Principles of Clinical Gastroenterology

Article Outline

• Copyright

While clinicians continue to debate the importance of evidence- versus experience-based medicine, the editors of Principles of Clinical Gastroenterology have effectively integrated the principles of evidence-based medicine into practical, case-based experiences. Each of the 31 chapters in this compact text is organized with the clinician–patient interaction at its core. Case scenarios provide a coherent backbone for exploring clinical decision making.

The book begins with important definitions of evidence-based medicine and how to critically assess articles related to both diagnostic testing and therapeutic management. The critical approach to diagnosis and therapy is clearly delineated and framed by a series of questions, which are then answered in the context of the chapter. This internal dialogue constantly focuses on case scenarios and proves to be an intriguing and effective teaching technique.

Cases and practical interpretation of pharmacoeconomics, physiology, and pharmacology are refreshing and consistently remind the reader that this hard-bound text is intended for practicing gastroenterologists, internists, surgeons, and clinicians—including students and residents—who care for patients with gastrointestinal (GI) and liver diseases.

Patients' symptoms and signs provide the organizing framework for Principles of Clinical Gastroenterology. The questions that echo and reverberate throughout the book are how does the clinician interpret and balance the basic science underlying GI and liver diseases and how do our interpretations impact our patients' lives?

The authors present practical advice on symptomatic pattern recognition, diagnostic testing, and management strategies. Clearly diagrammed management algorithms often accompany management guidelines, making the book palatable and easy to read. The approaches to dysphagia, dyspepsia, peptic ulcer disease as well as to gross and occult GI bleeding are consistently thorough, current, and concise. Figures illustrating endoscopic band ligations adorn the same page as modified Sengstaken–Blakemore tube and transjugular intrahepatic portosystemic shunts, serving to visually unify the practical principles of managing esophageal varices.

Similarly, evidence of the effectiveness of screening for colorectal cancer is methodically discussed and delineated in clearly organized charts describing outcomes of randomized controlled trials of 2-step screening for colorectal cancer by guaiac-based fecal occult blood testing. The nuances of practical decisions regarding colonoscopy and screening tests of first choice is placed contextually in a clear overview of outcomes in case-controlled and cohort studies evaluating the impact of endoscopic screening on colorectal cancer. Analyses of literature and practical approaches to the patient are always thoughtful and wise.

Despite the many authors—all respected experts in their fields—the consistent patient case–oriented approach embedded in an integrative narrative exploring management strategies is a welcomed change in a unifying underpinning of individual chapters and the collective text. For example, the approach to diarrhea is wide reaching from day care diarrhea to the classification of secretory diarrhea and cholera. The definitions and physiology of diarrhea are incorporated into the practical approach towards treatment. Autoimmune enteropathy is well described and referenced in both children and adults.

Interestingly, inflammatory bowel disease (IBD) is allotted only 1 paragraph and fully 1 sentence is devoted to effective treatment of this disease. It should be noted that on page 329, salicylates are referred to as effective treatments for IBD. The distinction between salicylates and nonsteroidal anti-inflammatory agents, which may actually exacerbate IBD, and aminosalicylates is not made in this text. Although on page 541, the error is partly corrected with several paragraphs devoted to aminosalicylates—not salicylates—in the drug treatment of IBD during pregnancy. Sadly, there is a dearth of information on IBD, an area of gastroenterology that surely lends itself to the thoughtful, practical evidence- and experienced-based approach so amply displayed throughout this text.

The approach to constipation, abnormal liver chemistries, jaundice, ascites, liver failure, liver mass, and hepatitis B and C are at once comprehensive and concise as well as well referenced. These chapters provide a summary of management algorithms, study results, and guidelines. All figures and tables are clear and of high quality. The approach to GI and liver disease in pregnancy is consistently well researched and comprehensive. The discussions on nutrition and genetic counseling also serve to simplify complex areas of gastroenterology and underscore the importance of incorporating both nutrition and genetics into an interdisciplinary health care team approach.

Bottom Line: The use of a symptom-oriented case format in the context of critical evaluation of basic science, evidence-based medicine, pharmacoeconomics, physiology, and pharmacology in this book is perfect for practicing gastroenterologists, internists, surgeons, and all clinicians caring for patients with GI or liver disease. The dynamic and consistent internal dialogue makes this book a treasured read whether on the beach, in the library, or at the bedside. I would recommend that a paperback and DVD version of the book be developed and that parts of this book be incorporated into medical school pathophysiology syllabi.