsored by the Eastern Pennsylvania Branch of the American Society for Microbiology in cooperation with the Philadelphia area medical schools and the Bureau of Laboratories of the Pennsylvania Department of Health. This year a generous contribution from Merck, Sharp and Dohme has helped to make the program a reality. The subject matter for this symposium represents an attractive spectrum of medical, biological and molecular approaches to the practical solution of a public health prob1em--name1y, prevention of infection with the hepatitis B virus. The symposium may be unique in that it focuses on a product which was first marketed less than three months ago, but included in the program are presen tations on two new approaches to hepatitis B vaccine production which may replace the one which is newly unveiled. The rapidity of progress in our present era of biological research is indeed astonishing."

Foundations of Colorectal Cancer provides a holistic and comprehensive dive into colorectal cancer, discussing the contributions of each discipline that studies it, allowing its understanding from the most demographic and ethical facts, to the treatment process, its varieties and genetic background. Written by experts in diverse areas such as cancer research, oncology, genetics, biochemistry, psychology, social sciences, bioinformatics and palliative care, the book brings real-world experiences to help readers with any challenge they may face when dealing with patients or during their research workflow. The content is split into nine sections: Clinical manifestations and disease detection, covering primary and secondary prevention, and the role of primary care; Diagnosis and staging, discussing endoscopy, colonoscopy, molecular pathology, and anatomopathological diagnosis; Treatment, including endoscopic, surgical, radiological, and postoperative approaches; Molecular and biological mechanisms, with the role of intestinal microbiota, stem cells and signaling pathways; New diagnostic methods, encompassing biomarkers and bioinformatics tools for research; Biobanks, with an overview of their regulations and importance in the research; Epidemiological studies, focusing on incidence and mortality globally and by regions; Hereditary colorectal cancer, differentiating nonpolyposis and polyposis types; and Addressing the consequences of colorectal cancer, covering psychological effects, nutrition and ethical issues.

The Anglo-Swiss Colo-Proctology Meeting, held at Lausanne in May 1983, enabled numerous specialists to share their experiences of lower gastrointestinal tract pathology. The focus was on ischae mic disease and tumours of the colon, rectum and anus. By featuring ischaemic disease in our programme we hoped to give this too often underestimated process a fair hearing. Ischaemic lesions are far more common than is recognised on clinical grounds alone, particularly in the gastrointestinal tract. Large intestine is chaemia is often confused with other syndromes, especially since the clinical features evoked are, in most cases, atypical. Thus diag nosis is frequently late, with dramatic consequences. The oncology section basically discusses the early diagnosis of gastrointestinal tumours, a prerequisite for improving survival in af fected patients, and also presentation and treatment of certain rare tumours. The third section of this volume covers various diverse subjects including surgical technique, functional disorders of the large intes tine, inflammatory bowel disease, haemorrhoids and investigatory procedures. Several of the articles come from international authorities in their field. Some communications contain unpublished results, and others may lead to new diagnostic and therapeutic methods. We feel that the quality and variety of the texts from the Anglo-Swiss Colo Proctology Meeting merit wide appreciation. We are grateful to Springer-Verlag for accepting these proceed ings for publication."

The intestinal protozoan Giardia was first described over 300 years ago in 1681 by Leeuwenhoek, from his own stools. In his description of Giardia, he noted the size, movement, and morphology of the organism, and associated its presence with the diarrheic nature of his stools and his dietary habits. This truly remarkable account contains the first description of Giardia in morphologic, pathogenic, and epidemiologic terms. Our knowledge of the organisms in the genus Giardia has advanced tremendously in the past two decades. With the advent of new tech nologies, including techniques in electron microscopy, biochemistry, immunochemistry, tissue culture, and physiology, a tidal wave of information has appeared on the organization and function of this parasitic protozoan and its interaction with its host. The purpose of this book is to celebrate the tricentennial discovery of Giardia by Leeuwenhoek by presenting the above-mentioned advances in our knowledge of Giardia and giardiasis. In the first section of this book, the dominant theme is the biology of the organism and the correlation of structure-function relationships."

Antimicrobial-associated diarrhea is often caused by Clostridium difficile; this disease can best be diagnosed by detection of fecal cytotoxin in a tissue culture assay and, when therapy is indicated, can be effectively treated with orally administered vancomycin. The cause of disease in most cases of antimicrobial-associated diarrhea that do not involve C. difficile is not known; fortunately, this form of diarrhea 1S usually mild. Antimicrobial-associated diarrhea may also rarely involve s. aureus and certain enteric pathogens. 37 QHAPTER 4 Qf. TECTlON. ISOLATION Al:iQ...IQENTlFICATlON OF CLOSTRIDIUM PIFFICILE S. P. BORRIELLO and PAULINE HONOUR Introduction 38 Detection of Co dlfflcile in stools 38 Direct methods 38 Indirect methods 39 Isolation of Co djfficjle 40 Identification of Co difflcile 44 38 DETECTION ISOLATION AND IDENTIFICATION OF CLOSTRIDIUM DIFFICILE S. P. Borriello and Pauline Honour Introduction In view of the mounting evidence generated world wide in the last few years that firmly implicates GBP. difficile as the aetiological agent in both antibiotic and non-antibiotic associated pseudomembranous colitis (Larson ~ al. , 1978, Bartlett ~ al. , 1978a, George ~ al. , 1978a), and also recent recognition of the fact that there may be a spectrum of gastrointestinal diseases associated with GBP. difficile infections (Borriello and Larson, 1981, Bolton ~ al. , 1980, Brettle ~ al. , 1982), an increasing number of laboratories are seeking to detect, isolate and identify GBP. difficile from clinical samples.

"Gastrointestinal Disease" is the first monograph in a new series on management and treatment in major clinical subspecialties and patient groups. Further volumes will be published over the next few years. Each book is complete in its own right. The whole series, however, has been prepared to fill a gap, perceived by the publisher, myself and the volume authors, between standard textbooks of medicine and therapeutics and research reviews, symposia and original articles in specialist fields. Each volume aims to provide a concise, up to date account of treatment in its subject area with particular reference to drug therapy. Traditional clinical and therapeutic approaches have been presented in the context of developments in clinical pharmacology. Wherever possible, authorship has been under taken by practising clinicians who themselves have training and experience in clinical pharmacology. The volumes are intended to be guides to treatment, to assist in the choice of drug and other treatment and to provide easy references to drug interactions and adverse reactions. It is expected that these monographs will be particularly useful for the young hospital doctor in training for higher qualifications. However, they should also be valuable to or senior medical students and to those in established hospital general practice who are seeking to update their knowledge and to view recent developments in other fields in a balanced context. The aims of the series should be upheld by this volume on "Gastrointestinal Disease.""

In collaboration with Consulting Editor, Dr. Charles J. Lightdale, Guest Editor Dr. Sachin Wani has put together a state-of-the art issue that presents the latest advances in Barrett's Esophagus. He has secured expert authors who have contributed clinical reviews on the following topics: The epidemiology of Barrett's esophagus and esophageal adenocarcinoma - implications for screening and surveillance; Endoscopic screening for Barrett's esophagus and esophageal adenocarcinoma: rationale, candidates and challenges; Progress in screening for Barrett's esophagus: beyond standard upper endoscopy; Best practices in surveillance for Barrett's esophagus; Pathologic assessment of Barrett's esophagus and Barrett's related neoplasia: Do we need quality indicators; Cost effectiveness of screening, surveillance and endoscopic eradication therapies in Barrett's esophagus and early esophageal cancer; Advanced imaging and sampling in Barrett's esophagus: Artificial intelligence to the rescue; Advances in biomarkers for risk stratification in Barrett's esophagus; Current status of chemoprevention in Barrett's esophagus; Optimizing outcomes with radiofrequency frequency ablation of Barrett's esophagus: candidates, efficacy and durability; Updates in cryotherapy for Barrett's esophagus; Role of endoscopic mucosal resection and endoscopic submucosal dissection in the management of Barrett's related neoplasia; Practical approach to refractory and recurrent Barrett's esophagus; Surgical management of Barrett's related neoplasia; and Measuring Quality in Barrett's esophagus: Time to embrace quality indicators. Endoscopists will come away with the information they need to screen, diagnose, and treat patients with Barrett's Esophagus.

This book of diagnostic exercises cannot be used to good advantage without a good grasp of elementary sonoanatomy and the most common pathologic l images . We have tried to follow a pedagogical progression from the simple to the complicated for each group of clinical situations. We recommend that the sonograms at the beginning of each case study be thoroughly analysed before proceeding to the commentaries which explain the grounds for the final diagnosis. These explanatory remarks are accompanied by the same sonograms, but with arrows and letters added so as to pinpoint the details referred to as the diagnosis progresses. In reading the commentaries it will therefore be a good idea to cover over the figures in which the details are picked out for you, uncovering them one by one as required. 1 Which the reader may obtain from our previous books: Ed., 1982) Ultrasonography of Digestive Diseases (Mosby Publ., 2nd Renal Sonography (Springer Verlag, 1981) 1 Chapter 1 In Which the Reader is Invited to Clean His Glasses 1.1. Mrs. Beech, 75 years, has the complexion of a young girl, but she is losing weight and complains of epigastric pain. She has undergone a whole series of conventional radiological procedures; this may be good news for the film manufacturers, but it has not aided in the diagnosis. Finally, she is referred for an ultrasound examination. Look first at ultrasonic cuts 1.1a, b (transverse), then LId (sagittal).

The endoscopic use of lasers in the treatment of gastrointestinal d seases began within the last decade and has evolved rapidly. Work is now being done at more than 150 centers in Europe, the United States, Japan and the rest of the world. To date no publi cation has defined the state of the art. This text attempts to fill that void. To disseminate information about therapeutic laser endoscopy, an increasing number of short courses have been sponsored in the United States wherein the attendee hears didactic lectures, views video tapes, and in addition, has the opportunity to have a "hands-on" experience with endoscopic laser therapy in the animal labs. This book is an expansion of the material presented in one such course sponsored by The Cook County Hospital in Chicago, Illinois, in October, 1982. The course was organized by Peter Bright-Asare, M. D., Chairman of Gastroenterology at the time of the course and chaired by Dr. Bright-Asare and myself. Some of the lectures from the course have been broadened and formalized. Other chapters were invited and added. Also included are group discussions about issues that are either controversial or undefined. Attempts were made to secure consensus opinion from experienced investigators in areas where no hard scientific experimental or clinical data exists. The contributors have a wide range of interest and expertise. Dr."

Ever since the invention of the fiberoptic endoscope in 1888, gastrointestinal endoscopy has grown increasingly popular in day-to-day patient management. Most recently, a variety of therapeutic procedures are also being performed through the endoscope. With increasing technological advances, new endo scopic procedures will be appearing on the horizon. It, therefore, becomes extremely relevant for the gastrointestinal nurse or assistant to be familiar with various endoscopic procedures. Gastrointestinal Endoscopy and Related Procedures will be a useful and practical guide in the making of a qualified gastrointestinal assistant. This book is notable for its elegant style, illustrations, detailed account of procedures, and especially the instructions on patient care. Discussions on physical preparation of gastrointestinal procedures, helpful hints and instrument care add to the value of this book. The psychological impact on the patient undergoing endo scopic procedures and the nurse's role in alleviating 'the fear of the unknown' also is properly covered in the text. It is refreshing to see a nursing perspective in the writing of this text. Throughout the whole book, one can feel a warm and humane approach towards patients with gastrointestinal disease. All these and more are, of course, a result of Sister Morag Ravenscroft's vast experience along with the guidance of Dr Charles Swan. It is a textbook worth reading and relishing. Marcia Pfeifer R.N."

Howard C. Thomas In normal subjects the regulatory apparatus of the immune system permits responses to foreign antigens but suppresses those directed to "self' components. Autoimmune disease occurs as a failure ofthis system either as a result of a primary defect in the regulatory apparatus (primary autoimmunization) or because of a change in the antigenicity of the tissues (secondary autoimmunization). Autoaggressive reactions are characterised by the presence of autoantibodies. When these are directed to membrane displayed antigens (Fig. 1) they are probably of importance in the lysis of hepatocytes. Those directed to cytoplasmic antigens may be useful diagnostically but are of unknown pathogenic significance. When no extrinsic aetiological factor can be identified, the process is assumed to be the result of a failure ofthe regulatory system, allowing the spontaneous expansion of a clone of autoreactive lymphocytes. The defect may be generalised or specific to certain groups of self-antigens and thus the autoimmune disease may be either multi- or unisystemic. The recent development of techniques to enumerate and measure the functional activity of the suppressor lymphocytes which control the effector limbs of the immune system has enabled investigators to test whether the various purported autoimmune diseases do have as their basis a generalised defect in immunoregu lation. Assessment of antigen-specific immunoregulatory function is, however, not yet readily available. liver Membrane I Antigen (LIM) I Liver I HLA, A, B, C, Sensitisation to Specific -;::!IIIL. .

Dieses Buch ist nach der "Ulcus-Therapie" und den "Postoperativen Syndromen" der dritte Folgeband der Reihe "Interdisziplinare Gastro- enterologie". Die Reflux-Therapie erschien uns als interdisziplinares Thema besonders geeignet. Mehr noch als bei der Ulcus-Therapie ist die Grenzlinie zwischen konservativer und operativer Therapie verwaschen. Wahrend bei der Ulcuskrankheit zumindestens gewisse Vorstellungen uber die Definition des Krankheitsbildes und die Haufigkeit der Er- krankungen bestehen, besteht hieruber - auch heute noch - bei der Refluxkrankheit Unklarheit. Viele Arzte arbeiten nicht mit dem Begriff "Refluxkrankheit" , sondern sehen des Problem einzig im Zusammenhang mit der Hiatushernie. Andere fuhren Refluxbeschwerden automatisch auf eine "Gastritis" zuruck. Dementsprechend herrschen auch uber die therapeutischen Moglichkeiten Unklarheiten. Wahrend die einen auto- matisch beim Vorliegen einer Hiatushernie eine chirurgische Therapie anstreben, beginnen die anderen beim Vorliegen von "Hyperaziditats- beschwerden" nicht einmal mit einer Diagnostik, sondern begnugen sich mit halbherzigen palliativen Massnahmen. Es schien uns deshalb angezeigt, eine Gruppe von Sachkennern dieser Materie zusammenzurufen, eine Bestandsaufnahme vorzunehmen und therapeutische Richtlinien zu erarbeiten. Solche Bemuhungen sind bedeutungsvoll, da die Refluxkrankheit bei ahnlicher Symptomatologie im einen Fall eine harmlose, fast zu vernachlassigende Storung dar- stellt, im anderen Fall aber zu einer bedrohlichen Erkrankung fort- schreiten und im schlimmsten Fall sogar der Schrittmacher eines malignen Tumors sein kann.

The acute abdomen often perplexes the expert as well as the young physician. There are few areas in medicine in which Hippocrates' aphorism-the art is long, life is short, decision difficult, and delay perilous-is more applicable than here. Too often the harried physician fails to listen to the patient who is trying desperately to suggest the diagnosis. The significance of various types and location of pain often are neglected by the doctor. Physical findings are influenced by experience; the presence or absence of tenderness or a mass may be answered in entirely different ways by various observers. Because solid facts frequently are lacking, attempts to resolve diagnostic dilemmas by computer analysis or by algorithms are not likely to be successful. Fortunately, in the great majority of cases, unusual and difficult diagnostic procedures are not necessary for the identification of the acute abdomen and of the major disease. Astute clinical judgment must be based primarily upon careful attention to the pa tient's words and detailed observation."

Gastroenterologic endoscopy has made important progress in the past decade. New techniques and ideas have given it new life. The end of this evolution is not yet in sight. FuIly flexible fiberoptic instruments have eliminated all blank areas from the map of the gastrointestinal tract. Retro- grade visualization of the pancreatic and biliary system has been achieved in conjunction with radiologic methods. Operative endoscopy has de- veloped beyond the removal of foreign bodies, to a stage where laparotomy can be avoided in a number of situations. Hemostasis by laser coagulation and crushing of concrements by ultrasound and electric energy have reached the threshold of clinical applicability. With all these spectacular develop- ments, however, it is important to maintain a firm grasp of the fundamentals of endoscopy. This is the basis of day-to-day success and includes knowl- edge of the proper indications, the ability to manage complications, famil- iarity with the technical properties of the instruments, their skillful handling, and experience in organizing an endoscopy section. Endoscopists, particu- larly members of the Erlangen group, have undertaken the task of charting these fundamentals and of compiling them into a working manual for those already practicing endoscopy or intending to do so. They have been sup- ported in this effort by colleagues from other parts of the Federal Republic of Germany and from Italy.

For at least three centuries, Holland has been at the centre of research on intestinal malabsorption. In the 17th and 18th centuries, early descriptions of coeliac disease and tropical sprue were published by physicians trained in Holland, and it was in 1950 that Dicke published his painstaking and vital observations that coeliac disease in children was caused by the inges tion of wheat flour. Subsequent careful work with van de Kamer and Weijers showed that the harmful agent was gluten. Since these discoveries were made, research in intestinal malabsorption, particularly in the adult, has continued in several centres in Holland. At Nijmegen, for example, dr. Cluysenaer, dr. van Tongeren and their as sociates have been involved in long-term studies of patients with intestinal disease for the past fifteen years. In this book they describe their experience of the investigation and treatment of fifty patients with the adult form of coeliac disease. Their monograph gives an account of the history, definition and incidence of the disorder, and then goes on to undertake a critical review of the pathogenesis of the coeliac lesion. Before embarking on the different patterns of malabsorption seen in adult coeliac disease, the authors describe the normal small intestine, its morphology and function."

VI J. R. VON RONNEN PREFACE This atlas is a selection of the roentgenograms of patients who visited the Radiology Department at the University Hospital in Leiden between 1970 and 1974. The heads of this department are Prof. J. R. von Ronnen and Prof. A. E. van Voorthuisen. In this atlas, the most frequently occurring radiological abnormalities of the small intestine are illustrated as clearly as possible - without the shadows caused by flocculation or segmentation of the contrast fluid. The author hopes it will be a positive contribution towards the attainment of the highest possible diagnostic score. It should be remembered that the key to good diagnostics is not only a perfect examination technique, but also the knowledge and character of the physician. If these factors are optimal, then the best possible series of roentgenograms will be obtained, at least as far as technique is concerned. All patients were examined by the enteroclysis technique. With this method of examination of the small intestine, the contrast fluid is administered via an infusion directly into the duodenum instead of orally. The infusion method has added a new dimension to the radiological examination of the small intestine. This method has turned out to be especially suitable for the comparative evaluation of motility, and also for the study of disturbed motility.

Practical, handy and succinct, this full colour pocketbook provides clear-cut clinical guidance to the main symptoms that infants and children commonly present with in both primary and secondary care. Clearly divided into specific sections covering the GI tract, liver and nutrition, Professor Kelly and her team discuss how best to investigate and manage specific clinical problems such as vomiting, abdominal pain, acute diarrhoea, constipation and jaundice using a highly clinical problem-orientated approach. They cover the management of important clinical problems such as chronic liver disease, ascites, malnutrition, obesity, coeliac disease and inflammatory bowel disease, and provide advice on nutritional problems in premature infants and children including weaning and food aversion. Key points, potential pitfalls, and management algorithms allow for rapid-reference, and link with the latest evidence, guidelines and protocols from ESPGHAN and NASPGHAN providing coverage of the major professional society recommendations for clinical practice. Brought to you by the experts, Practical Approach to Gastroenterology, Hepatology and Nutrition is the perfect accompaniment for trainees in gastroenterology, hepatology and pediatrics, as well as nutritionists, GI nurses and GPs.