This fully revised and updated third edition of the Oxford Handbook of Gastroenterology and Hepatology provides up-to-date, pragmatic advice on the management of common conditions and emergencies. An essential resource for all those involved in the care of patients with gastroenterological and hepatological disease, both for specialists and trainees in gastroenterology and hepatology, and also clinicians from other specialties. The handbook includes a problems-based approach, a unique A to Z compendium of conditions, and sections on therapeutic drugs, and emergencies. Thoroughly revised and updated, it now includes such updates as new approaches for the management of eating disorders, and post-liver transplant patients, the latest advances in endoscopy, new therapies, refined advice on how to select between therapeutic options, as well as additional emergency topics on abdominal trauma, bowel obstructions, and major haemorrhage.

This is a classification of tumours and tumour-like lesions of the liver. It is based primarily on the microscopic characteristics of the tumours, and is therefore concerned with morphologically identi- fiable cell types and histological patterns. The haematoxylin- and eosin-stained section remains the mainstay of morphological diag- nosis, but special histochemical stains are often helpful and have been referred to in the explanatory notes. Readers interested in specific special stains mentioned in the text should consult Labora- tory Methods in Histotechnology of the Armed Forces Institute of *Pathology, Washington, D. c., USA. 1 The results of immunohisto- chemical methods for identifying various tumour "markers" have also been noted whenever indicated. The present classification incorporates all the previously classi- fied tumours, but also includes several new lesions, viz. biliary papil- lomatosis, the fibrolamellar variant of hepatocellular carcinoma and epithelioid haemangioendothelioma. Several subtypes of hepato- blastoma are mentioned. A serous type of bile duct cystadenoma is described. The section on tumour-like lesions has been expanded to include focal fatty change and inflammatory pseudotumour. The section on adenomatous hyperplasia, including macroregenerative nodules, has been amplified. The number of photomicrographs has been increased from the original 56 to 150. Unlike the first edition, the photomicrographs in the second edition are mostly black and white. All are new and were taken of representative cases on file at the Armed Forces Institute of Pathology.

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

Chronic viral hepatitis remains one of the major medical problems worldwide. Neither a cure nor eradication of this disease is in sight. The chronic disease caused by hepatitis viruses type B, C and D is a much greater problem than the acute disease caused by the same viruses or by hepatitis viruses type A and E. Chronic viral hepatitis often remains unrecognized until the patient develops decompensated liver cirrhosis or hepatocellular carcinoma. Furthermore, unrecognized chronic virus carriers are a persistent source of infection by sexual and other close contacts as well as during many medical procedures. The viruses of chronic hepatitis are very different from each other from a taxonomical point of view, but they share many common pathogenic properties and they often coinfect individuals. Six years ago Carlo De Bac, Gloria Taliani (Rome) and I undertook an effort to bring together, under the auspices of the European Society against Virus Diseases, clinicians, laboratory physicians, epidemiologists, pathologists and molecular biologists whose primary research interest is chronic viral hepatitis. The contributions from these quite divergent participants to a meeting devoted solely to chronic viral hepatitis were most stimulating and valuable. As a result of the success of the first meeting in Fiuggi (Italy), a second followed in Siena (Italy) 1990 and the recent third meeting was held in Pisa (Italy). Most of the speakers expressed interest in publishing their contributions in the form of a proceedings volume, as was done in the case of the Siena meeting.

Chronic viral hepatitis is discussed here in a multidisciplinary approach. The editors' goal was to assemble contributions from clinicians, laboratory physicians, epidemiologists, pathologists, and molecular biologists to provide a synopsis of all the important aspects of this disease. A key element in the chronic evolution of viral hepatitis is the persistent coexistence of a cytotoxic immune response and viral gene expression which is discussed in eleven articles on immune pathogenesis. The oncogenicity of hepatitis B virus at the molecular level and of hepatitis C virus at the epidemiological level is discussed in two chapters. The application of PCR for the detection of hepatitis viruses and their variants is a major topic of both practical and theoretical interest. The clinical significance of newly developed serological assays for diagnosis and prevention is discussed in depth by specialists from clinics, transfusion centers and virological laboratories. The therapy of chronic viral hepatitis is still unsatisfactory, but some slow progress is described in several articles. Furthermore, the volume has a special chapter on the often neglected topic of chronic hepatitis in childhood.

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

Clinical Dilemmas in Non-Alcoholic Fatty Liver Disease offers hepatologists practical, up-to-date and expert guidance on the most topical dilemmas, difficulties and areas of controversy/difficulty surrounding this ever-increasing area of liver disease they face in daily practice. Roger Williams and Simon Taylor-Robinson, two of Europe s leading hepatologists, have recruited leading figures from across the world to assist them, resulting in a truly international approach. Each chapter covers a specific area of difficulty, containing clear learning points and providing evidence-based expert guidance on the latest hot topics in clinical management such as: * Is NAFLD different in absence of Metabolic Syndrome? * Are the pros outweighed by the cons of obtaining a liver biopsy? * Is progression to cirrhosis more likely in children with NAFLD? * What are the dangers as well as the true benefits of bariatric surgery? * How is it best to use antifibrotic agents in clinical practice? Clinical Dilemmas in Non-Alcoholic Fatty Liver Disease provides the answers to the questions and challenges that clinicians face every day in this area. It is essential reading for hepatologists of all levels and researchers in hepatology, as well as all those involved in the care of patients with NAFLD, including gastroenterologists, pathologists and specialist hepatology nurses.

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.

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.

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

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.

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.

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.

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.

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."

Operative ultrasound, which permits direct We have divided the material into three placement of the probe on the organ to be principal sections: hepatic surgery, biliary studied during surgery, has been in existence surgery, and the surgery of portal hyperten for over 20 years. Early experiences with its sion. Our experience with operative ultra use in urologic [15] and biliary surgery [7, 8, sound in pancreatic disease is not adequate 9] were limited by technical difficulties but for discussion in this manual, although many the evolution of B-mode, real-time ultra useful applications have been suggested. sound has made possible the broad applica Each chapter includes an anatomical review tion of ultrasound in the operating room. and a presentation of the basic sonographic The goal of operative ultrasound is to signs to clarify the diagnosis and therapy of provide the surgeon with information about a pathologic conditions. Emphasis has been solid organ which is not obvious from its ex placed on the practical applications of opera ternal morphology. What is the nature of the tive ultrasound. lesion? What is its precise localization within With most of the ultrasound images (all the organ? What vascular and anatomical are presented on a black background) two constraints limit its surgical treatment? Mod schematic diagrams are shown: ern ultrasound technology, which produces The first indicates the position of the probe an image faithful to the true anatomy, per on anterior and lateral projections.

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.

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."

"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.""

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).

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. .

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.