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Gut. 2007 July; 56(7): 1036.
PMCID: PMC1994348

The clinician's guide to pancreaticobiliary disorders

Reviewed by Markus M Lerch

Edited by Gregory G Ginsberg and Nuzhat A Ahmad. New Jersey: Published by Slack Incorporated, 2006, pp 400. ISBN 1-55642-694-1

Ginsberg and Ahmad from Philadelphia have edited a compendium on pancreaticobiliary disorders within the Clinician's Guide series. Overall, this is a concise book and makes for good reading. The referencing is somewhat inconsistent from chapter to chapter. Sometimes citations are extensive, and sometimes chapters are rather short on direct references to statements made in the text. Some chapters like chapter 1 recommend further reading instead, whereas others such as chapters 11 and 2 are well referenced.

At the start of the book, congenital abnormalities of the pancreas, such as pancreas divisum, are outlined, and guidelines for interventional therapy are given. Chapter 2 on gallstones and gallbladder disorders is detailed on the pathobiology of gallstone formation. Some facts are repeated in Chapter 3 on choledocholithiasis, which also contains the technical intricacies of various types of sphincterotomes. Unfortunately, no reference is provided for the indicated 25% late complication rate after endoscopic sphincterotomy, a proportion I regard as very high. In Chapter 5, diseases of the ampulla of Vater sphincter of Oddi dysfunction are reviewed in a very pragmatic and helpful way that includes examples like the benefits of using the Milwaukee classification in clinical practice. This chapter also points out where additional randomised multicentre trials would be needed. Chapter 6, dealing with cholangiocarcinoma, goes into detail on stent placement and surgery, but not on chemotherapy or radiation therapy.

Chapter 8 on acute pancreatitis gives a very good overview. The Marshall Score cited should currently be replaced by the Sequential Organ Failure Assessment score. The extensive tables on medication‐induced pancreatitis are very useful, but they do not provide the degree of evidence required for each drug, such as whether the information is from a single case report or from rechallenge evidence or from multicentre controlled trials. Although the previous review on the pathogenesis and pathophysiology of gallstone formation in an earlier chapter was excellent, that for pancreatitis is missing. Prophylaxis for endoscopic retrograde cholangiopancreatography‐induced pancreatitis is not endorsed, and the approach outlined here is very practical. Also, the approach to CT scan indications in acute pancreatitis is based on personal experience, straightforward and to the point: “The patient usually had one (CT) before we see him. If he doesn't we don't perform one but allow the clinical course to determine the indication.”

I only disagree with the authors' assumption that C‐reactive protein levels should be “relegated to the realm of research tools”, since it is widely available and used both in the US and Europe to determine the severity of pancreatitis outside of imaging techniques. Where the chapter sees great promise (trypsinogen activation peptide), the assay is no longer commercially available and was discontinued a few years ago. The chapter is very up to date and practical as far as the use of antibiotics in necrotising pancreatitis and the use of parenteral nutrition are concerned. The statement on page 169 that “all would agree that an NPO (nil per mouth) status is mandatory to put the pancreas to rest and allow healing to proceed” is now utterly obsolete. Endorsing enteral nutrition over parenteral nutrition in the absence of ileus, on the other hand, is now evidence‐based clinical practice. If the authors of the pancreatitis chapter do not use severity scores or C‐reactive protein level, the question remains as to how do they follow their own recommendation to determine the severity of pancreatitis other than by means of a CT scan.

Chapter 9 on chronic pancreatitis gives a good overview on pathophysiology and pathology. Unfortunately, the concepts regarding tropical pancreatitis are completely outdated, since neither Cassava nor selenium aetiology hypotheses have stood the test of scientific inquiry, and serine protease inhibitor Kazal 1 mutations are found in 50% of patients with tropical pancreatitis. The statement that “furthermore myriad mutations have been plausibly linked to pancreatitis” is incorrect; also, only a single trypsinogen mutation for hereditary pancreatitis (R117H) is mentioned in this chapter and denoted according to the old chymotrypsinogen classification that was dropped a decade ago (the mutation is now referred to as R122H). The chapter states the varying and conflicting hypotheses about the underlying mechanisms of hereditary pancreatitis as though they are based on experimental evidence—which they are not. The chapter states further that there is a plethora of non‐invasive, indirect tests of pancreatic function that do not require passage of collection tubes. However, it lists only five of those, of which two are no longer commercially available. An advantage of the chapter is that it is extensively referenced. Chapter 11 on solid pancreatic tumours has unfortunately no section on chemotherapy or adjuvant therapy. A review on intraductal endoscopic ultrasound appears in this chapter on solid tumours rather than in the preceding chapter on pancreatic ductal complications and their diagnosis. Chapter 12 on pancreatic cystic lesions includes intraductal papillary mucinous neoplasia and is very up to date. Table 11‐1 and Table 13‐1 are, however, identical. The imaging of the pancreatobiliary system as covered in Chapter 15 is immensely readable, Chapter 16 on MRI has excellent photo quality and Chapter 17 covers interventional radiology.

Overall, I found this book concise, mostly up to date, very readable and sometimes even entertaining. A more detailed coverage would be found in existing text books. The authors Ginsberg and Ahmad should be congratulated on editing this practical clinician's guide.

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