gastro-jРоссийский журнал гастроэнтерологии, гепатологии, колопроктологииRussian Journal of Gastroenterology, Hepatology, Coloproctology1382-43762658-6673«Gastro» LLC10.22416/1382-4376-2017-27-4-75-95gastro-j-171Research ArticleКЛИНИЧЕСКИЙ РАЗБОРCLINICAL ANALYSISКлинические рекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению гастроэзофагеальной рефлюксной болезниDiagnostics and treatment of gastroesophageal reflux disease: clinical guidelines of the Russian gastroenterological associationИвашкинВ. Т.IvashkinV. T.noemail@neicon.ruМаевВ. И.MayevI. V.noemail@neicon.ruТрухмановА. С.A.s. TrukhmanovI. .troukh@mail.comБаранскаяЕ. К.BaranskayaYe. K.noemail@neicon.ruДроноваО. Б.DronovaO. B.noemail@neicon.ruЗайратьянцО. В.ZayratyantsO. V.noemail@neicon.ruСайфутдиновР. Г.SayfutdinovR. G.noemail@neicon.ruШептулинА. А.SheptulinA. A.noemail@neicon.ruЛапинаТ. Л.LapinaT. L.noemail@neicon.ruПироговС. С.PirogovS. S.noemail@neicon.ruКучерявыйЮ. А.KucheryavyYu. A.noemail@neicon.ruСтороноваО. А.StoronovaO. A.noemail@neicon.ruАндреевД. Н.AndreyevD. N.noemail@neicon.ruФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова»РоссияFederal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical UniversityRussian FederationФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И. Евдокимова»РоссияFederal state government-financed educational institution of higher education «Yevdokimov Moscow State University of Medicine and Dentistry»Russian FederationФГБОУ ВО «Оренбургский государственный медицинский университет»РоссияFederal state government-financed educational institution of higher education «Orenburg State Medical University»Russian FederationКазанская государственная медицинская академияРоссияFederal state government-financed educational institution of higher education «Kazan state medical university»Russian FederationМосковский научно-исследовательский онкологический институт им. П.А. ГерценаРоссияGertsen Moscow oncological research instituteRussian Federation2017120820182747595Copyright © Ивашкин В.Т., Маев В.И., Трухманов А.С., Баранская Е.К., Дронова О.Б., Зайратьянц О.В., Сайфутдинов Р.Г., Шептулин А.А., Лапина Т.Л., Пирогов С.С., Кучерявый Ю.А., Сторонова О.А., Андреев Д.Н., 20182018Ивашкин В.Т., Маев В.И., Трухманов А.С., Баранская Е.К., Дронова О.Б., Зайратьянц О.В., Сайфутдинов Р.Г., Шептулин А.А., Лапина Т.Л., Пирогов С.С., Кучерявый Ю.А., Сторонова О.А., Андреев Д.Н.Ivashkin V.T., Mayev I.V., A.s. Trukhmanov I..., Baranskaya Y.K., Dronova O.B., Zayratyants O.V., Sayfutdinov R.G., Sheptulin A.A., Lapina T.L., Pirogov S.S., Kucheryavy Y.A., Storonova O.A., Andreyev D.N.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/171

Цель публикации. Познакомить практикующих врачей с новейшими данными о методах адекватной диагностики, тактике лечения и особенностях рациональной фармакотерапии гастроэзофагеальной рефлюксной болезни (ГЭРБ), основанными на принципах доказательной медицины. Основные положения. По распространенности ГЭРБ занимает первое место среди гастроэнтерологических заболеваний. Ведущий симптом ГЭРБ - изжогу - выявляют у 20-40% населения развитых стран. В России распространенность ГЭРБ составляет 18-46%. Диагностика ГЭРБ на ранних стадиях основана на первичной обращаемости и анализе клинической картины заболевания. Эзофагогастродуоденоскопия (ЭГДС) дает возможность определить наличие рефлюкс­эзофагита, оценить степень его выраженности, выявить цилиндроклеточную метаплазию эпителия пищевода. При рефрактерном течении заболевания (отсутствие убедительной клинической и эндоскопической ремиссии в течение 4-8 нед проведения терапии ингибитором протонной помпы - ИПП - в стандартной дозе), а также наличии осложнений заболевания (стриктуры, пищевод Баррета) необходимо проведение обследования в условиях специализированного стационара или гастроэнтерологической клиники, в том числе в амбулаторных подразделениях этих учреждений. При необходимости больным должны быть проведены ЭГДС с биопсией стенки пищевода и гистологическим исследованием биоптатов для исключения пищевода Баррета, аденокарциномы и эозинофильного эзофагита; внутрипищеводная суточная рН­метрия или рН­импедансометрия; пищеводная манометрия высокого разрешения; рентгенологическое исследование пищевода и желудка. Лечение пациентов с ГЭРБ должно быть индивидуализировано в соответствии с клиническими проявлениями заболевания и выраженностью симптомов. Цель лечения - устранение симптомов, при эрозивном эзофагите - заживление эрозий и предупреждение осложнений, при пищеводе Баррета - про­ филактика прогрессирования и развития дисплазии и аденокарциномы пищевода. На сегодняшний день ИПП считают наиболее эффективными и безопасными препаратами для лечения ГЭРБ. ИПП применяют для проведения длительной основной (не менее 4-8 нед) и поддерживающей (6-12 мес) терапии. Патогенетически обоснованным терапевтическим способом уменьшения «кислотного кармана» и нейтрализации кислоты в области пищеводно­желудочного перехода у больных с ГЭРБ является приём альгинатов, которые формируют механический барьер­плот, который предотвращает заброс содержимого желудка в пищевод. Антациды применяют как в качестве монотерапии редко возникающей изжоги, не сопровождающейся развитием эзофагита, так и в схемах комплексной терапии ГЭРБ для быстрого устранения симптомов. Адсорбенты используют как в качестве монотерапии неэрозивной рефлюксной болезни, так и в составе комплексной терапии ГЭРБ, особенно при смешанном (кислотный+желчный) рефлюксе. Прокинетические препарты способствуют восстановлению нормального физиологического состояния пищевода, воз­ действуя на патогенетические механизмы ГЭРБ, уменьшая количество преходящих расслаблений нижнего пищеводного сфинктера и улучшая пищеводный клиренс благодаря стимуляции двигательной функции нижележащих отделов пищеварительного тракта. Прокинетики могут быть примены в составе комплексной терапии ГЭРБ вместе с ИПП. Антирефлюксное хирургическое лечение показано при осложненном течении заболевания (повторные кровотечения, пептические стриктуры пищевода, развитие пищевода Баррета с дисплазией эпителия высокой степени, часто возникающие аспирационные пневмонии). Хирургическое лечение ГЭРБ более эффективно у пациентов с ее типичными про­ явлениями и при эффективности лечения ИПП. Заключение. Выполнение клинических рекомендаций может способствовать улучшению качества оказания медицинской помощи пациентам с ГЭРБ и профилактики осложнений, в частности при соблюдении необходимых сроков лечения, проведении активного амбулаторного наблюдения за соответствующими группами больных.

Aim of publication. To present the latest data on adequate diagnostic methods, treatment approaches and features of rational pharmacotherapy of gastroesophageal reflux disease (GERD) based on the principles of evidence­based medicine to general practitioners. Summary. The prevalence of GERD occupies the first place of other gastroenterological diseases. The heartburn that is a leading GERD symptom is present at 20-40% of the population of developed countries. The prevalence of GERD in Russia ranges 18­46%. Diagnosis of GERD early stages is based on the primary appealability and clinical presentation evaluation. Esophagogastroduodenoscopy (EGDS) gives the chance to define the presence of reflux esophagitis, to estimate severity grade, to reveal development of esophageal epithelium columnar metaplasia. At the refractory course (lack of conclusive clinical and endoscopic remission within 4-8 wks of treatment by standard dose of proton pump inhibitor - PPI), and development of complications (strictures, Barret's esophagus) examination within specialized hospital or gastroenterological clinic is required, including their out­patient departments. Under certain indications the patient should undergo EGDS with esophageal biopsy and histological examination of biopsy specimens to rule out the Barret's esophagus, esophageal adenocarcinoma and/or eosinophilic esophagitis; intraesophageal 24­hour pH­metry or pH­impedance measurement; high resolution esophageal manometry; X­ray study of the esophagus and stomach. The treatment of GERD has to be individualized according to the pattern and severity of clinical symptoms. The goal of treatment is symptom relief, at erosive esophagitis - healing of erosions and complication prevention, at Barret's esophagus - prophylaxis of disease progression and dysplasia and adenocarcinoma development. Nowadays PPIs are considered as the most effective and safe agents for GERD treatment. PPIs are applied for the long­term baseline treatment (no less than 4-8 wks) and maintenance therapy (6-12 months). Intake of alginates is pathogenically reasonable therapeutic approach for reduction of «acid pocket» and acid neutralization in the area of gastro­esophageal junction in GERD patients by formation of mechanical barrier raft which prevents reflux of the stomach content into the esophagus. Antacid monotherapy is recommended for the cases of rare heartburn which is not accompanied by esophagitis and in complex modes of GERD treatment for achievement of rapid symptom relief. Adsorbents are applied as monotherapy at non­ erosive reflux disease, and as a component of comprehensive GERD treatment, especially of the cases of mixed (acid + biliary) refluxes. Prokinetic drugs promote recovery of a normal physiological state of the esophagus, controlling the pathogenic mechanisms of GERD, reducing the number of transient lower esophageal sphincter relaxations and improving esophageal clearance due to stimulation of the lower gastrointestinal motor function. Prokinetics can be applied as a component of comprehensive treatment of GERD along with PPI. Anti­reflux surgery is indicated in complicated cases (recurrent bleeding, peptic esophageal strictures, development of Barret's esophagus with high­grade epithelial dysplasia, frequent aspiration pneumonias). Surgical treatment of GERD is more effective in patients was typical manifestations and positive treatment response to PPIs. Conclusion. Implementation of clinical guidelines can promote improvement of healthcare quality for GERD patients and prevent complications, in particular if terms of treatment will be observed, at active outpatient follow­up for certain groups of patients.

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