Aim of review. To present the modern concepts on epidemiological pattern and risk factors of esophageal adenocarcinoma (EAC) and analyze the modern screening approach. Summary. In developed countries EAC is characterized by rapid increase of mobidity, as well as by high mortality level. As a rule, EAC is diagnosed at the late stage: diagnosis is often made at the 3rd or 4th stage of the tumor that is a major contributing factor for high mortality as treatment options at these stages are significantly limited. The basic established risk factor for EAC is the gastroesophageal reflux disease (GERD). EAC develops usually as a complication of the Barret's esophagus (BE) being a consequence of the long-standing GERD. Male gender, Caucasian race, obesity and metabolic syndrome, tobacco smoking, and series of genetic markers are considered to be significant EAC risk factors. A main goal of EAC screening programs is the early diagnosis that allows to improve patient survival. Conclusion. Only GERD patients develop EAC, with the highest risk in males, Caucasians, smokers, overweight patients and those with uncontrolled symptoms. Timely diagnosis of GERD, its effective treatment and follow-up of BE cases can prevent EAC development.

Aim of review. To analyze the update to in the Rome-IV criteria for the functional heartburn and reflux hypersensitivity syndrome in comparison to the Rome-III criteria. Summary. The definition of functional heartburn in the Rome-IV criteria is updated by the statement according to which absence of response to the proton pump inhibitor therapy is indispensable feature to establishing the functional heartburn diagnosis. Reflux hypersensitivity of the esophagus that was initially considered as one of the forms of the non-erosive gastroesophageal reflux disease (NERD) in the new criteria system is included in the spectrum of functional esophageal diseases. The diagnostic algorithm for the patient presenting with heartburn, having normally looking esophageal mucosa at upper endoscopy, is given. Tricyclic antidepressants and selective serotonin reuptake inhibitors play the major role in the treatment of above-mentioned functional esophageal diseases. Conclusion. The basic change in the Rome-IV criteria of the functional esophageal diseases is addition of esophageal hypersensitivity syndrome to the reflux disease entity, that was initially considered as a form of NERD.

Aim of investigation. To estimate the prevalence rate of Herpes simplex virus type 1 and 2 (HSV-1 and HSV-2), Epstein-Barr virus (EBV), human papillomavirus (HPV), cytomegalovirus (CMV) and Helicobacter pylori (H. pylori) in the stomach and duodenal mucosa of patients with chronic gastritis and chronic duodenitis of different age, and to analyze the correlation between morphological scores and pattern of mucosa infection. Material and methods. The original study included 116 patients (66 children and 50 adults) with the verified chronic gastritis and chronic gastroduodenitis. All patients underwent upper endoscopy with biopsy of the stomach and duodenal mucosa. Biopsy samples were processed by the standard technique with hematoxyline and eosine staining of sections. The basic morphological features were estimated by semiquan titative method according to modified Sydney system. Helicobacter pylori infection was diagnosed by histological method i.e.: Romanovsky-Gimza stain of biopsy samples. HSV-1, HSV-2, EBV, CMV and HPV antigens were determined by streptavidin-biotin method in paraffin sections. Results. Pathological scores of the stomach and duodenal mucosa are related to the pattern of infection in children and adults. Conclusions. Virus antigens were found in 57% of the studied children and 64% of adults in stomach and duodenal mucosa. Presence of HSV-1 infection alters of the severity and activity of chronic inflammation in stomach mucosa in children and adults.

Aim of review. To summarize the modern data on the course, diagnostics and treatment approach in seronegative autoimmune hepatitis (SAH). Summary. The number of articles devoted to SAH is quite low at the present time, while all of them are based on the small case series or single cases. Absence of elevated serum γ-globulins, immunoglobulin G and autoantibodies is most commonly seen in acute onset of the disease that is probably caused by delay of humoral immune response of the disease. According to available information one can postulate following: 1) clinical vigilance for SAH, especially at liver diseases with high biochemical activity; 2) performing liver biopsies in all cases of unclear diagnosis; 3) application of standard scoring diagnostic system at autoimmune hepatitis; 4) prescription of immunosuppressive therapy at justified suspicion for SAH (at ruling out of the other causes for liver disease). Conclusion. SAH is a rare type of autoimmune hepatitis which is observed mostly at the acute onset of the disease and require obligatory morphological confirmation.

Aim of investigation. To estimate efficacy and safety of two pharmacological forms of «Phosphogliv» (lyophilizate for intravenous administration and capsules) for the treatment of fatty liver degeneration of non-alcoholic etiology. Material and methods. Original study included overall 180 patients with nonalcoholic fatty liver disease that were randomized to the basic and control groups in the ratio of 2:1. The basic group patients received Phosphogliv 5 mg/day as intravenous bolus injection for 2 weeks, followed by oral intake of 2 capsules t.i.d. for 10 weeks (the total treatment duration was 12 weeks), control group patients received placebo in the same mode. Serum levels of inflammatory marker adiponectin, NAFLD fibrosis score, treatment effect on quality of life and safety of patients were monitored. Results. In 12 wks in patients with more significant cytolysis (threefold and higher serum alanine transaminase activity) and the rate of adiponectin level improvement on the background of Phosphogliv was 57.9% versus only 10.0% (p=0.019) in the placebo group. The mean NAFLD fibrosis score in the basic group remained almost unchanged, while in the control group negative dynamics was revealed, that resulted in statistically significant differences between groups (2.5±1.2 units versus 2.0±1.3 units respectively; р=0.009). At Phosphogliv injection already during the first 2 wks more pronounced improvement of subjective perception of dyspeptic symptoms was observed (mean score was 5.6±1.3 versus 5.1±1.4; р=0.021). When the treatment course was completed the basic group patients had higher mean score by «level of energy» scale (5.9±1.0 versus 5.6±1.0; р=0.034). Only sporadic adverse effects were found to the background of treatment, no statistically significant differences in their rate in were recorded. Dynamics of the basic physical parameters and laboratory tests was comparable as well. Conclusions. Treatment of non-alcoholic fatty liver disease that includes Phosphogliv provides reduction of steatohepatitis activity, retardation of fibrosis progression, improvement of overall disease prognosis and high satisfaction of patients at a favorable safety profile.

Aim of investigation. To estimate the frequency of Clostridium difficile (C. difficile) infection and its effect on severity and pattern of complications at the compensated liver cirrhosis (LC). Material and methods. The original study included overall 47 patients with decompensated LC (Child-Pugh class B - 27 patients and class C - 20 patients). All patients underwent clinical interviewing with assessment of past history, daily blood pressure (BP) measurement with calculation of the mean blood pressure level, blood tests, ECG, abdominal ultrasound, esophagogastroduodenoscopy, echocardiography, chest X-ray, lactulose hydrogen breath test, Clostridium difficile ELISA stool test. Results. Clostridium difficile infection was found in 26 (55.3%) of 47 patients with decompensated LC. Of patients with alcoholic LC the mean Maddrey score in Clostridium difficile-infected subgroup was significantly higher than the score of non-infected patients. For the last 6 months prior to the study enrollment 50% of patients with Clostridium difficile infection were hospitalized and received antibiotics significantly more frequently. Metronidazole was prescribed more frequently to Clostridium difficile-infected patients (92.3% versus 9.5%; р<0.001), 69.2% of infected patients received proton pump inhibitors vs 85.7% of non-infected patients (p=0.3). According to laboratory test results the trend to increase of fibrinogen level and microhematuria severity at clostridial infection was found. At abdominal ultrasound significant difference in craniocaudal dimension of the left liver lobe between the studied groups of patients (p=0.026) was found. Conclusions. Study results indicate high frequency of C. difficile infection at decompensated liver cirrhosis (55.3%), but it is symptomless in most of the cases (in 95.7% of patients). The causes for such course of disease is poorly understood. Clostridial infection increases severity of the patient state with the alcoholic liver disease as confirmed by higher Maddrey score. C. difficile infection develops much more frequently in patients who previously received metronidazole treatment for the last 6 months. In spite of the fact, that metronidazole is one of drugs of choice at C. difficile eradication, obtained results indicate the possible interrelation of metronidazole treatment to clostridial infection that was previously described in the literature.

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.

Aim of review. To generalize scientific data and to develop modern concept on the issue of diagnosis, staging and treatment of early rectal cancer. Summary. The world-wide issues of early rectal cancer are discussed in the review. Diagnostic methods and staging of the early cancer and premalignant states are discussed. Prospects of improvement of early rectal cancer treatment approach are outlined, advantages of the rectum-preserving techniques are justified. Conclusion. Early rectal cancer is rarely observed neoplasm that may be the main cause for diagnostic and staging difficulties. So far the choice of surgical method for early rectal cancer is a subject for discussion, at the same time the choice of method is determined not only by the tumor invasion depth, but also by the presence of risk factors for regional lymph node involvement.

Aim of review. To justify and present the protocol of the prospective, multicenter randomized clinical trial for evaluation of the choice of preventive intestinal stoma formation method after rectectomy. Summary. Modern surgery for the rectal cancer is featured by preferential sphincter-preserving operations. It is established that colorectal anastomosis incompetence is severe and in some cases lethal complication that reduce quality of life of patients and an increase the risk of disease relapses, which rate reaches 15 to 20% at low colorectal anastomosis. Formation of preventive stoma is an effective way to avoid this complication that is why it’s inclusion to treatment protocols for the middle and low ampullary rectal cancers is undisputed by the most of surgeons. However the choice of preventive stoma formation method is under discussion yet and remains to be an urgent issue. In the western countries the preferred method is double barreled ileostomy due to more rapid formation and closure, as well as due to lower rate of stoma-related morbidity. In Russia and CIS countries application of double-barreled transverse colostoma is preferred traditionally due to lower rate of electrolytic disorders and related repetitive hospital admissions in conditions of imperfect stoma care system, along with series of unproven advantages, usually defined as hospital tradition. Conclusion. Presented study will allow to reveal the early and late postoperative morbidity rate and the related repeated hospital admissions in real-life clinical practice of Russia from the standpoints of evidencebased medicine, to define indications and contraindications for each method of «low» colorectal anastomosis protection with the least risk for the patient.

The aim of review. To highlight the modern concept of the gallstone disease (GSD) pathogenesis at pregnancy and to discuss modern diagnostic and treatment approaches. Summary. The risk of biliary sludge and cholesterol gallstones at pregnancy is significantly increased that is caused mainly due to elevation of estrogen and progesterone level leading to increased cholesterol synthesis, decreased gallbladder contractility and, as a result, to increased lithogenicity of bile. Clinical presentation of GSD at pregnant patients is similar to that at nonpregnant women. Transabdominal ultrasound investigation play the major role in diagnosis of cholelithiasis at pregnancy. For treatment of symptomatic GSD forms in this the period active surgical approach is becoming more and more common. Laparoscopic cholecystectomy is a method of choice, and the optimal term for its implementation is the second trimester of pregnancy. Prevention and treatment of biliary sludge in pregnancy may be carried out by ursodeoxycholic acid. Conclusion. Increased risk of cholelithiasis at pregnant women requires further improvement of management approach and search for better methods for treatment and prophylaxis