IS CROHN'S DISEASE A MYCOBACTERIAL DISEASE'! The fact that the differential diagnosis of inflammatory bowel disease includes intestinal infections has been a source of much interest and clinical concern for many years. Since the recognition of ulcerative colitis and Crohn's disease as clinical entities, numerous attempts have been made to identify a specific organism resulting in the clinical and pathologic picture of Inflammatory Bowel Disease. The first suggestion about a connection between Johne's disease, a chronic mycobacterial enteritis in cattle, and Crohn' s disease occurred in 1913, when Dalziel described enteritis in humans which, although resembling intestinal tuberculosis, he believed to be a new disorder. Since the work of Crohn in the thirties a few investigators attempted to look for mycobacteria in Crohn's disease. Until now the work of Van Patter, Burnham and others did not receive widespread recognition. In 1984 the isolation of M. paratuberculosis was reported by Chiodini et al. This report initiated the current interest and controversy about a mycobacterial etiology in Crohn's disease. The hypothesis "Crohn's disease is Johne's disease" did not receive widespread recognition, but has lead to the first muIticentered efforts to determine whether or not mycobacteria are associated with Crohn's disease.

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 ...

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.

Gastrointestinal diseases present a considerable problem in human medicine in terms of both morbidity and mortality. The aim of this book is to cover the different immunological disorders of the gut with special reference to immunopathological and protective mechanisms. It will be of general interest to clinicians, scientists and students concerned with the gastrointestinal tract. Topics covered include: the current status of research into toxin-secreting pathogens, Campylobacter, Giardia and HIV; the immunological features of idiopathic inflammatory gut diseases such as Crohn's disease and intractable diarrhoea; the genesis of the flat mucosa; the iatrogenic diseases of the gut such as graft-versus-host disease and small bowel allografts; the immune mechanisms and lesions in the gut of patients with parasitic nematode infections (very important in the tropics). Basic background on the immune apparatus in the intestine is also discussed, as are the effects of inflammation on intestinal permeability.

A book that compiles symposia papers from the International Journal of Colorectal Disease on issues that are highly controversial and hotly debated.

This is a classification of tumours and tumour-like lesions of the gall- bladder and extrahepatic bile ducts, including the ampulla of Vater. Although most of the lesions are found in all three sites, variations in frequency of the histological types occur and will be noted. The incidence of carcinoma of the gallbladder varies in different parts of the world. Variation is also found in different ethnic groups within the same country. In the United States, for example, carcino- ma of the gallbladder is more common in American Indians than in Caucasians or in Blacks; the rate among female American Indians is 21 per 100000 compared with 1.4 per 100000 among Caucasian fe- males. In Latin American countries, the highest rates are found in Chile, Mexico and Bolivia. In other countries, such as Japan, the inci- dence rates are intermediate between those of American Indians and those of Caucasians. Despite certain features in common, carcinomas of the gallblad- der and carcinomas of the extrahepatic bile ducts show a number of differences. Gallbladder carcinomas are usually associated with cholelithiasis and have a strong female predominance. In contrast, extrahepatic bile duct carcinomas are seen less often, occur in both sexes with equal frequency, are usually not associated with choledo- cholithiasis, produce early biliary obstruction, and are better differen- tiated histologically as a group. Moreover, they are seen in patients with primary sclerosing cholangitis and ulcerative colitis.

Interventional Radiology has as its main goal the performance of surgical techniques using a percutaneous approach to simplify patient care. Percutaneous cholecystostomy now has many advocates; still, it is practised in comparatively few centers. Over many years it was used as a last resort at failed transhepatic cholangiography to provide images of the bile ducts in biliary obstruction. Transhepatic cholecystostomy is reputed to be safer than transperito- neal puncture, since bile leaks do not enter the peritoneum. The advo- cates of percutaneous cholecystolithotomy, almost without exception, fa- vour subcostal cholecystostomy and puncture of the fundus of the gall- bladder. There is no evidence of bile peritonitis after successfully making a track to the gallbladder 18 F in diameter or larger for stone removal. After 1-7 days a postlithotomy drain is removed from the gallbladder and the patient is allowed home. Transhepatic cholecystostomy for gallstone lysis, in contrast, requires only a 5-F track to the hepatic surface of the gallbladder. Loss of the gallbladder is not as great a fear with this technique as it is during dilata- tion of a subcostal track for cholecystolithotomy. During the latter pro- cedure this may result in laparotomy to avoid bile peritonitis, while in the former, if the gallbladder is still visualised, the procedure may be re- commenced immediately. Catheter dislodgement is a fear when prolon- ged catheterisation is considered.

In the past 15 years much evidence has accumulated which indicates the paramount importance of sensory nerves in reg ulating functions of the gastrointestinal tract. In parallel, the attention of researchers in this field has been increas ingly attracted to the role played by neuropeptides in the normal and diseased gut. Basic research on the peculiar properties of capsaicin, the pungent ingredient from plants of the genus Capsicum, has allowed the gap between these two areas of research to be bridged. Sincethen, the study of gut afferents and neuropeptides has become more and more interconnected and recognized as a major avenue to understand ing the pathophysiology of various human diseases. It is widely recognized that a certain subset of primary afferents synthesize, store and release neuropeptides (such as tachykin nins and calcitonin gene-related peptide) from their central and peripheral endings, the latter being widely distributed in the alimentary canal and related organs (liver, pancreas). The First International Meeting on Sensory Nerves and Neuropeptides in Gastroenterology, held in Florence from December 4-5, 1989, sponsored and organized by Fondazione Internazionale Menarini, aimed to focus the current status of research in this field. The contributions presented at the meeting and in this book delineate a suggestive scenario in which sensory nerves of the gut, and the multiple messages they carry through the release of neuropeptides, are to be considered as a major target for the development of new drugs potentially useful in a number of diseases of the gastro intestinal tract."

This volume is the proceedings of the symposium 'Trends in Inflammatory Bowel Disease Therapy 1999' held in Vancouver, Canada, August 27-29, 1999, and sponsored by the Canadian Association of Gastroenterology, The Crohn's and Colitis Foundation of Canada and Axcan Pharma. It is the seventh international IBD symposium to be held in Canada and focuses on all areas of IBD therapy.Topics include: genetics; pathogenesis with reference to the role of autoimmunity, bacterial factors and neutrophil -- epithelial interactions; special clinical problems such as difficult diagnoses and challenges presented by children and the elderly; bone disease in IBD; an overview of current therapy; and a discussion of alternative therapy.

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.

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.

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.

Management of Swallowing and Feeding Disorders in Schools examines the most significant issues in swallowing and feeding facing school-based speech-language pathologists (SLPs). Topics addressed are unique to the school setting, ranging from organizing a team procedure in a district to serving children with complex medical issues, behavioral feeding disorders, and neurological feeding disorders. Ethical, legal, and cultural issues are also addressed.Many students exhibit the signs and symptoms of dysphagia, and children who were originally treated for dysphagia in hospitals and other settings often begin attending public schools at three years old. The difficulty they had with swallowing and feeding frequently follows them to the school setting. Further, there are many students who develop swallowing and feeding disorders as a result of traumatic brain injury, neurological disorders and syndromes, behavioral disorders, and so forth. The range of students needing services for swallowing and feeding disorders in the school setting can be from three to twenty-two years of age and from mild dysphagia to tube feeding.The identification and treatment of swallowing and feeding disorders in schools is relatively new. There are still many districts in the country and internationally that do not address the needs of children with dysphagia. As school-based SLPs take on the challenge of this population there is a need for information that is current, accurate, and thorough. University programs include very little training, if any, at this time in the area of swallowing and feeding in the school setting. This text is appropriate for both a dysphagia course as well as courses that train SLP students to work with school-aged students.

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.

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."

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.

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.

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.

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

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."

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.

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.