book reviews

ery hematology department and on the shelf of every specialist in this field. Charles Singer, F.R.C.P., F.R.C.Path.
Royal United Hospital Bath BA1 7NG, United Kingdom

pancreatitis and its complications

(Clinical Gastroenterology.) Edited by Chris E. Forsmark. 338 pp., illustrated. Totowa, N.J., Humana Press, 2005. $125. ISBN 1-58829-179-0.

he pancreas never sounds a lub dub, makes no borborygmi, and is rarely palpable on physical examination. Nonetheless, gram for gram, it is just about the most active and efficient protein-synthesizing factory in the body. Moreover, when activated spontaneously, its vast store of digestive enzymes cannot distinguish between a hamburger and the human retroperitoneum. So when the pancreas is troubled, serious medical problems follow. Pancreatitis and Its Complications is edited by Chris E. Forsmark of the University of Florida College of Medicine, who comes from a background in clinical academic research and has extensive experience in sophisticated endoscopic imaging and in treatment. The authors of various chapters of this book virtually delineate the global experts in pancreatic disease. The text is divided into two parts, the first dealing with acute pancreatitis, and the second with chronic pancreatitis. The section on acute pancreatitis is particularly strong in its discussions of epidemiology, pathophysiology, and risk stratification. There is an extensive discussion of the pathophysiology of alcoholic acute pancreatitis and gallstone pancreatitis. Some other causes of acute pancreatitis, such as peptic ulcer disease and acute penetrating or blunt abdominal trauma, are discussed only in passing, unfortunately. The chapter on treatment of severe acute pancreatitis is exceptional, yet it has only a very limited discussion of drug therapies. Indeed, there is twice as much discussion about the role of fasting and nasogastric suction in treating acute pancreatitis as there is discussion devoted to new, albeit disappointing, drug treatments, including octreotide, aprotinin, and gabexate. Readers should pay particular attention to an exemplary and illuminating chapter dealing with the

Biliary Stones Causing Acute Pancreatitis.

management of pancreatic-fluid collection and pseudocysts in patients with acute pancreatitis. Excellent tables and a particularly helpful and erudite algorithm provide an intelligent and well-balanced approach to the treatment of patients with these common complications of acute pancreatitis. The second section, on chronic pancreatitis, is also well written and very well illustrated. The tendency has always been, particularly in general medical and surgical circles, to consider chronic pancreatitis as merely the long-standing, painful consequence of multiple bouts of acute pancreatitis. The insidious, and sometimes silent, yet relentless development of chronic pancreatitis with its multiple manifestations is nicely displayed in both text and illustration format. Four important areas are exceptionally well covered: the pathophysiology and diagnosis of chronic pancreatitis, the use of pancreatic-enzyme preparations, and the endoscopic approach to patients with chronic pancreatitis. David Whitcombs chapter dealing with the pathophysiology of chronic pancreatitis discusses genetic mutations that are probably associated with the condition, specifically those involving the CFTR, PRSS1, and SPINK1 genes. He also discusses the possible contributions of less

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appreciated factors, such as tobacco smoking and renal failure, to the development of chronic pancreatitis. Forsmarks chapter on the diagnosis of chronic pancreatitis leaves one wondering why so many of the tests he mentions are simply not available in the United States, including bentiromide (NBTPABA) and pancreaolauryl tests, triolein breath tests, and secretin and cholecystokinin (CCK) simulation tests. Reluctantly, one has to conclude that American medicine has bypassed these inexpensive and noninvasive tests of pancreatic function for the more invasive and remunerative tests, such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. An important therapeutic point mentioned by contributor Phillip P. Toskes is the use of nonenteric-coated pancreatic enzymes in the treatment of chronic pancreatitis. Unfortunately, most clinicians fail to recognize that for patients with small-duct chronic pancreatitis, the use of nonenteric-coated pancreatic enzymes such as pancrelipase (Viokase 16) can have dramatic beneficial effects on recurrent abdominal pain. Finally, the chapter by Lee McHenry, Glen Lehman, and Stuart Sherman on the endoscopic approach is particularly well written, but it suffers from the lack of color endoscopic photographs. All in all, this book is an important compendium of the current state of the art and science in treating patients with pancreatitis. It is certainly a must have for gastroenterologists and probably for internists and surgeons as well. John P. Cello, M.D.
University of California, San Francisco San Francisco, CA 94143 jpcsf@aol.com

pharmacotherapy of obesity: options and alternatives

Edited by Karl G. Hofbauer, Ulrich Keller, and Olivier Boss. 488 pp., illustrated. Boca Raton, Fla., CRC Press, 2004. $149.95. ISBN 0-415-30321-4.

ith the global epidemic of obesity and its coexisting conditions, the need for effective obesity treatments has never been greater. Current behavioral and dietary therapies frequently lead to sufficient weight loss to reduce risk factors such as hypertension and dyslipidemia. However, with the exception of bariatric surgery, treatments resulting in long-term maintenance of lost weight remain elusive. At the same time, advances in basic
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science have led to a better understanding of the pathways that affect energy balance and to the identification of myriad potential central and peripheral drug targets. Hence, a comprehensive textbook focusing on the pharmacotherapy of obesity is timely. The target audience of Pharmacotherapy of Obesity is physicians and other health care professionals who treat obesity. The books six sections cover the pathophysiology of obesity, general therapeutic aspects, benefits of weight loss, drugs on the market, drugs in research and development, and treatment alternatives (which include herbal supplements and bariatric surgery). The quality of the chapters and the level of detail vary considerably. The chapter titled Diet, Physical Activity, and Behavior is written for the nonspecialist and provides practical advice on behavioral strategies, whereas the chapter titled The Pathophysiology of Appetite Control is more appropriate for a graduate student or researcher. A chapter (or at least more information) on the use of medications to treat obesity in children and adolescents would have been helpful. The inclusion of a chapter on antipsychotic drugs, weight gain, and diabetes is timely. This chapter delves into the mechanisms by which atypical antipsychotic drugs may contribute to insulin resistance and diabetes. In a book targeted to the clinician, more attention might have been paid to potential ways to prevent and treat these consequences, which are discussed in only a few paragraphs. Additional review of the many other psychotropic medications that may contribute to weight gain would also have been useful. There is much overlap between chapters, and the sometimes-differing interpretations of the same data may be confusing for the uninitiated reader. For example, when trying to determine whether the effect of sibutramine on pulse and blood pressure may change the riskbenefit ratio, a reader of the chapter titled Basic Considerations and Guidelines for Treatment is told that noradrenergic agents have an effect on pulse and blood pressure, but this action tends to be neutralized by the opposite effect from weight loss. However, the reality is that a similar amount of weight loss due to lifestyle changes will have a larger favorable impact on pulse and blood pressure than will weight loss due to the effects of certain weight-loss medications, such as sibutramine. This observation is correctly discussed in the following chapter, titled Weight Loss and Cardiovascular Risk Factors. A possible limitation of this book about a fastchanging field is that it may be outdated by the time it
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