gastro-jРоссийский журнал гастроэнтерологии, гепатологии, колопроктологииRussian Journal of Gastroenterology, Hepatology, Coloproctology1382-43762658-6673«Gastro» LLC10.22416/1382-4376-2020-30-4-70-97gastro-j-513Research ArticleКЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИCLINICAL GUIDELINESРекомендации Российской гастроэнтерологической ассоциации по диагностике и лечению гастроэзофагеальной рефлюксной болезниRecommendations of the Russian Gastroenterological Association in Diagnosis and Treatment of Gastroesophageal Reflux Diseasehttps://orcid.org/0000-0002-6815-6015ИвашкинВ. Т.IvashkinV. T.

Ивашкин Владимир Трофимович — академик РАН, профессор, доктор медицинских наук, заведующий кафедрой пропедевтики внутренних болезней, гастроэнтерологии и гепатологии ИКМ им. Н.В. Склифосовского; директор клиники пропедевтики внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко ПМГМУ им. И.М. Сеченова (Сеченовский Университет) МЗ РФ.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Vladimir T. Ivashkin — Member of the Russian Academy of Sciences, Prof., Dr. Sci. (Med.), Head of the Chair of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sklifosovsky Institute of Clinical Medicine; Director, Vasilenko Clinic of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

kont07@yandex.ruhttps://orcid.org/0000-0001-6114-564XМаевИ. В.MaevI. V.

Маев Игорь Вениаминович — академик РАН, профессор, доктор медицинских наук, заведующий кафедрой пропедевтики внутренних болезней и гастроэнтерологии.

127473, Москва, ул. Делегатская, д. 20, стр. 1.

Igor V. Maev — Member of the Russian Academy of Sciences, Prof., Dr. Sci. (Med.), Head of the Chair of Internal Medicine Propaedeutics and Gastroenterology, Moscow State University of Medicine and Dentistry.

127473, Moscow, Delegatskaya str., 20, bld. 1.

https://orcid.org/0000-0003-3362-2968ТрухмановА. С.TrukhmanovA. S.

Трухманов Александр Сергеевич — доктор медицинских наук, профессор кафедры пропедевтики внутренних болезней, гастроэнтерологии и гепатологии Института клинической медицины им. Н.В. Склифосовского.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Alexander S. Trukhmanov — Dr. Sci. (Med.), Prof., Chair of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

troukh@mail.ruhttps://orcid.org/0000-0003-4456-8725ЛапинаТ. Л.LapinaT. L.

Лапина Татьяна Львовна — кандидат медицинских наук, доцент кафедры пропедевтики внутренних болезней, гастроэнтерологии и гепатологии Института клинической медицины им. Н.В. Склифосовского.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Tatyana L. Lapina — Cand. Sci. (Med.), Assoc. Prof., Chair of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

tatlapina@gmail.comhttps://orcid.org/0000-0002-0960-1166СтороноваО. А.StoronovaO. A.

Сторонова Ольга Андреевна — кандидат медицинских наук, врач отделения функциональной диагностики клиники пропедевтики внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Olga A. Storonova — Cand. Sci. (Med.), Physician, Department of Functional Diagnostics, Vasilenko Clinic of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

storonova@yandex.ruhttps://orcid.org/0000-0003-3606-3823ЗайратьянцО. В.ZayratyantsO. V.

Зайратьянц Олег Вадимович — доктор медицинских наук, профессор, заведующий кафедрой патологической анатомии.

127473, Москва, ул. Делегатская, д. 20, стр. 1.

Oleg V. Zayratyants — Dr. Sci. (Med.), Prof., Head of the Chair of Pathology, Moscow State University of Medicine and Dentistry.

127473, Moscow, Delegatskayastr., 20, bld. 1.

ovzair@mail.ruДроноваО. Б.DronovaO. B.

Дронова Ольга Борисовна — доктор медицинских наук, профессор кафедры хирургии факультета последипломной подготовки специалистов.

460000, Оренбург, ул. Советская, д. 6.

Olga B. Dronova — Dr. Sci. (Med.), Prof., Chair of Surgery, Orenburg State Medical University.

460000, Orenburg, Sovetskaya str., 6.

mdc2005@yandex.ruhttps://orcid.org/0000-0001-7760-2091КучерявыйЮ. А.KucheryavyyYu. A.

Кучерявый Юрий Александрович — кандидат медицинских наук, доцент кафедры пропедевтики внутренних болезней и гастроэнтерологии, научный сотрудник лаборатории функциональных методов исследования в гастроэнтерологии МГМСУ им. А.И. Евдокимова.

127473, Москва, ул. Делегатская, д. 20, стр. 1.

Yury A. Kucheryavyy — Cand. Sci. (Med.), Assoc. Prof., Chair of Internal Medicine Propaedeutics and Gastroenterology, Moscow State University of Medicine and Dentistry; Researcher, Laboratory of Functional Research in Gastroenterology, Moscow State University of Medicine and Dentistry.

127473, Moscow, Delegatskaya str., 20, bld. 1.

proped@mail.ruhttps://orcid.org/0000-0002-8101-2155ПироговС. С.PirogovS. S.

Пирогов Сергей Сергеевич — доктор медицинских наук, заведующий отделом эндоскопии.

125284, Москва, 2-й Боткиский проезд, д. 3.

Sergei S. Pirogov — Dr. Sci. (Med.), Head of the Department of Endoscopy, Herzen Moscow Oncology Research Center — Branch of the National Medical Research Radiology Center.

125284, Moscow, Vtoroy Botkinskiy Proezd, 3.

pirogov@mail.ruСайфутдиновР. Г.SayfutdinovR. G.

Сайфутдинов Рафик Глимзянович — доктор медицинских наук, профессор, заведующий кафедрой госпитальной и поликлинической терапии КГМА филиала ФГБОУ ДПО РМАНПО Министерства здравоохранения Российской Федерации.

420012, Казань, ул. Муштари, д. 11.

Rafik G. Sayfutdinov — Dr. Sci. (Med.), Prof., Head of the Chair of Hospital and Outpatient Therapy, Kazan State Medical Academy — Branch of the Russian Medical Academy of Continuous Professional Education.

420012, Kazan, Mushtaristr., 11.

rgsbancorp@mail.ruhttps://orcid.org/0000-0001-6434-1267УспенскийЮ. П.UspenskiyYu. P.

Успенский Юрий Павлович — доктор медицинских наук, профессор, заведующий кафедрой факультетской терапии имени профессора В.А. Вальдмана.

191014, Санкт Петербург, Литейный проспект, д. 56.

YuryP. Uspenskiy — Dr. Sci. (Med.), Prof., Head of the Chair of Faculty Therapy named after V.A. Valdman, Saint-Petersburg State Pediatric Medical University.

191014, St. Petersburg, Liteyniy prospekt, 56.

uspenskiy65@mail.ruhttps://orcid.org/0000-0002-1395-9566ШептулинА. А.SheptulinA. A.

Шептулин Аркадий Александрович — доктор медицинских наук, профессор кафедры пропедевтики внутренних болезней, гастроэнтерологии и гепатологии Института клинической медицины им. Н.В. Склифосовского.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Arkady A. Sheptulin — Dr. Sci. (Med.), Prof., Chair of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

arkalshep@gmail.comhttps://orcid.org/0000-0002-4007-7112АндреевД. Н.AndreevD. N.

Андреев Дмитрий Николаевич — кандидат медицинских наук, доцент кафедры пропедевтики внутренних болезней и гастроэнтерологии, научный сотрудник лаборатории функциональных методов исследования в гастроэнтерологии.

127473, Москва, ул. Делегатская, д. 20, стр. 1.

Dmitriy N. Andreev — Cand. Sci. (Med.), Assoc. Prof., Chair of Internal Medicine Propaedeutics and Gastroenterology, Moscow State University of Medicine and Dentistry; Researcher, Laboratory of Functional Research in Gastroenterology, Moscow State University of Medicine and Dentistry.

127473, Moscow, Delegatskaya str., 20, bld. 1.

dna-mit8@mail.ruРумянцеваД. Е.RumyantsevaD. E.

Румянцева Диана Евгеньевна — кандидат медицинских наук, врач отделения гастроэнтерологии клиники пропедевтики внутренних болезней, гастроэнтерологии и гепатологии им. В.Х. Василенко.

119435, Москва, ул. Погодинская, д. 1, стр. 1.

Diana E. Rumyantseva — Cand. Sci. (Med.), Physician, Department of Gastroenterology, Vasilenko Clinic of Internal Diseases Propaedeutics, Gastroenterology and Hepatology, Sechenov First Moscow State Medical University (Sechenov University).

119435, Moscow, Pogodinskaya str., 1, bld. 1.

diana-ryazanceva@yandex.ruПервый Московский государственный медицинский университет им. И.М. Сеченова (Сеченовский Университет) Министерства здравоохранения Российской ФедерацииРоссияSechenov First Moscow State Medical University (Sechenov University)Russian FederationМосковский государственный медико-стоматологический университет им. А.И. Евдокимова Министерства здравоохранения Российской ФедерацииРоссияMoscow State University of Medicine and DentistryRussian FederationОренбургский государственный медицинский университет Министерства здравоохранения Российской ФедерацииРоссияOrenburg State Medical UniversityRussian FederationМНИОИ им. П.А. Герцена — филиал ФГБУ «Национальный медицинский исследовательский радиологический центр» Министерства здравоохранения Российской ФедерацииРоссияHerzen Moscow Oncology Research Center — Branch of the National Medical Research Radiology CenterRussian FederationКазанская государственная медицинская академия — филиал ФГБОУ ДПО «Российская медицинская академия непрерывного профессионального образования» Министерства здравоохранения РоссийскойРоссияKazan State Medical Academy — Branch of the Russian Medical Academy of Continuous Professional EducationRussian FederationСанкт-Петербургский государственный педиатрический медицинский университет Министерства здравоохранения Российской ФедерацииРоссияSaint-Petersburg State Pediatric Medical UniversityRussian Federation2020140920203047097Copyright © Ивашкин В.Т., Маев И.В., Трухманов А.С., Лапина Т.Л., Сторонова О.А., Зайратьянц О.В., Дронова О.Б., Кучерявый Ю.А., Пирогов С.С., Сайфутдинов Р.Г., Успенский Ю.П., Шептулин А.А., Андреев Д.Н., Румянцева Д.Е., 20202020Ивашкин В.Т., Маев И.В., Трухманов А.С., Лапина Т.Л., Сторонова О.А., Зайратьянц О.В., Дронова О.Б., Кучерявый Ю.А., Пирогов С.С., Сайфутдинов Р.Г., Успенский Ю.П., Шептулин А.А., Андреев Д.Н., Румянцева Д.Е.Ivashkin V.T., Maev I.V., Trukhmanov A.S., Lapina T.L., Storonova O.A., Zayratyants O.V., Dronova O.B., Kucheryavyy Y.A., Pirogov S.S., Sayfutdinov R.G., Uspenskiy Y.P., Sheptulin A.A., Andreev D.N., Rumyantseva D.E.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/513Цель

Цель. Настоящие рекомендации Российской гастроэнтерологической ассоциации разработаны с целью ознакомления практикующих врачей с современными методами диагностики, тактикой лечения и особенностями рациональной фармакотерапии больных с гастроэзофагеальной рефлюксной болезнью (ГЭРБ).

Основные положения

Основные положения. Распространенность ГЭРБ в Российской Федерации варьирует от 11,3 до 23,6 %. Диагноз ГЭРБ устанавливается на основании анамнестических данных и результатов инструментального обследования. Эзофагогастродуоденоскопия (ЭГДС) позволяет обнаружить признаки рефлюкс-эзофагита разной степени выраженности, выявить цилиндроклеточную метаплазию эпителия пищевода. Пациентам с рефрактерным течением заболевания (при отсутствии убедительной клинической и эндоскопической ремиссии в течение 4-8 недель проведения терапии стандартной дозой ИПП) или при наличии стриктур, пищевода Баррета необходимо проведение ЭГДС с биопсией пищевода и гистологическим исследованием биоптатов. По показаниям пациентам должны быть выполнены внутрипищеводная суточная рН-метрия или рН-импедансометрия, манометрия высокого разрешения, позволяющие полно изучить функциональное состояние пищевода и пищеводно-желудочного перехода, прогнозировать варианты течения заболевания и результаты его лечения.

Лечение пациентов ГЭРБ должно быть индивидуализировано в соответствии с клиническими проявлениями заболевания, интенсивностью симптомов и направлено на устранение симптомов, заживление эрозий при эрозивном эзофагите, предупреждение осложнений, профилактику прогрессирования пищевода Баррета и развития дисплазии и аденокарциномы пищевода.

Наиболее эффективными препаратами для лечения ГЭРБ являются ИПП, которые применяются для проведения как основной (4-8 нед), так и поддерживающей терапии. В качестве монотерапии редко возникающей изжоги, которая не сопровождается развитием эзофагита, а также в схемах комплексной терапии ГЭРБ для быстрого устранения симптомов пациентам рекомендованы антациды. Прокинетические препараты могут быть применены в составе комплексной терапии ГЭРБ вместе с ИПП, так как они способствуют восстановлению нормального физиологического состояния пищевода, воздействуя на патогенетические механизмы ГЭРБ.

При осложненном течении заболевания (повторные кровотечения, пептические стриктуры пищевода) больным показано антирефлюксное хирургическое лечение с предварительным исследованием функциональных показателей пищевода с помощью рН-импедансометрии и манометрии высокого разрешения.

Заключение

Заключение. Настоящие клинические рекомендации обобщают актуальную информацию о ГЭРБ с позиции доказательной медицины. Соблюдение рекомендаций позволит улучшить качество оказания медицинской помощи пациентам ГЭРБ, а также проводить своевременную профилактику осложнений.

Aim

Aim. Current recommendations of the Russian Gastroenterological Association are developed to acquaint medical practitioners with modern diagnostics, treatment and trends in rational drug therapy for gastroesophageal reflux disease (GERD).

General provisions

General provisions. Incidence rate of GERD in the Russian Federation varies from 11.3 to 23.6%. GERD is diagnosed with medical history and laboratory examination evidence. Esophagogastroduodenoscopy (EGDS) allows detection of reflux esophagitis of various severity and cylindrical epithelial metaplasia of esophagus. The refractory form of disease (lack of conclusive clinical and endoscopic remission during 4-8 weeks of standard-dose PPI therapy), presence of strictures and Barrett's esophagus require EGDS with esophageal biopsy and bioptic histological examination. Patients should be conclusively performed esophageal 24-hour pH-metry or pH-impedance monitoring, high-resolution manometry to thoroughly examine functionality of esophagus, esophagogastric junction and assess disease prognosis and therapy outcomes.

Treatment of GERD should be personalised accounting for clinical manifestations and severity, as well as aimed at symptom improvement, lesion healing in erosive esophagitis, averting complications, Barrett's esophagus progression, dysplasia and esophageal adenocarcinoma.

Proton pump inhibitors (PPIs) are most effective agents in primary (4-8 weeks) and maintenance anti-GERD therapy. Antacids are recommended in monotherapy for occasional nonerosive heartburn and complex anti-GERD settings for fast symptom improvement. Prokinetics can be used in combination with PPIs for their properties to recover normal functionality of esophagus through affecting pathogenetic mechanisms of GERD.

Complicated patients (repeated bleedings, peptic esophageal strictures) are recommended anti-reflux surgery with prior examination of esophageal functionality using pH-impedance and high-resolution manometry.

Conclusion

Conclusion. Current recommendations provide an up-to-date evidential medicial review of GERD and guidelines to advance special medical care and timely preventive measures.

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