gastro-jРоссийский журнал гастроэнтерологии, гепатологии, колопроктологииRussian Journal of Gastroenterology, Hepatology, Coloproctology1382-43762658-6673«Gastro» LLC10.22416/1382-4376-2017-27-2-54-80gastro-j-135Research ArticleКЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИCLINICAL GUIDELINESКлинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению экзокринной недостаточности поджелудочной железыDiagnostics and treatment of exocrine pancreatic insufficiency: clinical guidelines of the Russian gastroenterological AssociationИвашкинВ. Т.IvashkinV. T.noemail@neicon.ruМаевИ. В.MayevI. V.noemail@neicon.ruОхлобыстинА. В.OkhlobystinA. V.okhlobystin@mail.ruАлексеенкоС. А.AlekseyenkoS. A.noemail@neicon.ruБелобородоваЕ. В.BeloborodovaYe. V.noemail@neicon.ruКучерявыйЮ. А.KucheryavyYu. A.noemail@neicon.ruЛапинаТ. Л.LapinaT. L.noemail@neicon.ruТрухмановА. С.TrukhmanovA. S.noemail@neicon.ruХлыновИ. Б.KhlynovI. B.noemail@neicon.ruЧикуноваМ. В.ChikunovaM. V.noemail@neicon.ruШептулинА. А.SheptulinA. A.noemail@neicon.ruШифринО. С.ShifrinO. S.noemail@neicon.ruФГБОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова»РоссияThe State Education Institution of Higher Professional Training «The First Sechenov Moscow State Medical University»Russian FederationФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И. Евдокимова»РоссияState educational government-financed institution of higher education «Yevdokimov Moscow State University of Medicine and Dentistry»Russian FederationФГБОУ ВО «Дальневосточный государственный медицинский университет»РоссияState educational government-financed institution of higher education «Far East state medical university»Russian FederationФГБОУ ВО «Сибирский государственный медицинский университет»РоссияThe State educational institution of higher education «Siberian State Medical University»Russian FederationФГБОУ ВО «Уральский государственный медицинский университет»РоссияThe State educational institution of higher education «Ural state medical university»Russian Federation2017120820182725480Copyright © Ивашкин В.Т., Маев И.В., Охлобыстин А.В., Алексеенко С.А., Белобородова Е.В., Кучерявый Ю.А., Лапина Т.Л., Трухманов А.С., Хлынов И.Б., Чикунова М.В., Шептулин А.А., Шифрин О.С., 20182018Ивашкин В.Т., Маев И.В., Охлобыстин А.В., Алексеенко С.А., Белобородова Е.В., Кучерявый Ю.А., Лапина Т.Л., Трухманов А.С., Хлынов И.Б., Чикунова М.В., Шептулин А.А., Шифрин О.С.Ivashkin V.T., Mayev I.V., Okhlobystin A.V., Alekseyenko S.A., Beloborodova Y.V., Kucheryavy Y.A., Lapina T.L., Trukhmanov A.S., Khlynov I.B., Chikunova M.V., Sheptulin A.A., Shifrin O.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.gastro-j.ru/jour/article/view/135

Цель публикации. Ознакомить практикующих врачей с современными представлениями о причинах развития и патогенезе экзокринной недостаточности поджелудочной железы (ПЖ), а также принятыми в настоящее время подходами к диагностике и лечению данного синдрома. Основные положения. Экзокринная панкреатическая недостаточность (ЭПН) развивается в том случае, если активность ферментов, секретируемых в просвет двенадцатиперстной кишки в ответ на прием пищи, недостаточна для поддержания нормального переваривания пищи. Это состояние может развиваться как первично, вследствие различных заболеваний ПЖ (хронический панкреатит, рак ПЖ, муковисцидоз), так и вторично, вследствие нарушения стимуляции панкреатической секреции или нарушения условий для действия пищеварительных ферментов. Основные клинические проявления ЭПН - синдромы мальдигестии и мальабсорбции, приводящие к развитию трофологической недостаточности. Стандартизованные методы оценки экзокринной функции ПЖ не разработаны, поэтому не существует общепринятых критериев диагностики ЭПН. В клинической практике ЭПН диагностируют на основании сниженных показателей эластазного теста у больных с доказанными заболеваниями, которые могут вызвать снижение экзокринной функции ПЖ. Основной метод лечения ЭПН - заместительная ферментная терапия (ЗФТ). За прошедшие 50 лет произошло существенное развитие ЗФТ, были разработаны многочисленные лекарственные формы панкреатина. Для ЗФТ необходимо использовать только препараты в виде капсул, содержащих микрочастицы, защищённые энтеросолюбильной оболочкой. Наибольшая доказательная база эффективности при ЭПН получена для мини-микросфер панкреатина в капсулах. Начальная доза панкреатических ферментов для взрослых составляет 25 тыс. ед. липазы на прием пищи, которую в последующем следует увеличивать до достижения полного эффекта, подтвержденного клиническими или лабораторными показателями. Ферменты следует принимать во время приема пищи, для повышения эффективности терапии можно использовать антисекреторные препараты. В процессе подбора диетотерапии должен принимать участие диетолог. Пациентам необходимо рекомендовать употреблять пищу как минимум с нормальным содержанием жира и разделять дневной рацион на 6 приемов пищи и более. Пациентов следует мотивировать отказаться от употребления алкоголя и курения, поскольку они могут привести к дальнейшему ухудшению экзокринной функции ПЖ и увеличению выраженности симптомов ЭПН.

The aim of publication. To present the modern concept of etiology and pathogenesis of exocrine pancreatic insufficiency to general practitioners as well as with the established approach to diagnostics and treatment of this syndrome. Summary. Exocrine pancreatic insufficiency (EPI) develops if activity of the enzymes in duodenal lumen in response to meal stimulation is insufficient to maintain normal nutrient digestion. This state can develop primarily, due to various pancreatic diseases (chronic pancreatitis, pancreatic cancer, cystic fibrosis), and secondarily, due to impaired stimulation of pancreatic secretion or non-physiological conditions for activity of digestive enzymes. Basic manifestations of EPN the syndromes of maldigestion and malabsorption leading to development of nutritional failure. At the present time there is no standardized diagnostic method for estimation of pancreatic exocrine function, therefore there are no standard diagnostic criteria for EPN. In clinical practice EPN is diagnosed according to decreased fecal elastase activity in patients with verified pancreatic disease, which can cause decrease of pancreatic exocrine function. The basic EPN treatment method is pancreatic enzyme replacement therapy (PERT). For last 50 years there was an significant progress in development of PERT, numerous pancreatin-containing preparations were developed. Treatment of PERT require prescription of capsules, containing pancreatin microparticles protected by enteric coating. The highest evidential base at EPN is accumulated for pancreatin mini-microspheres. The starting dose of pancreatic enzymes for adults is 25 000 units of lipase per meal, which should be subsequently increased up to achievement of complete response confirmed by both clinical and laboratory scores. Digestive enzymes should be taken at the beginning of food intake, to increase treatment efficacy PERT should be accompanied by prescription of proton pump inhibitors. Patient’s diet quantity and content should be adjusted with participation of nutritionist. Patient should intake at least normal daily amount of fat and divide daily ration to at least six meals. Patients should be motivated to restrain from alcohol consumption and smoking as they can lead to further progression of pancreatic exocrine insufficiency and symptoms of pancreatitis.

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The authors declare that there are no conflicts of interest present.