Origins and Directions of Inflammatory Bowel Disease, Early Studies of the “Nonspecific” Inflammatory Bowel Diseases

Origins and Directions of Inflammatory Bowel Disease, Early Studies of the “Nonspecific” Inflammatory Bowel Diseases

March 2003 plications, and malignancy. The first appendix focuses on activity indices; the second has useful addresses where patients can be referred...

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March 2003

plications, and malignancy. The first appendix focuses on activity indices; the second has useful addresses where patients can be referred for self-help and more information on IBD. The individual chapters are short and to the point. For those readers who want more information on a specific topic, the chapters are extensively referenced, with 368 citations in the chapter on medical therapy. Why another IBD book? There are multiple authoritative texts in the area of IBD with the 800-page Kirsner text (Inflammatory Bowel Disease, 5th edition, 2000, Saunders) serving as a model. The main attribute that the Forbes guide provides has to do with the length of the text. The chapters are succinct and to the point. The references allow the reader who wishes to delve deeper into the subject matter to do that. For a busy practitioner who is faced with a specific question regarding IBD management such as “What are the fertility issues in women with IBD,” the answers can be found in 2 paragraphs in the chapter on Obstetrics and Pediatrics. The information is up to date and the index is well structured. The main drawback to the book is that with the explosion of knowledge in the immunology and pathogenesis of IBD, the pathogenesis section and the therapy sections are likely to become quickly outdated. The clinical basics, however, will remain the same. This book is likely to appeal to fellows in gastroenterology, and to practicing gastroenterologists, residents, and students with an interest in IBD. Bottom Line: A succinct, focused monograph on clinical aspects of IBD.

KIM ISAACS, M.D., Ph.D. Division of Digestive Diseases and Nutrition University of North Carolina at Chapel Hill Chapel Hill, North Carolina Evidence-Based Gastroenterology. By E. Jan Irvine and Richard Hunt. 464 pp. $99.95. B.C. Decker, Inc., Hamilton, Ontario, 2001. ISBN 155009-105-0. Web address for ordering: http:// The practice of evidence-based medicine (EBM) has become increasingly common in internal medicine and its subspecialties. EBM has been defined as “the conscientious, explicit and judicious use of current best evidence from clinical care research in the management of individual patients.” This textbook fills a thus far neglected niche for gastrointestinal textbooks. Most textbooks in the field are written from an expert’s perspective, which may be correct but often lacks corroboration with current best evidence in clinical research. This can also be referred to as “eminence-based” medicine. This book’s introduction nicely frames the intent of the textbook, as well as explaining the classification used for levels of evidence. The book has 31 chapters describing various areas in gastroenterology, hepatology, and nutrition. Each chapter has been formatted so that a case scenario is presented to frame the clinical question(s) in that area. Next learning objectives are listed. Next follows an evidence-based assessment of the



literature pertaining to the subject area. Finally, in most chapters, this data is used to answer the questions brought up by the initial case. Although most authors follow this format, there is some variability in the quality of the chapters. The excellent chapters on colon cancer screening, gastroesophageal reflux, and Barrett’s esophagus deserve mention. Other topics, such as postcholecystectomy pain and pediatric recurrent abdominal pain don’t lend themselves well to this format. The book is somewhat skewed to the foregut with 4 chapters related to gastroesophageal reflux and its sequelae and 5 chapters on peptic ulcer disease and H. pylori. There is one chapter each on hepatitis B and C but nothing on cholestatic liver disease, hemochromatosis, or drug-induced liver disease. An evidence-based approach to evaluation of abnormal liver chemistries would have been nice. The chapter on economic evaluation in gastrointestinal disease is a good primer in that area. Perhaps in the next edition, the editors could include a chapter (or more) on study design, including a discourse on metaanalyses (frequently used in EBM). The obvious strength of this book is that data and clinical recommendations are overtly linked to evidence. The reader is then able to decide whether the current best evidence merits the subsequent clinical decision. I applaud the editors for undertaking this task, since this type of textbook has been sorely lacking in our field. It appears most newer textbooks are attempting to take an evidence-based approach (without necessarily calling it EBM). The textbook comes with a companion CD-ROM, which allows PDF viewing of all the chapters. A search function would greatly increase its value. One shortcoming with this textbook (as with all) is that by the time of publication, much new research has been done. This text was published in January 2001 and there are few references from even 2000. Because the practice of EBM depends greatly on the current best evidence, the book is already somewhat dated. However, it does provide readers with an excellent review of the evidence in the topics covered up until 2000. Perhaps, the editors can provide an annual update via CD-ROM or the web for those interested. Overall, I strongly recommend this book for trainees, those in practice, as well as the eminent among us.

GLENN EISEN, M.D., M.P.H. Department of Medicine Vanderbilt University Medical Center Nashville, Tennessee Origins and Directions of Inflammatory Bowel Disease, Early Studies of the “Nonspecific” Inflammatory Bowel Diseases. By Joseph B. Kirsner. 246 pp. $92.00. Kluwer Academic Publishers, Dordrecht/Boston/London, 2001. ISBN 0-7923-8777-5. Web address for ordering: In Origins and Directions of Inflammatory Bowel Disease Dr. Joseph Kirsner has provided a comprehensive historiography of efforts during the last century to identify, understand, and treat the idiopathic inflammatory bowel diseases (IBD). Ele-



ments of this material have been published as book chapters and journal reviews, but never with the scope and density of this text. With the conviction that our hubris for the present ignores important lessons gleaned from the past, I can recommend this book to those who value understanding how we have come to be where we are, and to anyone who cares for, investigates, or wishes to better understand patients who have “nonspecific” IBD. One way of viewing this book is as an annotated bibliography of the past 100 years of published medical observations relating to ulcerative colitis and Crohn’s disease. Yet with over 1345 references cited, Dr. Kirsner has clearly made choices as to which studies would be included. Some investigators who have contributed to this body of work may be disappointed or pleased when they look for their studies. However, this is simply a consequence of annotation. With no particular ax to grind, I found the choices sound and valuable, in that they provided historical context for understanding IBD. The comments and perspectives of an author who has participated in the events he describes are an added delight. Indeed, for me, one deficiency of the book is that Dr. Kirsner did not allow his personal observations enough free rein. Using the text as a bibliographic resource, one can define a focal area of IBD history (e.g., psychosomatic illness) when needed. I would encourage dauntless readers, however, to examine the book from cover to cover. Though the going is at times difficult, it can be ultimately satisfying. Dr. Kirsner’s book reads as a descriptive natural history of our continuing search to develop a conceptual framework for a group of diseases that we don’t understand. This struggle is not unique to medicine. Umberto Eco in Kant and the Platypus describes the 80-year period from the first sighting of the platypus to the agreement by the scientific community that the animal was a


different kind of mammal that lays eggs rather than a furry bird that couldn’t fly. We can only describe new “things” relative to icons that we have created, or that have currency. That the “answer” for IBD would be defined in morphological, infectious, allergic, psychosomatic, nutritional, or even genetic and immunological terms is not surprising from this perspective, as this simply reflects the “dictionary” that we had (have) to use in describing the unknown. Whether the “truth” will come from the current paradigms of genetics and immunology, or from some rephrasing of an older iconography (e.g., probiotics), only time will tell. For this reason, it is important to understand the origins of our concepts. Reading this as a book, rather than as a reference, led me to discover many gems that I would have otherwise missed. For instance, a curious case involving the simultaneous onset of ulcerative colitis both in the rectum and in the artificial vagina previously created from that rectum gave me pause to reflect on the current excitement about the role of indigenous intestinal flora in the pathogenesis of IBD. And the description, only 50 years ago, of frontal lobotomy being used to “successfully” treat IBD, made me feel a bit more secure in my inherent therapeutic nihilism when evaluating the newest approaches to IBD therapy. Give this book to a bright GI fellow. I think he or she will like it. Bottom Line: Compelling medical history by one of the giants of our specialty.

JOEL S. LEVINE, M.D., F.A.C.P. Division of Gastroenterology-Hepatology University of Colorado School of Medicine Denver, Colorado