Gastroenterological endoscopy

853 Pages·2010·58.58 MB·English

by  Meinhard Classen

Gastroenterological Endoscopy
Meinhard Classen, MD Charles J. Lightdale, MD
ProfessorEmeritusandformerChairman ProfessorofClinicalMedicineand
DepartmentofInternalMedicine DirectorofClinicalResearch
TechnicalUniversityofMunich DivisionofDigestiveandLiverDiseases
Munich,Germany NewYorkPresbyterianHospital/ColumbiaUniversity
MedicalCenter
Guido N. J. Tytgat, MD, PhD NewYork,USA
ProfessorEmeritusofGastroenterology
Associate Editors
UniversityofAmsterdam
FormerChiefofDepartmentofGastroenterology JacquesJ.G.J.M.Bergman,AlexanderMeining,
AcademicMedicalCenter D.NageshwarReddy,MichaelB.Wallace,HisaoTajiri
Amsterdam,theNetherlands
Second edition
Withcontributionsby
DouglasG.Adler,FurqaanAhmed,Hans-DieterAllescher,AnthonyT.R.Axon,RamiJ.Badreddine,JohnBaillie,JuergenBarnert,
ToddH.Baron,HughBarr,J.F.W.M.Bartelsman,WitoldBartnik,VikramBhatia,DavidBjorkman,WojciechBlonski,LawrenceJ.Brandt,
MarcoJ.Bruno,AndrewK.Burroughs,DavidCave,JeanPierreCharton,EvangelosCholongitas,MeinhardClassen,GuidoCostamagna,
StefanvonDelius,MichelDelvaux,JamesA.DiSario,StevenA.Edmundowicz,AxelEickhoff,ShungoEndo,PietroFamiliari,
PaulFeuerstadt,HubertusFeußner,DavidE.Fleischer,EvanL.Fogel,VictorL.Fox,GérardGay,KarelGeboes,JosephE.Geenen,
NaliniM.Guda,NeilGupta,GregoryB.Haber,RobertH.Hawes,JuergenHochberger,KeiichiIkeda,JohnM.Inadomi,SreeniJonnalagadda,
MichaelJung,AbdelMeguidKassem,RalfKiesslich,KiyonoriKobayashi,DavidKotlyar,RichardA.Kozarek,Shin-eiKudo,SpirosD.Ladas,
JamesY.W.Lau,GlenA.Lehman,BlairS.Lewis,GaryR.Lichtenstein,JeniferR.Lightdale,JuergenMaiss,ElisabethM.H.Mathus-Vliegen,
KojiMatsuda,KaiMatthes,HelmutMessmann,HideyukiMiyachi,FarisM.Murad,HorstNeuhaus,H.JuergenNord,HiroyukiOno,
JacekPachlewski,SandyH.Y.Pang,ShabanaF.Pasha,AndrewT.Pellecchia,Jan-WernerPoley,ThierryPonchon,JeffreyL.Ponsky,
BenjaminK.Poulose,ChristianPrinz,D.NageshwarReddy,JaroslawRegula,JürgenF.Riemann,GurpalS.Sandha,YasushiSano,
ShivKumarSarin,BrianSaunders,StefanSeewald,MarcoSenzolo,PrateekSharma,StuartSherman,Chan-SupShim,NathanJ.Shores,
NibSoehendra,MaSomsouk,JosephJ.Y.Sung,PaulSwain,HisaoTajiri,ShinjiTanaka,GeorgeTriadafilopoulos,AndreaTringali,
K.M.A.J.Tytgat,GuidoN.J.Tytgat,KennethK.Wang,JeromeD.Waye,JustinC.Y.Wu,ByungMooYoo
1820 illustrations
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IV
Preface
Sevenyearsaftertheinitialpublicationofourbookwenowpresent scopicimage,usingdyes,autofluorescence,high-definitionendos-
the second edition. This new edition employs the same proven copy,andalsobymanipulatingthewavelengthoftheappliedlight
concept as before. However, its content fully reflects the rapid by means of narrow-band imaging (NBI) and Fujinon intelligent
advancesthathavecharacterizedthedevelopmentofgastroentero- colorenhancement(FICE).Morepreciseevaluationofthesubstrate
logicalendoscopyinrecentyears.Thisdevelopmentisnotsolelythe alsopermitsendoscopicclassificationofchangesaspremalignantor
resultoftechnicalprogressbuthasalsobeendrivenbyanincreasing malignant lesions; the Paris–Japan and Kudo classifications are
interestinendoscopyofthegastrointestinaltract.Itisevidentthat convincingexamplesofsuchasystem.Butthisisnotall.Withthe
the number of endoscopic centers has continuously increased in aidofconfocallasermicroscopyitispossibletoobtainimagesofthe
recentyears.Wenotewithsomesatisfactionthatthisdevelopment deeperlayeroftheintestinalmucosabeneaththeepithelialsurface.
hasembracedeverycontinent.Themajorendoscopicjournalsre- Thismodalitycanvisualizehigh-gradedysplasiainulcerativecolitis
port both increasing subscriptions and increasing submissions of thatmightgoundetectedwithwhitelightmicroscopy.Havewenot
scientific papers. The major emerging economic powers in Asia, comeveryclosetomanyolderendoscopists’dreamofpracticable
such as China and India, have apparently decisively influenced “endoscopichistology”?
this development. We also note that scientific papers in the field Theendoscopicsubmucosaldissection(ESD)developedbyour
ofendoscopynolongercomeexclusivelyfromuniversityhospitals, Japanesefriendsrepresentsagreatadvanceinbothdiagnosisand
butincreasinglyfrommunicipalhospitalsandprivatepracticesas therapy. In contrast to endoscopic mucosal resection (EMR), ESD
well. allowsbetterenblocresectionofthetumor-bearingareaofthewall,
Thisnewlyacquiredknowledgeextendstoallaspectsofgastro- more precise histopathological diagnostic studies, and a deeper
enterological endoscopy that are relevant to the patient: patient resection.Inthefirsteditionofourbookwehaddescribedendo-
preparationpriortoexamination,premedication,screeningofpre- scopic mucosal resection as a revolutionary advance. Now this
malignant and malignant lesions, endoscopic diagnosis, and ther- elegantmethodrisksbeingsupplantedbyendoscopicsubmucosal
apy. dissection. This will hold true especially if the modification sug-
Completelynewtechnologyandmethodshavebeenintroduced. gested by the American Apollo group, namely first marking the
Notonlyhastheendoscopist'sfieldofendeavorexpandedcontinu- affected area of the wall laterally with electrocautery and lifting
ouslyasaresultofthisdevelopment,ithasalsoundergonesignifi- the wall by inflating a balloon in the submucosa, does indeed
cantchange. increasesafetyandreducethetimerequiredforsurgery.
The magic acronym NOTES has evoked fascination. It refers to Newimagingmodalitiessuchashigh-resolution–high-magnifi-
transluminal invasive procedures in which the endoscope is ad- cation endoscopy, autofluorescence, spectra modulation, etc., and
vancedthroughthewalloftheorganofapproach(stomach,vagina, newtherapeutictechnologywereappliedinthecolon.Thisnovel
etc.)toreachthetargetorganintheabdominalorretroperitoneal technology was also applied in other fields such as esophagus,
space in order to remove the appendix, gallbladder, kidney, etc. stomach,andbilio-pancreaticarea.ParticularlyBarrett'sesophagus
Surgical teams that include gastroenterologists now see a com- wasfavoredtoapplyandevaluateallnoveltechnologybutprogress
pletelynewfieldofendeavorunfoldingfortheintrepidgastroen- in diagnostic and therapeutic possibilities was also made in the
terologicalendoscopist. bilio-pancreaticfield.
Colorectal carcinoma is byfar the most impressive example of Atruenoveltyinthissecondeditionoftheatlasistheindepth
theimpactofhealthcarepoliciesonthefieldofendoscopy.Where description of investigational possibilities for small intestinal dis-
colonoscopyistheestablishedmethodofscreeningforcoloncancer, easeswithcapsuleendoscopyandmono-anddoubleballoonen-
asintheUnitedStatesandmanyEuropeancountries,endoscopists doscopy.Thelastendoscopicfrontierhasnowbeentackled,allow-
areveritablyfloodedwithscreenees.Mightthisnotmeanthatother inginvestigationoftheentireintestinaltract,wheneverclinically
equally important tasks of the physician are being neglected as a indicated.
result?Obviouslynewbiomarkersforcoloncancerwithhighsen- Inparallelwiththeamazingendoscopicevolutionwasthefur-
sitivityandspecificityareneededtofilteroutunsuitablecandidates therdevelopmentofdiagnosticandparticularlytherapeuticendo-
sothatonlythosecaseswhereagenuinesuspicionexistsaresentto sonography.Somethingwhichwasunthinkableinthepastisnow
colonoscopy. enteringthearenaofroutineproceduresinanoptimallyequipped
Naturally,colonoscopyandtheremovalofadenomasareindis- andskilledendoscopicunit.
pensableestablishedmethodsofcoloncancerscreening.However, The key contributions of the gastroenterologal endoscopist to
noteveryinterventiondetectsprecancerouslesionsorsmallmalig- digestive oncology are hardly at risk of being usurped by other
nancies, permitting timely endoscopic or surgical removal. Obvi- disciplines.Thesituationisdifferentinthecaseofclassicchemo-
ouslyimprovementstoendoscopicmethodologyorcompletelynew therapyor the application of biologicals by gastroenterologists in
methodsarerequiredtoreducethenumberofintervalcarcinomas advancedgastrointestinaltumors.Thisiscommonpracticeincer-
tonearzero. tainEuropeancountries.Indeed,theuseofbiologicalsishardlynew
Recent findings that flat and dimpled adenomas and certain togastroenterologistsusedtotreatingpatientswithchronicinflam-
serratedpolypsinthecolonentailahigherriskofmalignantdegen- matoryboweldisease.
eration are important. Here there is some good news. Clear im- This book addresses all endoscopists throughout the world as
provementsinthedetectionofchangesintheepithelialsurfaceof wellascolleaguesfromrelatedfields.Itisespeciallyintendedfor
the gastrointestinal tract have resulted from enlarging the endo- our fellows, for gastroenterologists in private practice and those
V
Preface
practicing in tertiary referral centers, whowork closely with sur- hadalreadycontributedtothefirstedition.Weknowoffewgastro-
geons,pathologists,radiologists,andoncologists,aswellasforall enterologicalbookprojectswithsuchabroadinternationalgroupof
thosewhoareinvolvedinresearchandparticipateinclinicalstudies contributingauthors.Theeditorswouldliketothankalltheauthors
whereverpossible.Wearewellawareofthegreateconomicdiffer- for their understanding for our urgent wishes and for their out-
encesbetweenthevariousregionsandcountriesoftheworld,and standingcooperation.
weexplicitlyencourageourcolleaguesinthedevelopingcountries. Thehighqualityoftextandimagematerialtheeditorsstrivedfor
Ourexpressthanksgotothosemanufacturersofendoscopesand wasnearlyinvariablyachieved.Wethanktheenthusiasticdonors
add-ondeviceswhohelptoestablishgastroenterologicalandendo- (especiallyfromJapan)fortheirexcellentimagematerial.
scopictrainingcentersfortrainingphysiciansandassistantsinthe Wepresentreadersthroughouttheworldwithabookthatdoes
developingcountries. justicetotheadvancesinmedicalscienceandtothedevelopment
Thisedition hasseen achangein thegroupofeditors.Jacques andimportanceofgastroenterologicalendoscopy.Gastroenterolo-
Bergman, Alexander Meining, D Nageshwar Reddy, Michael Wal- giststhroughouttheworldwillreceivetheinformationtheyrequire
lace, and Hisao Tajiri have been brought on board as associate forplanninganendoscopydepartment,fortheirendoscopicworkin
editors in an effort to involve younger endoscopists with solid bothprivatepracticeandthehospital,andfordetectingandtreating
scientificandclinicalreputations,whohavealreadyacquiredexpe- evenrarepathologyinthegastrointestinaltractandmajordigestive
rienceanddemonstratedsoundcriticaljudgmentinbothresearch glands.
and practice. These colleagues have also played a crucial role in OurspecialthanksgotothestaffofThiemePublishers,especially
designingthebookandwillberesponsibleforthecomingeditions. Dr. Wachinger and Dr. Bergman. Ms. Rachel Swift not only did
We felt it important that they already become familiar with the justicetohername,butwontheeditors’boundlessadmirationfor
responsibilities of editors. It is essential for a textbook to keep her knowledge, patience, and kindness. Dr. Hauff was a generous
abreast of the latest developments. New aspects and changing publisherwhoagreedtogivethebookanexcellentlayout.
emphasis make it important to enlist younger authors as well.
This approach has paid off. However, the majority of our authors Theeditors
VI
List of Contributors
Associate Editors
JacquesJ.G.J.M.Bergman,MD D.NageshwarReddy,MD MichaelB.Wallace,MD
Professor Chairman AssociateProfessorofGastroenterology
AcademicMedicalCenter AsianInstituteofGastroenterology MayoClinic
DepartmentofGastroenterology Hyderabad,India Jacksonville,FL,USA
Amsterdam,theNetherlands
HisaoTajiri,MD
AlexanderMeining,MD ChairmanandProfessor
DepartmentofGastroenterology DivisionofGastroenterology
TechnicalUniversityofMunich andHepatology
KlinikumrechtsderIsar DepartmentofInternalMedicine
Munich,Germany TheJikeiUniversitySchoolofMedicine
Tokyo,Japan
Contributors
DouglasG.AdlerMD,FACG,FASGE JohnBaillie,MB,ChB,FRCP,FACG WitoldBartnik,MD
AssistantProfessorofMedicine Professor,InternalMedicine Professor
DirectorofTherapeuticEndoscopy (Gastroenterology) DepartmentofGastroenterology
GastroenterologyandHepatology Director,Hepatobiliaryand andHepatology
HuntsmanCancerCenter PancreaticDisordersServices MedicalCenterforPostgraduate
UniversityofUtah WakeForestUniversityBaptist Educationand
SaltLakeCity,UT,USA MedicalCenter theMariaSklodowska-Curie
MedicalCenterBoulevard MemorialCancerCenterandInstitute
FurqaanAhmed Winston-Salem,NC,USA ofOncology
Fellow,DivisionofGastroenterology Warsaw,Poland
andHepatology JuergenBarnert,MD
DepartmentofMedicine SupervisingPhysician VikramBhatia,MD,DM
IndianaUniversityMedicalCenter 3rdMedicalDepartment AssistantProfessor(MedicalHepatology)
Indianapolis,IN,USA KlinikumAugsburg InstituteofLiverandBiliarySciences
Augsburg,Germany NewDelhi,India
Hans-DieterAllescher,MD
Professor ToddH.Baron,MD,FASGE DavidBjorkman,MD,MSPH
KlinikumGarmisch-PartenkirchenGmbH DivisionofGastroenterology Dean,UniversityofUtahSchoolofMedicine
CenterforInternalMedicine andHepatology ExecutiveMedicalDirector
Garmisch-Partenkirchen,Germany MayoClinic DivisionofGastroenterology
AnthonyT.R.Axon Rochester,MN,USA andHepatology
ProfessorofGastroenterology SaltLakeCity,UT,USA
DepartmentofGastroenterology HughBarr,MD,ChM,FRCS,FRCSE,FHEA
TheGeneralInfirmaryatLeeds Professor WojciechBlonski,MD,PhD
Leeds,UK CranfieldHealth DivisionofGastroenterology
GloucestershireRoyalHospital UniversityofPennsylvania
RamiJ.Badreddine,MD Gloucester,UK Philadelphia,PA,USA
DivisionofGastroenterology DepartmentofGastroenterology
andHepatology J.F.W.M.Bartelsman andHepatology
MayoClinic Professor MedicalUniversity
Rochester,MN,USA DepartmentofGastroenterology Wroclaw,Poland
andHepatology
AcademicMedicalCenter
Amsterdam,theNetherlands
VII
List of Contributors
LawrenceJ.Brandt,MD JamesA.DiSario,MD GérardGay,MD
Chief,DepartmentofGastroenterology AdjunctProfessorofMedicine DepartmentofInternalMedicine
MontefioreMedicalCenter UniversityofUtahHealthSciencesCenter andDigestivePathology
AlbertEinsteinCollegeofMedicine Utah,USA HopitauxdeBrabois
Bronx,NY,USA UniversityHospitalofNancy
StevenA.Edmundowicz,MD Nancy,France
MarcoJ.Bruno,MD,PhD FASGEProfessorofMedicine
ErasmusMedicalCentre ChiefofEndoscopy KarelGeboes,MD
UniversityMedicalCenterRotterdam DivisionofGastroenterology Professor
DepaertmentofGastroenterology WashingtonUniversitySchoolofMedicine DepartmentofPathology
andHepatology St.Louis,MO,USA UniversityHospitalKULeuven
Rotterdam,theNetherlands Leuven,Belgium
AxelEickhoff,MD
AndrewK.Burroughs MedicalDepartmentC JosephE.Geenen,MD
ConsultantPhysicianandHepatologist KlinikumLudwigshafen ClinicalProfessorofMedicine
LiverTransplantationand AcademicHospitalofthe MedicalCollegeofWisconsin
HepatobiliaryMedicine UniversityofMainz Director,PancreatobiliaryServices
RoyalFreeHospital Ludwigshafen,Germany St.Luke’sMedicalCenter
London,UK Milwaukee,WI,USA
ShungoEndo,MD
DavidCave,MD,PhD DigestiveDiseaseCenter NaliniM.Guda,MD
ProfessorofMedicine ShowaUniversityNorthern ClinicalAssociateProfessorofMedicine
DirectorofClinical YokohamaHospital UniversityofWisconsinSchoolofMedicine
GastroenterologyResearch Yokohama,Japan andPublicHealth
UMassMemorialMedicalCenter PancreatobiliaryServices
Worcester,MA,USA PietroFamiliari,MD,PhD St.Luke’sMedicalCenter
UniversitàCattolicadelSacroCuore Milwaukee,WI,USA
JeanPierreCharton,MD A.GemelliUniversityHospital
Consultant,Gastroenterology DigestiveEndoscopyUnit NeilGupta,MD,MPH
EvangelischesKrankenhaus Rome,Italy Fellow,Divisionof
Düsseldorf,Germany Gastroenterology/Hepatology
PaulFeuerstadt,MD UniversityofKansasMedicalCenter
EvangelosCholongitas,MD Fellow,DepartmentofGastroenterology KansasCityVeteransAdministration
LiverTransplantationand MontefioreMedicalCenter KansasCity,MO,USA
HepatobiliaryMedicine AlbertEinsteinCollegeofMedicine
RoyalFreeHospital Bronx,NY,USA GregoryB.Haber,MD
London,UK DirectorofGastroenterology
HubertusFeußner,MD LenoxHillHospital
MeinhardClassen,MD Professor NewYork,NY,USA
ProfessorEmeritusandformerChairman DepartmentofSurgery
DepartmentofInternalMedicine KlinikumRechtsderIsar RobertH.Hawes,MD
TechnicalUniversityofMunich TechnicalUniversityofMunich ProfessorofMedicine
Munich,Gerrmany Munich,Germany PeterCottonChairfor
EndoscopicInnovation
GuidoCostamagna,MD,FACG DavidE.Fleischer,MD DivisionofGastroenterology
UniversitàCattolicadelSacroCuore ProfessorofMedicine andHepatology
A.GemelliUniversityHospital MayoClinicCollegeofMedicine DigestiveDiseaseCenter
DigestiveEndoscopyUnit DivisionofGastroenterology MedicalUniversityofSouthCarolina
Rome,Italy andHepatology Charleston,SC,USA
Scottsdale,AZ,USA
StefanvonDelius JuergenHochberger,MD,PhD
AssistantPhysician EvanL.Fogel ProfessorofMedicineandChairman
2ndMedicalClinic ProfessorofClinicalMedicine DepartmentofMedicineIII–
KlinikumrechtsderIsar IndianaUniversitySchoolofMedicine Gastroenterology,InterventionalEndoscopy
TechnicalUniversityofMunich DivisionofGastroenterology St.BernwardAcademicTeachingHospital
Munich,Germany andHepatology Hildesheim,Germany
DepartmentofMedicine,IndianaUniversity
MichelDelvaux,MD,PhD MedicalCenter KeiichiIkeda,MD
DepartmentofInternalMedicine Indianapolis,IN,USA DepartmentofEndoscopy
andDigestivePathology TheJikeiUniversitySchoolofMedicine
HopitauxdeBrabois VictorL.Fox,MD,FAAP Tokyo,Japan
UniversityHospitalofNancy Director,GastroenterologyProcedureUnit
Nancy,France AssistantProfessorofPediatrics
HarvardMedicalSchool
Children'sHospitalBoston
Boston,MA,USA
VIII
List of Contributors
JohnM.Inadomi,MD JamesY.W.Lau,MD HideyukiMiyachi,MD
GIHealthOutcomes DepartmentofSurgery DigestiveDiseaseCenter
PolicyandEconomics(HOPE) PrinceofWalesHospital ShowaUniversityNorthern
ResearchProgram Shatin YokohamaHospital
DepartmentofMedicine HongKong,China Yokohama,Japan
UniversityofCalifornia
SanFrancisco,USA GlenA.Lehman,M.D. FarisM.Murad,MD
IndianaUniversityMedicalCenter AdvancedFellow
SreeniJonnalagadda,MD DepartmentofMedicine Gastroenterology,
AssociateProfessorofMedicine DivisionofGastroenterology AdvancedTherapeuticEndoscopy
DirectorofBiliaryandPancreaticEndoscopy andHepatology MayoClinic
InterventionalEndoscopySection Indianapolis,IN,USA Rochester,MN,USA
WashingtonUniversitySchoolofMedicine
St.Louis,MO,USA BlairS.Lewis,MD HorstNeuhaus,MD
TheMountSinaiSchoolofMedicine ProfessorandChiefPhysician
MichaelJung,MD,FRCP NewYork,NY,USA DepartmentofGastroenterology
ProfessorandChiefPhysician EvangelischesKrankenhaus
DepartmentofGastroenterology GaryR.Lichtenstein,MD Düsseldorf,Germany
St.Hildegardis-Krankenhaus ProfessorofMedicine
KatholischesKlinikumMainz UniversityofPennsylvania H.JuergenNord,
Mainz,Germany SchoolofMedicine MD,MACG,FACP,FASGE,AGAF
Director,Centerfor ProfessorofMedicine
AbdelMeguidKassem,MD InflammatoryBowelDisease UniversityofSouthFlorida
AssociateProfessor UniversityofPennsylvaniaHealthSystem CollegeofMedicine
DepartmentofTropicalMedicine DivisionofGastroenterology Tampa,FL,USA
andGI-Endoscopy Philadelphia,PA,USA
FacultyofMedicine,CairoUniversity HiroyukiOno,MD
Cairo,Egypt JeniferR.Lightdale,MD,MPH ChiefofEndoscopy
AttendingPhysician ShizuokaCancerCenter
RalfKiesslich GastroenterologyandNutrition Shizuoka,Japan
ProfessorandChief Children'sHospitalBoston
EndoscopyUnit Boston,MA,USA JacekPachlewski,MD
1stMedicalDepartment DepartmentofGastroenterology
JohannesGutenbergUniversity JuergenMaiss,MD,PhD andHepatology
Mainz,Germany Kerzel&Maiss MedicalCenterforPostgraduateEducation
GastroenterologyAssociates MariaSklodowska-CurieMemorial
KiyonoriKobayashi,MD Forchheim,Germany CancerCenterandInstituteofOncology
DepartmentofGastroenterology Warsaw,Poland
KitasatoUniversityEastHospital ElisabethM.H.Mathus-Vliegen,MD
Sagamihara,Japan Professor SandyH.Y.Pang,MD
DepartmentofGastroenterology DepartmentofMedicineandTherapeutics
DavidKotlyar,MD andHepatology PrinceofWalesHospital
UniversityofPennsylvania AcademicMedicalCentre Shatin
SchoolofMedicine Amsterdam,theNetherlands HongKong,China
Philadelphia
Pennsylvania,USA KojiMatsuda,MD,PhD ShabanaF.Pasha,MD
DepartmentofEndoscopy AssistantProfessorofMedicine
RichardA.Kozarek,MD TheJikeiUnversityAotoHospital DivisionofGastroenterology
FASGEDivisionofGastroenterology Tokyo,Japan andHepatology
VirginiaMasonMedicalCenter MayoClinicCollegeofMedicine
Seattle,WA,USA KaiMatthes,MD,PhD Scottsdale,AZ,USA
DivisionofGastroenterology
Shin-eiKudo,MD BethIsraelDeaconessMedicalCenter AndrewT.Pellecchia,MD
DigestiveDiseaseCenter HarvardMedicalSchool AttendingPhysician
ShowaUniversityNorthern Boston,MA,USA DepartmentofGastroenterology
YokohamaHospital JacobiMedicalCenter/
Yokohama,Japan HelmutMessmann,MD AlbertEinsteinCollegeofMedicine
ProfessorandDirector Bronx,NY,USA
SpirosD.Ladas,MD 3rdMedicalDepartment
ProfessorofMedicineandGastroenterology KlinikumAugsburg Jan-WernerPoley,MD
Chairman,1stDepartmentof Augsburg,Germany ErasmusMedicalCentre
InternalMedicine UniversityMedicalCenterRotterdam
LaikoGeneralHospitalofAthens DepartmentofGastroenterology
MedicalSchool,UniversityofAthens andHepatology
Athens,Greece Rotterdam,theNetherlands
IX