This volume contains the papers presented at the International Symposium on "Cirrhosis, Hyperammonemia and Hepatic Encephalopathy," held in Valencia, Spain, January 24th-27th, 1994. Liver cirrhosis and other hepatic dysfunctions such as fulminant hepatic failure and congenital defects of urea cycle enzymes can lead to hepatic encephalopathy, coma and death. Hepatic encephalopathy is one of the main causes of death in western countries. The ability to detoxify ammonia by its incorporation into urea is diminished by impaired liver function, resulting in increased ammonia levels in blood and brain. Hyperammonemia is considered one of the main factors in the mediation of hepatic encephalopathy and the classical clinical treatments are directed towards reducing blood ammonia levels. However, the molecular bases of the pathogenesis of hepatic encephalopathy and the role of hyperammonemia in this process remain unclear and several hypotheses have been proposed. To clarify the mechanisms involved in hepatic encephalopathy and hyperammonemia suitable animal models are necessary. The animal models available and the ideal features of an animal model are presented in the initial part of the book.

Crohn's disease is an inflammatory bowel disease, whose symptoms are similar to other intestinal disorders, such as irritable bowel syndrome and ulcerative colitis; it can therefore be difficult to diagnose. Its knowledge and understanding have increased considerably in the last years; new advances in genetics, medical and surgical management offer today new possibilities for patients suffering from an inflammatory bowel disease. However, Crohn's disease remains a difficult disease to deal with, both from a research and clinical point of view. This book provides general practitioners with a basic knowledge of the disease, offering in the same time an update on new facts about Crohn's disease to specialists. It can also be useful for residents willing to develop a deeper knowledge of inflammatory bowel diseases.

This volume contains the papers presented in the International Summer Course on "Cirrhosis, Hyperammonemia and Hepatic Encephalopathy," which was one of the prestigious Summer Course, of the Complutense University of Madrid held in EI Escorial, Spain, during August 10-14, 1992. Liver cirrhosis is one of the main causes of death in western countries. In addition there is a series of liver dysfunctions including fulminant hepatic failure, Reye's syndrome and congenital defects of urea cycle enzymes that could lead to hepatic encephalopathy, coma and death. As a consequence of impaired liver function, the ability to detoxify ammonia by its incorporation into urea is diminshed, resulting in increased ammonia levels in blood and brain. Hyperammonemia is considered one of the main factors in the mediation of hepatic encephalopathy and the classical clinical treatments are directed towards reducing blood ammonia levels. A part of the book is therefore devoted to the study of certain aspects of ammonia metabolism such as the regulation of the urea cycle, the main mechanism of ammonia detoxification in mammals, which is located mainly in the liver. The metabolism of ammonia in other tissues, including brain, is also presented, as well as the effects of hyperammonemia on brain metabolism and function and on brain microtubules. The control of cerebral protein breakdown is reviewed. The classical and some recently proposed clinical treatments as well as nutritional considerations in the management of patients with liver failure are also discussed.

This book is a review of the basic tests available in gastroenterology. Emphasis is placed on these techniques of which the authors have personal experiece. The philosophy has been to evaluate investigations for their current clinical usefulness in the management of patients. A critical analysis has been made to describe those older tests which have proved their worth alongside the newer procedures which have been introduced. Just as some recent additions have rapidly gained importance, some familiar tests have lost significance because of medical progress. Testing for Helicobacter pylori has more use than acid secretory studies in the age when antibiotics have displaced the surgeon in the management of chronic peptic ulcer disease. 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 gastroenterology investigation units. Special thanks are due to the nurses on the Bishop Auckland Gastroenterology Unit, and to Amanda Gallagher who typed the manuscript. Malcolm C. Bateson Ian A.D. Bouchier 1996 Xl CHAPTER 1 H elicobacter pylori INTRODUCTION The discovery of the presence of this organism in many human stomachs and its association with disease has revolutionized our approach to peptic ulcer. Detection of H. pylori infection of the gastric mucosa and proof of its absence after eradication therapy have become pivotal in patient management. EPIDEMIOLOGY H. pylori infection is strongly associated with age and inversely with wealth.

Modern surgical oncology is characterized by multimodal therapy. In recent years numerous therapeutic approaches of pre-, peri-, intra-and postoperative treatment have been in vestigated with regard to their use in combination with surgi cal intervention. It now is time to analyze and to define the state of our knowledge. For tumors of the gastrointestinal tract there are several encouraging therapeutic approaches, such as preop erative chemotherapy in esophageal and perioperative chemotherapy in colon cancer. For some special tumors, like anal carcinoma, we have clearly defined combined therapies which even now must be viewed as standard treatment. It is also time to demonstrate the results of several clini cal studies that have been conducted within the last few years that combined surgical efforts with pre- or postinter ventional chemotherapy or radiotherapy. It is necessary to evaluate whether these trials contribute to progress in onco logical therapy. The editors of this volume - surgeons at the university hospitals of Heidelberg and Zurich - must be given the mer it of achieving these goals. It was especially appropriate for the Department of Surgery in Heidelberg, in close coopera tion with the Comprehensive Cancer Center Heidelberg/ Mannheim, to prepare a review of our present knowledge of surgical oncology as it is in the tradition of attempting to combine different therapeutic approaches to cancer therapy.

The regenerative capacity of the liver cell is almost unlimited. Therefore after acute liver damage, be it viral, toxic, hypoxic, or surgical in origin, restitutio ad integrum is the usual outcome. In two forms of liver disease, however, this is not the case: in fulmi nant hepatic failure, liver regeneration often is not fast enough to keep the organism alive; in end-stage cirrhosis, regeneration is dis turbed by a hypertrophic architecture of fibrotic tissue. For these extreme forms of liver disease and for critical situations before and after liver surgery, artificial liver support is needed. This book contains the latest results in this area of research pre sented by scientists from allover the world at an international symposium held in Celle, Germany, June 2-4, 1980. Exciting new methods like continuous membrane plasma sepa ration and liver cell transplantation into the spleen have been de veloped. The older methods of hemoperfusion and dialysis have been improved. Enzymological methods and liver transplantation have made good progress. We hope that this volume will help the clinician in his decision-making and stimulate ingenious new re search for the benefit of our liver patients."

A century ago the Italian pathologist Bizzozero described the relationships between spiral bacteria and the mammalian gastro intestinal tract. Since 1982, when Helicobacter pylori was discovered, gastroduodenal disease have been completely revised as a con sequence of the results of basic and clinical research in this field. Progress in understanding the pathogenesis of this bacterium has been made by studying H. pylori infection in animal models. More specific diagnostic tools have been developed using new molecular biology techniques. Future trends are directed towards preparing a specific H. pylori vaccine. A new classification for gastritis, the Sydney System, including H. pylori gastritis, was proposed in 1990. As concerns the clinical approach to peptic ulcer disease in the 1990's, the majority of authors agree on the importance of H. pylori eradication. Moreover, recent clinical studies suggest that H. pylori infection can be associated with other gastroduodenal diseases, such as non ulcer dyspepsia and gastric cancer. Multicenter trials to standardize serological methods and evaluate the efficacy of new antimicrobial therapy schedules are planned throughout different European countries. The fourth Workshop of the European Helicobacter Pylori Study Group was held in Bologna, Italy, in November 1991. Two years before Bologna University celebrated its ninth centennial, giving evidence of being the oldest University in the modern world. Thus the H. pylori story that has continued for more than a century has been discussed once again at the University with the oldest tradition in the world."

Are you looking for concise, practical answers to those questions that are often left unanswered by traditional pediatric GI references? Are you seeking brief, evidence-based advice for complicated cases or controversial decisions? Curbside Consultation in Pediatric GI: 49 Clinical Questions provides quick answers to the tricky questions most commonly posed during a "curbside consultation" between pediatricians. Drs. Joel R. Rosh and Athos Bousvarous have designed this unique reference which offers expert advice, preferences, and opinions on tough clinical questions commonly associated with pediatric GI. The unique Q&A format provides quick access to current information related to pediatric GI with the simplicity of a conversation between two colleagues. Numerous images, diagrams, and references allow readers to browse large amounts of information in an expedited fashion. Some of the questions that are answered: * How is infantile colic diagnosed and treated? * How is GERD diagnosed in infants and what are the best treatments? * How can I optimize my treatment of childhood constipation and does this vary by age? * How can I effectively intervene in a child that is overweight or obese? * Celiac disease seems so much more common -- is this an epidemic? * Why have food allergies become so common and what are the most accurate means of diagnosis? Curbside Consultation in Pediatric GI: 49 Clinical Questions provides information basic enough for residents while also incorporating expert advice that even high-volume pediatricians will appreciate. Pediatricians, nurse practitioners, physician assistants, family practitioners and pediatric residents will benefit from the user-friendly, casual format and the expert advice contained within.

The classification of tumors is important for understanding tumor histogenesis, for predicting prognosis, for differential diagnosis, and for recommending appropriate therapy. Since 1836, when pancreatic cancer was first described, progress has been made in pancreatic cancer morphology, and a number of classifications have been proposed. All of these classifications are mainly based on morphological characteristics. Some are too detailed to be of practical use while others are more pragmatic. Some of the inherent problems in the previous classifications included difficulties in obtaining an adequate number of pan creatic tumors for examination and insufficient clinical data and follow-up. With the increasing incidence of pancreatic cancer in many parts of the world during the past six decades, and with the availability of more tumors to patho logists, advances have been made in pancreatic tumor studies. Classifications by Cubilla and Fitzgerald and by Kloppel, which are generally similar, mostly considered prominent morphological features and their histogenesis. These pathology-oriented classifications, although complete, were not practical from the standpoint of clinicians concerned with the prognosis of individual tumors."

Diagnostic Pathology of the Intestinal Mucosa - An Atlas and Review of Biopsy Interpretation offers a comprehensive overview of intestinal mucosal structure as defined through peroral or endoscopic biopsy specimens obtained in normal and disease states. It describes small intestinal biopsy pathology in conjunction with morphologic, functional, and pathophysiologic correlations. Routine methods of processing tissues for light microscopy, electron microscopy, histochemistry, and light- and electron- microscopic-immunoperoxidase techniques are presented so that the novice in the area of intestinal structure may have an easily accessible reference for setting up a morphologic laboratory.

The most comprehensive and conceptual one-volume treatment of this field available and the first to emphasize the cellular and molecular aspects of gut peptide biology. Authored by an array of internationally distinguished scientists, it deals with issues of peptide localization and biosynthesis in gastrointestinal cells, mechanisms of peptide release and inactivation and the nature of peptide receptors. The breadth and readability make it an invaluable reference source for scientists in all disciplines interested in any aspect of brain-gut peptides.

In the past 30 years, gastroesophageal and reflux disease (GERD) has become an important area of clinical medicine. GERD has gradually become associated with other common but unexplained disorders. These conditions have been designated as the extraesophageal manifestations of GERD. Dr. Anthony J. DiMarino, Jr. and Dr. Sidney Cohen and their contributors have written Extraesophageal Manifestations of GERD with the purpose to identify associations with conditions like hoarseness, laryngeal cancer, sleep disorders, and dental caries, and to explore possible causation and mechanisms of disease or possible noncausal relationships. The extraesophageal disorders have become widely accepted in clinical practice. The evidence supporting the pathogenesis of these conditions falls into three major categories: guilt by association, observed mechanistic studies, and therapeutic response to treatment. Inside the pages of Extraesophageal Manifestations of GERD the reader will find recognition and balance in treating patients with common symptom-based disorders. Final resolution of some of the controversies inherent in these associations may require advanced diagnostic tools and advanced pharmacological therapies. With chapters written by experts in the fields of medicine, pediatrics, otolaryngology, and dentistry, Extraesophageal Manifestations of GERD will be a must have for gastroenterologists, internal medicine residents, surgeons, otolaryngologists, and pediatricians.

There has long been disagreement about various aspects of the structure and function of the "gatekeeper" (Greek pyloros, from pyle = gate and ouros = guard). In recent years the problem has often been mentioned in anatomy, physiology, gastroenterology, radiology and even in nuclear medicine. For instance, while referring to manometric and gastric emptying studies, Schu- urkes and van Nuenten (1984 ) pointed out that there was considerable contro- versy as to whether a true pyloric sphincter existed in most species, and espe- cially in man. According to Reeve (1981) many functional aspects of sphincters are poorly understood; the exact mechanism of control of the transfer of chyme from stomach to duodenum through the pylorus is still not clear. Malagelada (1983) states that controversy surrounds the motor activity and function of the antro- duodenal junction; there is disagreement as to whether the pylorus functions as or as an integral part of the distal antrum. Ehrlein et al. (1984) a separate unit reiterate that pyloric motility is poorly understood, and according to Funch- Jensen (1987) there are many unsolved questions. Malagelada (1990) states that the stomach performs multiple functions with a deceivingly simple anat- omy; this is regarded as the key to the investigator's frustration when trying to uncover its secrets. One source of the many controversies surrounding the pylorus may be species differences, according to Schulze-Delrieu et al. (1984).

In this book, precursors of gastric cancer are described histopathologically, especially about the precancerous conditons and precancerous lesions of the stomach. In addition to those precancerous changes stated in previous monographs and textbooks, some newly recognized gastric dysplasias are proposed. In order to be able to ovjectively evaluate the atypism of dysplasic changes, achievements of morphometric studies were presented.

Although dyspepsia has been investigated for a long period of time, there is no international agreement on what constitutes this condition nor any standardized guidelines. National guidelines followed by practitioners in different countries vary in diagnostic and therapeutic approach, underlining the necessity for a unique definition worldwide. Dyspepsia in Clinical Practice summarizes the current guidelines while offering a unified, practical definition of dyspepsia, and a diagnostic algorithm with an emphasis on the upper gastrointestinal endoscopy and rational first-line therapeutic approach based on epidemiology, pathophysiology, clinical presentation, diagnostic workup and response to previous therapy. Up-to-date scientific information about dyspepsia is presented from a practical, clinician's point of view. Written by experts in the field, this volume addresses dyspepsia in childhood and in the elderly, a very important issue often insufficiently emphasized in the literature. Guidelines are provided that can be easily followed in clinical practice, leading to a reduction in costs and increased patient safety. Dyspepsia in Clinical Practice will be of great value to gastroenterologists, internists, primary care physicians, pediatricians, infectious disease specialists, residents and fellows in training.

Nonsurgical Biliary Drainage is a survey of the current status of the endoscopic and percutaneous transhepatic approaches. The editors - internationally recognized leaders in gastroenterology - have gathered together articles which discuss both the principles and methodology of these techniques as well as their results and limitations. With the wealth of authoritative information it contains, this book will also help lay the groundwork for future advances in the field.

Parasitic Disease in Clinical Practice is the sixth monograph to appear in the now established and flourishing Bloomsbury Series in Clinical Science. Written by a distinguished authority in the field, the book gives a comprehensive and detailed description of parasitic infections and their clinical consequences. Such infections are no longer confined to tropical parts of the world and now have a widespread distribution. Rapid advances are being made in understanding their epidemiology and in diagnosing and treating particular infections. Current literature is largely directed to the parasites, their characteristics and their isolation; a clinical review is clearly needed. This has now been provided, for the author's stated objective is to "inculcate a greater awareness, understanding and appreciation of human parastic disease in the minds of all clinicians". London, March 1990 Jack Tinker Preface Homo sapiens has always existed in a finely balanced equilibrium with a great diversity of infective agents, almost all of them of great antiquity. Many must have exerted a profound effect on the evolution of the human genome. While the average physician is usually aware of potentially pathogenic viruses, bacteria (and rickettsia), and to a lesser extent fungi, hislher knowledge of protozoan and helminthic infections is frequently imperfect and often rudimentary.

The purpose of this series of volumes is to present a comprehensive view of the complications that result from the use of acceptable diagnostic and therapeutic procedures. Individual volumes will deal with iatrogenic complications involving (1) the alimentary system, (2) the urinary system, (3) the respiratory and cardiac systems, (4) the skeletal system and (5) the pediatric patient. The term iatrogenic, derived from two Greek words, means physician-induced. Originally, it applied only to psychiatric disorders generated in the patient by autosuggestion, based on misinterpretation of the doctor's attitude and com ments. As clinically used, it now pertains to the inadvertent side-effects and com plications created in the course of diagnosis and treatment. The classic categories of disease have included: (1) congenital and developmental, (2) traumatic, (3) infectious and inflammatory, (4) metabolic, (5) neoplastic, and (6) degenerative. To these must be added, however, iatrogenic disorders-a major, although gen erally unacknowledged, source of illness. While great advances in medical care in both diagnosis and therapy have been accomplished in the past few decades, many are at times associated with certain side-effects and risks which may result in distress equal to or greater than the basic condition. Iatrogenic complications, which may be referred to as "diseases of medical progress," have become a new dimension in the causation of human disease."

A clinician's guideline for intra-abdominal infections written by experts in the field.

- A manual to help physicians to quickly recognize and better understand the pathogenesis of intra-abdominal
infections
- Includes several high-quality black and white and color photographs from real-life clinical cases
- Adheres to a simple format to serve as essential and quick reference guide for all non-surgical residents and physicians

The Leiden-Edinburgh Boerhaave Course on 'The Gastro-intestinal Tract', held in Leiden on October 29 and 30, 1969, resulted from the renewed co-operation between the Medical Faculties of Edinburgh and Leiden, based on very old ties. As one will know, the Edinburgh Faculty of Medi cine was founded in 1726 on the principles guiding the Leiden Faculty of Medicine at that time, on the instigation of John Monro I, who had studied medicine in Leiden under the famous Boerhaave. These old ties were revived some 8 years ago, first by students, later by the Faculties themselves, with the special purpose to facilitate and en large the exchange of medical knowledge between two medical centres. One of the results of this was that it was considered whether physicians from both countries could not profit from the knowledge gained specific ally in both these faculties by letting the investigators from both faculties tell about their work within the framework of courses for post-academic medical training, in Leiden called the 'Boerhaave Courses'."

This book is a unique work devoted to the subject of disordered defaecation. It contains chapters written by experts in the field of ano-rectal physiology and management of disordered defaecation. The various contributions present personal views and special clinical experience of individuals. There are some personal views which we felt should be commented upon and a few areas where the experience of others has been included into the text. For the sake of completeness of each chapter, a slight overlap in some cases was inevitable. We hope the book will serve as a useful collection of opinions on a subject which until recently has been largely ignored by the medical profession. The editors Major contributors H. O. ten Cate Hoedemaker Department of Surgery, University Hospital, Rijnsburgerweg 10,2333 AA Leiden, The Netherlands G. Coremans Department ofInternal Medicine, University Hospital Gasthuisberg, Here- straat 49, 3000 Leuven, Belgium S. Fasth Department of Surgery II, Sahlgrenska Hospital, S-413 45 G6teborg, Swe- den H. G. Gooszen Department of Surgery, University Hospital, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands J. A. Gruwez Department of General Surgery, University Hospitals KU, Brusselsestraat 63,3000 Leuven, Belgium M. M. Henry Department of Gastroenterology, Central Middlesex Hospital, Acton Lane, London NWlO 7NS, United Kingdom M. R. B. Keighley Department of Surgery, The General Hospital, Steelhouse Lane, Bir- mingham B4 6NH, United Kingdom J. H. C. Kuypers Department of Surgery, University Hospital St. Radboud, Geert Groote- plein Zuid 14,6500 HB Nijmegen, The Netherlands Ph. B.

A fine team of state-of-the-art researcher/clinicians who know their fields, have contributed to the advancement of knowledge, and are in a position to judge what is truly important have here pooled their thoughts in a series of chapters on the cutting edges of gastroenterology. Four attributes render this volume superior to other update-oriented publications. The first striking feature, which is immediately evident upon scanning the table of contents, is the imaginative choice of subjects, ranging from trav eler's diarrhea and sexually transmitted GI infections through TPN and interventional endoscopy to geriatrics and iatrogenic disease. A second outstanding feature of this volume is its success in balanc ing basic pathophysiology with practical considerations of clinical man agement. This is achieved in the discussions of such diverse topics as acid-peptic diseases, infectious and other diarrheal syndromes, and hep atitis immunization. Throughout the book we are led smoothly from basic science principles to specific recommendations for diagnosis and therapy. This practical emphasis appears repeatedly and sometimes pro duces a delightful surprise, such as a chapter on radiology that is not tech nology-based but instead problem-oriented."