Barry J. Marshall, Richard W. McCallum, and Richard L. Guerrant; eds. 226 pages. London: Blackwell Scientific Publications; 1991. $59.95.

The recognition of the significance of Helicobacter pylori in gastritis and peptic ulceration ranks in importance with the development of fiberoptic endoscopes, histamine-2 (H₂)-receptor antagonists, and proton pump inhibitors. Although the role of H. pylori infection in the pathogenesis of type B chronic gastritis is universally accepted, its role in the pathogenesis of peptic ulcer disease and, even more importantly, the implications of eradication of the infection in the natural history of peptic ulcer disease have been areas of great controversy. Research in this area abounds; the number of publications on it outnumber those relating to Crohn disease in 1991.

The editors of this book sought to provide an up-to-date synthesis of current knowledge covering the microbiology, taxonomy, molecular biology, pathogenesis, immunology, and epidemiology of the disease. This material provides a background to reviews of the laboratory techniques for the diagnosis of the infection and evaluation of its role in peptic ulcer disease, the significance of infection in childhood, and current medical therapy.

Just over half of the book relates to the basic science aspects of the infection. An extensive review of the classification of gastritis, including evaluation of the new Sydney system of classification is followed by a chapter on the microbiology and taxonomy of H. pylori and related bacteria that emphasizes the amount of basic microbiologic research remaining to be done. Excellent reviews of the epidemiology and natural history of nonulcer dyspepsia and of the epidemiology of H. pylori infection follow. The book also describes the difficulties in discovering a suitable animal model of H. pylori infection. Subsequent topics include interactions of microbial adhesions and toxins with the mucosa, laboratory diagnosis, and handling of H. pylori, the immunology of the infection, and the application of molecular biology to the field. The clinical chapters cover the role of H. pylori infection in duodenal ulcer, the practical diagnosis and treatment of the infection, its role in nausea and vomiting, the pharmacology of colloidal bismuth subcitrate and its use in nonulcer dyspepsia, and finally the significance of the infection in the pediatric population.

In general, the chapters are well written by active workers in the field. However, several chapters devote relatively limited space to the precise role of H. pylori in the particular topic under discussion. The chapters relating to the basic science aspects of the infection exceed those relating to clinical contribution and will have limited value to the interested clinician. The clinical chapters are more relevant, and there is a particularly good review of the role of H. pylori in ulcer disease. The chapter on the practical diagnosis and treatment of the infection is somewhat expansive and uncritical, with more than five pages devoted to the anatomical localization of the organism and even more space allocated to a review of urease tests. Likewise, the chapter on therapy is a litany of the experience of all available antibiotics and their combinations and permutations without providing a final recommendation. Extraneous information, such as how to obtain a gastric biopsy specimen with a Quinton tube and anecdotal accounts of individual cases can only have limited appeal to the reader seeking counsel on the best test for H. pylori infection, optimal therapy, and its outcome, and how the patient should be monitored.

The book also includes inconsistencies and questionable recommendations. For example, the area of nonulcer dyspepsia is covered in three separate chapters, each arriving at a different conclusion. The separate chapter on nausea and vomiting and H. pylori infection seems difficult to justify and is composed largely of tables, figures and perplexing recommendations, such as routinely screening the infected patient's spouse for infection. A similar recommendation is made in the chapter on therapy of H. pylori infection, where it is suggested that every patient with infection should be treated and that therapy should initially be followed with weekly breath tests. Even the spouse of the patient with an H. pylori syndrome should be screened. If infection is found and the spouse is considered to be symptomatic, treatment should be offered with a follow-up breath test. If the infection persists, no further therapy is needed.

The main flaw of this book is the contributors' inability to provide the reader with practical, specific recommendations for the management of patients with problems related to this organism. Perhaps the chapter on randomized, controlled trials of peptic ulcer therapy in the H. pylori era has the greatest relevance. It emphasizes that the goals of any randomized, controlled trial should be to answer a specific question, to mimic a real life situation, and to arrive at a confident answer. It stresses that although sample size in controlled trials should be sufficient to ensure statistical reliability, enough patients must be studied to provide clinical believability. Indeed, it is the limited number of patients in the various studies of H. pylori infection that is the cause of continued skepticism on the part of many clinicians.

The references are reasonably up to date. The index, however, is incomplete; for example, omeprazole is mentioned in the text but not included in the index.

The editors of this book are to be congratulated on providing authoritative chapters on basic scientific aspects of the infection; however, the clinical chapters are perhaps not as critical. In a field in which the number of studies increases at an almost logarithmic rate, it is increasingly difficult for a textbook to compete with supplements to the scientific journals, which can be published much more expeditiously. Nevertheless, this book should be of help to anyone wishing to read a global review of the current status of this fascinating organism.