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ClinicalDilemmasin
Inflammatory
Bowel Disease
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Clinical Dilemmas in
Inflammatory
Bowel Disease
New Challenges
Second Edition
EDITED BY
Peter M. Irving
MD, MRCP
ConsultantGastroenterologist
DepartmentofGastroenterology
Guy’sandStThomas’Hospitals
London,UK
Corey A. Siegel
MD, MS
AssistantProfessorofMedicineandTheDartmouthInstituteforHealthPolicyandClinicalPractice;
DartmouthMedicalSchool
Director,InflammatoryBowelDiseaseCenter
Dartmouth–HitchcockMedicalCenter
SectionofGastroenterologyandHepatology
Lebanon,NH,USA
David S. Rampton
DPhil, FRCP
ProfessorofClinicalGastroenterology
CentreforDigestiveDiseases
BartsandTheLondonSchoolofMedicineandDentistry
London,UK
Fergus Shanahan
MD
ProfessorandChair
DepartmentofMedicine
Director,AlimentaryPharmabioticCentre
UniversityCollegeCork
NationalUniversityofIreland
Cork,Ireland
A John Wiley & Sons, Ltd., Publication
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LibraryofCongressCataloging-in-PublicationData
Clinicaldilemmasininflammatoryboweldisease:newchallenges/editedby
PeterIrving...[etal.].–2nded.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN-13:978-1-4443-3454-8(pbk.:alk.paper)
ISBN-10:1-4443-3454-9(pbk.:alk.paper)
ISBN-13:978-1-4443-4254-3(ePDF)
ISBN-13:978-1-4443-4257-4(e-ISBN-10::WileyOnlineLibrary)[etc.]
1.Inflammatoryboweldiseases. 2.Inflammatoryboweldiseases–Decisionmaking.
I.Irving,Peter,1970-
[DNLM:1.InflammatoryBowelDiseases.WI420]
RC862.I53C5532011
616.3(cid:3)44–dc22
2011007515
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
Thisbookispublishedinthefollowingelectronicformats:ePDF9781444342543;WileyOnlineLibrary
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01 2011
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Contents
Contributors, ix PartIII: InvestigatingIBD
Preface, xv 11 BiomarkersinIBD:mythormarvel?,47
RichardB.GearryandAndrewS.Day
PartI: GenesandPhenotypeinIBD 12 RadiationexposureinIBD:howdoweminimize
thedangers?,51
1 WhichwilltakeusfurtherinIBD—studyofcoding OwenJ.O’Connor,AlanN.Desmond,FergusShanahan,
variationorepigenetics?,3 andMichaelM.Maher
MilesParkes
13 SurveillancecolonoscopyinUC:whatisthebestway
2 IBDindifferentethnicgroups:sameor todoit?,57
different?,7 MatthewD.Rutter
RupertW.L.Leong,DorothyK.L.,Chow,and
ChristianP.Selinger PartIV: MedicalTherapy
PartII: BugsandIBD—Good,Bad, 5-ASA
orIndifferent?
14 New5-ASAsforulcerativecolitis:atinysteporgiant
strideforward?,65
3 Howdoestheriskofinfectioninfluencemanagement
L.CampbellLevy
ofIBDaroundtheworld?,15
KiranK.PeddiandIanCraigLawrance 15 Do5-ASAspreventcancer?,69
RichardLoganandVenkataramanSubramanian
4 TravelingwithIBD,19
IngShian,SoonandGilaadKaplan 16 Whydowestilluse5-ASAsinCrohn’sdisease?,73
StephenB.Hanauer,HenitYanai,andEmmaCalabrese
5 WhattodoabouthepatitisBandhepatitisCinpatients
withIBD,23 Steroids
MorvenCunninghamandGrahamR.Foster
17 SteroidsinCrohn’sdisease:dothebenefitsoutweighthe
6 CMVinIBD—passengerorpathogen?,27 dangers?,79
AhmedKandielandBretLashner A.HillarySteinhart
7 ClostridiumdifficileinIBD:impact,prevention,and Immunomodulators
treatment,30
AshwinN.AnanthakrishnanandDavidG.Binion 18 Thioguaninenucleotidemeasurement:nonadherent,
underdosed,shunter,orrefractory?,85
8 Prebioticsandsynbiotics:panaceaorplacebo,34
MilesP.Sparrow
JamesO.Lindsay
19 Thiopurinesandthesun:whatshouldbedone?,89
9 Worms:lightattheendoftheirburrow,38 ConalM.Perrett,JaneM.McGregor,andCatherineA.
JohnLeungandJoelV.Weinstock Harwood
10 Dowereallyneedtovaccinateallpatients 20 Dothiopurinesworsenriskandprognosisofcervical
withIBD?,41 neoplasia?,94
GaureeGuptaandGilY.Melmed MelissaA.SmithandJeremyD.Sanderson
v
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vi Contents
21 Optimizinguseofmethotrexate,98 36 Complementarytherapy:isthereaneedleinthe
AnnaFoleyandPeterR.Gibson haystack?,164
ShaneM.Devlin
22 Whichcalcineurininhibitorandwhen?,102
A.BarneyHawthorne
PartVI: SurgicalDilemmasinIBD
37 OptimizingIBDpatientsforsurgery
Biologics
andrecovery,171
JonathanM.WilsonandAlastairWindsor
23 Areallanti-TNFagentsthesame?,109
JenniferL.Jones
38 Issurgerythebestinitialtreatmentforlimitedileocecal
24 Onedrugortwo:dopatientsonbiologicsneed Crohn’sdisease?,175
TomØresland
concurrentimmunomodulation?,113
GlenA.DohertyandAdamS.Cheifetz
39 LaparoscopicoropensurgeryforIBD?,178
DonnaAppletonandMichaelHershman
25 Howdoweidentifypatientsneedingearlyaggressive
therapyandwhatshouldweuse?,117 40 OptimizingmanagementofperianalCrohn’s
MarcFerranteandS´everineVermeire
disease,182
DavidA.SchwartzandNormanR.ClarkIII
26 WhatistheroleofbiologicsinUC?,120
JoannaK.LawandBrianBressler
41 Doesanti-TNFtherapyincreasetheriskofcomplications
27 WhatcanwedowithCrohn’spatientswhofailorlose ofsurgery?,186
MingValerieLin,WojciechBlonski,andGaryR.
responsetoanti-TNFtherapy?,124
DavidT.Rubin Lichtenstein
28 WhichextraintestinalmanifestationsofIBDrespond 42 PouchesforindeterminatecolitisandCrohn’sdisease:
tobiologics?,129 actnow,paylater?,192
TinaA.MehtaandChrisS.J.Probert PhillipFleshner
29 Useandabuseofbiologicsinpregnancy,133 43 Dealingwithpouchitis,196
MarlaC.Dubinsky SimonD.McLaughlinandBoShen
30 Isanti-TNFtherapysafetouseinpeoplewithahistory
PartVII: UnsolvedissuesinIBD
ofmalignancy?,136
MarkLustandSimonTravis
44 MucosalhealinginIBD:doesitmatter?,203
31 Therisksofimmunomodulatorsandbiologics:what GeertD’Haens
shouldwetellpatients?,140
45 VitaminDinIBD:fromgeneticstobonehealthviacancer
CoreyA.Siegel
andimmunology,207
32 When,how,andinwhomshouldwestop HelenM.PappaandRichardJ.Grand
biologics?,144
46 Gotmilk?Medicationuseandnursinginwomenwith
EdouardLouis,JacquesBelaiche,andCatherineReenaers
IBD,212
SunandaKane
PartV: OtherTreatments
47 Doesstressmatter?,215
RobertG.Maunder
33 Avoidingdruginteractions,151
TimElliottandPeterM.Irving 48 IBSiscommoninIBD:factorfallacy?,218
JamesGoodhandandDavidS.Rampton
34 Istherestillaroleforursodeoxycholicacidtreatmentin
patientswithinflammatoryboweldiseaseassociated 49 Sowhereisallthecancer?,222
withprimarysclerosingcholangitis?,156 JudithE.BaarsandC.JannekevanderWoude
EmmanouilSinakosandKeithD.Lindor
35 StemcelltransplantationforCrohn’s:willitfulfillits PartVIII: NutritioninIBD
promise?,159
VenkataramanSubramanianandChristopher 50 WhatshouldpatientswithIBDeat?,229
J.Hawkey EmileRichman,KeithLeiper,andJonathanM.Rhodes
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Contents vii
51 EnteralnutritioninCrohn’s—whofor,when,howand 54 Yourtreatmentwillnotworkifthepatientdoesnottake
whichformula?,233 it,247
RaananShamirandErnestG.Seidman RobHorne
52 Optimizingtreatmentofirondeficiency 55 Inflammatoryboweldisease:whattotellyour
anemia,237 emergencydepartment(ED)team,251
HermannSchulzeandAxelDignass LouiseLangmead
56 Transitioningfrompediatrictoadultcare,255
PartIX: ManagementProcess ElizabethJ.HaitandLaurieN.Fishman
57 Medicolegalpitfallsininflammatoryboweldisease
53 IBDStandards:willtheyenhancepatientcare?,243
care,258
MichaelD.Kappelman
WilliamJ.Tremaine
Index, 261
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Contributors
AshwinN.Ananthakrishnan WojciechBlonskiMD,PhD NormanR.ClarkIIIMD
MD,MPH ResearchScholar DivisionofGastroenterology
InstructorinMedicine DivisionofGastroenterology VanderbiltUniversityMedicalCenter
HarvardMedicalSchool UniversityofPennsylvania Nashville,TN,USA
GastrointestinalUnit Philadelphia,PA,USA;
MassachusettsGeneralHospital DepartmentofGastroenterology MorvenCunningham
Boston,MA,USA MedicalUniversity
MA(Hons),MBBS,MRCP
Wroclaw,Poland
ClinicalResearchFellow
DonnaAppletonMD,MRCS BlizardInstituteofCellandMolecular
SpecialistRegistrar BrianBresslerMD,MS,FRCPC Science
DepartmentofGeneralandColorectal ClinicalAssistantProfessorofMedicine BartsandTheLondonSchoolofMedicine
Surgery DivisionofGastroenterology andDentistry
StaffordGeneralHospital UniversityofBritishColumbia QueenMary,UniversityofLondon
Stafford,UK Vancouver,BC,Canada UK
JudithE.BaarsMSc,PhD EmmaCalabreseMD,PhD AndrewS.DayMB,ChB,MD,
MedicalStudent UniversityofRome“TorVergata” FRACP,AGAF
ErasmusUniversity Rome,Italy AssociateProfessor
Rotterdam,TheNetherlands DepartmentofPaediatrics
DepartmentofGastroenterologyand AdamS.CheifetzMD UniversityofOtago
Hepatology AssistantProfessorofMedicine; Dunedin,Otago,NewZealand;
ErasmusMCHospital ClinicalDirector,CenterforInflammatory PediatricGastroenterology
Rotterdam,TheNetherlands BowelDisease ChristchurchHospital
DivisionofGastroenterology Christchurch,NewZealand
JacquesBelaichePhD BethIsraelDeaconessMedicalCenterand
ProfessorofGastroenterology HarvardMedicalSchool AlanN.DesmondMB,BCh,
Departmentofgastroenterology Boston,MA,USA
BAO,BMedSc,MRCPI
CHULie`geandGIGAResearchUniversity
SpecialistRegistrar
ofLie`ge DorothyK.L.Chow MBChB, DepartmentofGastroenterologyand
Lie`ge,Belgium
MD,MRCP GeneralInternalMedicine
ClinicalAssistantProfessor(Honorary) CorkUniversityHospital
DavidG.BinionMD DepartmentofMedicineandTherapeutics Wilton,Cork,Ireland
VisitingProfessorofMedicine PrinceofWalesHospital
DivisionofGastroenterology,Hepatology, TheChineseUniversityofHongKong ShaneM.DevlinMD,FRCPC
andNutrition HongKongSAR,China ClinicalAssistantProfessor
UniversityofPittsburghSchoolofMedicine
DivisionofGastroenterology
Pittsburgh,PA,USA
MirandaClarkBSc(Hons) InflammatoryBowelDiseaseClinic
ClinicalTrialsCoordinator TheUniversityofCalgary
UniversityHospital Calgary,AB,Canada
Queen’sMedicalCentre
Nottingham,UK
ix
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x Contributors
GeertD’HaensMD,PhD AnnaFoleyMBBS(Hons),FRACP ElizabethJ.HaitMD,MPH
ProfessorofMedicine ConsultantGastroenterologist CenterforInflammatoryBowelDisease
AcademicMedicalCentre DepartmentofGastroenterologyand DivisionofGastroenterologyandNutrition
Amsterdam,TheNetherlands Hepatology Children’sHospitalBoston
BoxHillHospital HarvardMedicalSchool
AxelDignassMD,PhD,FEBG, Melbourne,VIC,Australia Boston,MA,USA
AGAF GrahamR.FosterFRCP,PhD StephenB.HanauerMD
ProfessorofMedicine
ProfessorofHepatology ProfessorofMedicineandClinical
Head,DepartmentofMedicineI
BlizardInstituteofCellandMolecular Pharmacology
MarkusHospital
Science SectionofGastroenterology,Hepatology,
Frankfurt/Main,Germany
BartsandTheLondonSchoolofMedicine andNutrition
andDentistry UniversityofChicagoMedicalCenter
GlenA.DohertyMB,PhD, QueenMary,UniversityofLondon Chicago,IL,USA;
MRCPI London,UK Chief,SectionofGastroenterology,
ConsultantGastroenterologist Hepatology,andNutrition
CentreforColorectalDisease RichardB.GearryMB,ChB, UniversityofChicagoMedicalCenter
StVincent’sUniversityHospital/University PhD,FRACP Chicago,IL,USA
CollegeDublin AssociateProfessorofMedicine
Dublin,Ireland ConsultantGastroenterologist CatherineA.Harwood
DepartmentofMedicine CentreforCutaneousResearch
MarlaC.DubinskyMD UniversityofOtago BlizardInstituteofCellandMolecular
AssociateProfessorofPediatrics Dunedin,Otago,NewZealand; Science
Director,PediatricIBDCenter DepartmentofGastroenterology BartsandTheLondonSchoolofMedicine
CedarsSinaiMedicalCenter ChristchurchHospital andDentistry
LosAngeles,CA,USA Christchurch,NewZealand QueenMaryUniversityofLondon
London,UK
TimElliottMBBS,FRACP PeterGibsonMD,FRACP
SpecialistRegistrar ProfessorofMedicineandConsultant ChristopherJ.HawkeyDM,
DepartmentofGastroenterology Gastroenterologist
FRCP
GuysandStThomas’Hospitals DepartmentofGastroenterologyand ProfessorofGastroenterology
London,UK Hepatology UniversityHospital
EasternHealthClinicalSchool Queen’sMedicalCentre
MarcFerranteMD,PhD MonashUniversity,Melbourne NottinghamUniversityHospitalsNHS
ConsultantGastroenterologist VIC,Australia Trust
DepartmentofGastroenterology
Nottingham,UK
UniversityHospitalGasthuisberg JamesGoodhandBSc(Hons),
Leuven,Belgium MBBS,MRCP A.BarneyHawthorneDM,
ClinicalResearchFellow
LaurieN.FishmanMD BartsandtheLondonSchoolofMedicine FRCP
AssistantProfessorofPediatrics andDentistry ConsultantGastroenterologist
CenterforInflammatoryBowelDisease QueenMary’sUniversityofLondon DepartmentofMedicine
DivisionofGastroenterologyandNutrition London,UK UniversityHospitalofWales
Children’sHospitalBoston Cardiff,UK
HarvardMedicalSchool RichardJ.GrandMD
Boston,MA,USA ProfessorofPediatrics MichaelHershmanDHMSA,
HarvardMedicalSchool MSc(Hons),MS(Hons),FRCS(Eng,
PhillipFleshnerMD,FACS, DirectorEmeritus,CenterforInflammatory Ed,Glas&Irel),FICS
FASCRS BowelDiseases ConsultantSurgeon
ProgramDirector,ColorectalSurgery DivisionofGastroenterologyandNutrition DepartmentofGeneralSurgery
Residency Children’sHospitalBoston StaffordHospital
LosAngeles,CA,USA; Boston,MA,USA Stafford,UK
ClinicalProfessorofSurgery
UCLASchoolofMedicine GaureeGuptaMD RobHorne
LosAngeles,CA,USA StaffPhysician ProfessorofBehaviouralMedicine
DepartmentofMedicine Director,CentreforBehaviouralMedicine
CedarsSinaiMedicalCenterandDavid TheSchoolofPharmacy
GeffenSchoolofMedicineatUCLA UniversityofLondon
LosAngeles,CA,USA London,UK
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Contributors xi
PeterM.IrvingMD,MRCP BretLashnerMD,MPH GaryR.LichtensteinMD
ConsultantGastroenterologist ProfessorofMedicine ProfessorofMedicine
DepartmentofGastroenterology DepartmentofGastroenterologyand DivisionofGastroenterology
Guy’sandStThomas’Hospitals Hepatology UniversityofPennsylvania
London,UK DigestiveDiseaseInstitute Philadelphia,PA,USA
ClevelandClinic
JenniferL.JonesMD,MSc, Cleveland,OH,USA MingValerieLinMD
DepartmentofInternalMedicine
FRCPC
JoannaK.LawMD,MA[Ed], PennsylvaniaHospital
Director,MDIBDClinicandIBDClinical
Trials FRCP(C) UniversityofPennsylvaniaHealthSystem
AssistantProfessor ClinicalInstructor,Divisionof Philadelphia,PA,USA
DepartmentsofMedicineandCommunity Gastroenterology
HealthSciencesandEpidemiology UniversityofBritishColumbia KeithD.LindorMD
UniversityofSaskatchewan Vancouver,BC,Canada ProfessorofMedicine
RoyalUniversityHospital DivisionofGastroenterologyand
Saskatoon,SK,Canada IanCraigLawrance Hepatology
MBBS(Hons),PhD,FRACP MayoClinic
Professor,SchoolofMedicineand Rochester,MN,USA;
AhmedKandielMD,MPH
Pharmacology Dean,MayoMedicalSchool
StaffGastroenterologist
UniversityofWesternAustralia MayoClinic
DepartmentofGastroenterologyand
Perth,WA,Australia; Rochester,MN,USA
Hepatology
Director,CentreforInflammatoryBowel
DigestiveDiseaseInstitute
Diseases JamesO.LindsayPhD,FRCP
ClevelandClinic
FremantleHospital ConsultantandSeniorLecturerin
Cleveland,OH,USA
Fremantle,WA,Australia Gastroenterology,
DigestiveDiseasesClinicalAcademicUnit
SunandaKaneMD,MSPH KeithLeiperMD,FRCP BartsandtheLondonNHSTrust
ProfessorofMedicine ConsultantGastroenterologist TheRoyalLondonHospital
MayoClinicCollegeofMedicine RoyalLiverpoolUniversityHospital Whitechapel,London,UK
Rochester,MN,USA Liverpool,UK
RichardLogan,MB,ChB,MSc,
GilaadKaplanMD,MPH,FRCPC RupertW.L.LeongMBBS,MD, FFPH,FRCP
AssistantProfessor FRACP ProfessorofClinical
DepartmentsofMedicineandCommunity AssociateProfessorofMedicine(Conjoint) Epidemiology/Consultant
HealthSciences TheUniversityofNewSouthWales Gastroenterologist
TeachingResearchandWellnessCenter Sydney,NSW,Australia; DivisionofEpidemiologyandPublicHealth
UniversityofCalgary DirectorofEndoscopy QueensMedicalCentre
Calgary,AB,Canada DepartmentofGastroenterologyandLiver NottinghamUniversityHospitals
Services Nottingham,UK
MichaelD.KappelmanMD, SydneySouthWestAreaHealthService
MPH ConcordandBankstownHospitals EdouardLouisMD,PhD
AssistantProfessor Sydney,NSW,Australia ProfessorofGastroenterology
DivisionofPediatricGastroenterology DepartmentofGastroenterology
DepartmentofPediatrics JohnLeungMD CHULie`geandGIGAResearchUniversity
UniversityofNorthCarolinaChapelHill Instructor ofLie`ge
ChapelHill,NC,USA DivisionofGastroenterology Lie`ge,Belgium
TuftsMedicalCenter
LouiseLangmeadBSc(Hons), Boston,MA,USA MarkLustMBBS,FRACP,PhD
MD SeniorClinicalFellowinGastroenterology
ConsultantGastroenterologist L.CampbellLevyMD TranslationalGastroenterologyUnit
EndoscopyUnit AssistantProfessorofMedicine JohnRadcliffeHospital
BartsandtheLondonNHSTrust DartmouthMedicalSchool Oxford,UK
TheRoyalLondonHospital SectionofGastroenterologyand
London,UK Hepatology
Dartmouth–HitchcockMedicalCenter
Lebanon,NH,USA
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xii Contributors
MichaelM.MaherMD TomØreslandMD,PhD JonathanM.RhodesMD,FRCP,
Professor Professor FMedSci
DepartmentofRadiology DepartmentofGISurgery DivisionofGastroenterology
AlimentaryPharmabioticCentre AkershusUniversityHospital SchoolofClinicalSciences
UniversityCollegeCork UniversityofOslo UniversityofLiverpoolandRoyalLiverpool
NationalUniversityofIreland Lørenskog,Norway UniversityHospital
Cork,Ireland Liverpool,UK
HelenM.PappaMD,MPH
RobertG.MaunderMD InstructorinPediatrics EmileRichmanBSc(Hons),MSc,
AssociateProfessorandStaffPsychiatrist HarvardMedicalSchool PGCE
MountSinaiHospitalandUniversityof Staff,CenterforInflammatoryBowel SpecialistGastroenterologyDietitian
Toronto Diseases DepartmentofNutritionandDietetics
Toronto,ON,Canada DivisionofGastroenterologyandNutrition RoyalLiverpoolUniversityHospital
Children’sHospitalBoston Liverpool,UK
JaneM.McGregorMA,MB Boston,MA,USA
DavidT.RubinMD
BChir,FRCP,MD
SeniorLecturerandHonoraryConsultant MilesParkesMA,DM,FRCP AssociateProfessorofMedicine
Dermatologist ConsultantGastroenterologist Codirector,InflammatoryBowelDisease
BartsandtheLondonNHSTrust Addenbrooke’sHospitalandUniversityof Center
London,UK; Cambridge ProgramDirector,Fellowshipin
CentreforCutaneousResearch Cambridge,UK Gastroenterology,Hepatology,and
Nutrition
BlizardInstituteofCellandMolecular
UniversityofChicagoMedicalCenter
Science KiranK.PeddiMBBS,MRCP(UK) Chicago,IL,USA
BartsandTheLondonSchoolofMedicine DepartmentofGastroenterology
andDentistry SpecialistRegistrarandFellowin MatthewD.RutterMBBS,MD,
QueenMaryUniversityofLondon, Gastroenterology
London,UK FremantleHospital FRCP
ConsultantGastroenterologistandTrust
Fremantle,WA,Australia
EndoscopyLead
SimonD.McLaughlinMD,
UniversityHospitalofNorthTees
MRCP ConalM.PerrettMB,ChB, Stockton-on-Tees,Cleveland,UK;
ConsultantGastroenterologist MRCP(UK),PhD ClinicalDirector,TeesBowelCancer
DepartmentofGastroenterology ConsultantDermatologistandHonorary ScreeningCentre
RoyalBournemouthHospital SeniorLecturer UniversityHospitalofNorthTees
Bournemouth,UK UniversityCollegeLondonHospitals Stockton-on-Tees,Cleveland,UK
London,UK
TinaA.Mehta JeremyD.SandersonMBBS,
DepartmentofGastroenterology ChrisS.J.ProbertMD,FRCP, MD,FRCP
BristolRoyalInfirmary ConsultantGastroenterologist
FHEA
Bristol,Avon,UK ProfessorofGastroenterology DepartmentofGastroenterology
BristolRoyalInfirmary StThomas’Hospital
GilY.MelmedMD,MS Bristol,UK London,UK;
AssistantClinicalProfessorofMedicine SeniorClinicalResearchFellow
CeGdaerfsfeSninSacihMooeldoicfaMlCedenictienreaantdUDCaLvAid DavidS.RamptonDPhil,FRCP NKiuntgrsitCioonlalelgSeciLeonncdesoRnesearch
LosAngeles,CA,USA ProfessorofClinicalGastroenterology London,UK
CentreforDigestiveDiseases
BartsandTheLondonSchoolofMedicine HermannSchulzeDr.med.
OwenJ.O’ConnorMD, andDentistry
FrankfurterDiakonie-Kliniken
FFR(RCSI),MRCSI London,UK Markus-Krankenhaus
RadiologyLecturer Frankfurt,Germany
DepartmentofRadiology CatherineReenaersMD,PhD
UniversityCollegeCork DepartmentofGastroenterology DavidA.SchwartzMD
NationalUniversityofIreland CHULie`geandGIGAResearchUniversity AssociateProfessorofMedicine
Cork,Ireland ofLie`ge Director,IBDCenter
Lie`ge,Belgium DivisionofGastroenterology
VanderbiltUniversityMedicalCenter
Nashville,TN,USA
