Gastroenterological endoscopy PDF
Preview Gastroenterological endoscopy
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 Thieme Stuttgart · New York LibraryofCongressCataloging-in-PublicationDataisavailablefromthepublisher. Importantnote:Medicineisanever-changingscienceundergoingcontinualdevel- opment.Researchandclinicalexperiencearecontinuallyexpandingourknowledge, inparticularourknowledgeofpropertreatmentanddrugtherapy.Insofarasthis bookmentionsanydosageorapplication,readersmayrestassuredthattheauthors, editors,andpublishershavemadeeveryefforttoensurethatsuchreferencesarein accordancewiththestateofknowledgeatthetimeofproductionofthebook. 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This PrintedinChinabyLeoPaperLtd,Hongkong appliesinparticulartophotostatreproduction,copying,mimeographing,prepara- ISBN 978-3-13-125852-6 123456 tionofmicrofilms,andelectronicdataprocessingandstorage. 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
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