Aim of review. To highlight the modern concept on the pathogenesis of postgastrectomy disorders and related morbid conditions, approach to their treatment and potential for improvement of postsurgical rehabilitation and quality of life of postsurgical gastric cancer patients. Summary. Surgical treatment of gastric cancer includes complete or partial resection of the organ, its lymphatic system and ligaments that is followed by impairment and reduction of digestive process and is associated to series of disorders, related to altered visceral innervation. Three basic groups of disorders are defined: disorders related to impaired organ anatomy; disorders caused by change in anatomical and physiological interrelations and developing as a compensatory response (mostly of functional origin); metabolic disorders. Development of inflammatory and of fibrotic anastomotic strictures and stenoses, erosions and/or ulcers, as well as obstruction caused by intestinal loop in relation or peritoneal adhesions make conservative treatment ineffective that require endoscopic or open surgical approaches: bougieurage, stenting or surgical reconstruction. Postoperative functional disorders are prone to conservative treatment: lifestyle modification, change in diet composition along with pattern of food intake combined to antisecretory, spasmolytic and prokinetic drugs. Severe functional disorders which do not respond to conservative treatment should be considered as possible indications for surgical treatment. Adequate metabolic correction is required: water and electrolyte disorders should be corrected by intravenous infusion therapy and maintaining of sufficient oral fluid intake; hypoproteinemia requires intake of protein-rich food and satisfactory conditions for its digestion and absorption; iron supplementation should be prescribed for microcytic anemia, as well as cyano- cobalamin for B12-deficiency. Nutritional failure that is frequently combined to above-listed postgastrectomy disorders. Patient requires dietic modification and balanced enteral feeding, combined to increased physical activity. Conclusion. Ultimate goals in treatment of postgastrectomy disorders and their complications in patients after extensive gastrointestinal surgery include improvement in quality of life, social and professional rehabilitation.

Aim of review. To present the data on main forms of hereditary colorectal cancer (CRC) and to discuss issues of its diagnostics, genetic testing and patient management. Summary. CRC is one of the most widespread oncologic diseases and takes the leading positions for morbidity and mortality in the pattern of neoplastic diseases in Russia. In 30% of cases disease development is associated to genetic predisposition, however only 5% of all CRC cases are linked to established hereditary syndromes, such as Lynch syndrome (hereditary non-polyposis colorectal cancer), family adenomatous polyposis, MUTYH-associated polyposis, juvenile polyposis, hereditary mixed polyposis syndrome, Peutz-Jeghers syndrome and serrated polyposis syndrome. The current review presents clinical and genetic features of two basic colorectal hereditary syndromes - Lynch syndrome and family adenomatous polyposis. Conclusion. Both clinical and molecular genetic investigations of hereditary CRC forms make possible individual comprehensive approach for diagnosis verification, evaluation of cancer risk, early diagnostics, treatment and prevention for decrease of morbidity and mortality.

Aim of review. To present management approach for acid-related diseases in patients with Helicobacter pylori (H. pylori) infection, under long-term proton pump inhibitor therapy. Summary. There is no relation of gastroesophageal reflux disease (GERD) symptom severity, the pattern of relapses and treatment efficacy to the presence or absence of H. pylori infection; successful H. pylori eradication does not cause relapse of pre-existing GERD and does not induce its development. At the same time it is impossible to neglect the data on potential induction or aggravation of GERD after H. pylori eradication in separate population groups, including those in Asia. The presence of GERD could not prevent infection eradication in the presence of other indications (e.g., peptic ulcer, chronic gastritis). Monotherapy by proton pump inhibitors (PPI) in H. pylori-positive patients with GERD may lead to progression of gastric corpus atrophy that can be regarded as risk factor for stomach cancer development. H. pylori infection eradication promotes reduction of gastritis-like changes severity irrespective of maintaining of acid-suppressive treatment. The choice of specific PPI for treatment of patients with GERD and other acid-related diseases, carrying out H. pylori eradication therapy or substitution of one PPI agent to another are individualized and depend on the indications registered in the drugs administration instructions, features of its pharmacokinetics and pharmacodynamics, possible drug-to-drug interactions. Conclusion. Testing for H. pylori infection and carrying out the subsequent eradication therapy could allow to prevent progression of corpus mucosa atrophy in patients with acid-related disorders, first of all those with GERD, who received long-term PPI treatment. Estimation of duration of PPI treatment at acid-related disorders, and terms of H. pylori eradication therapy should be evaluated according to clinical guidelines and treatment protocols of these diseases taking into account age of the patient, clinical features, course of disease, presence of complications.

Aim of review. To analyze the options of application of Lactobacillus reuteri DSMZ17648 (Pylopass™) within Helicobacter pylori eradication. Summary. H. pylori eradication therapy is considered as one of the optional spheres for clinical application of probiotic medications. According to available data certain strains of probiotics are effective in decreasing of gastrointestinal adverse effects rates, associated with eradication therapy while the other can potentiate the efficacy of H. pylori eradication itself. L. reuteri strain DSM17648 which was chosen from over 700 wildtype strains of Lactobacillus spp. possess the ability for selective adhesion to H. pylori in vivo in the gastric media. DSM17648 strain of L. reuteri form coaggregates with various H. pylori strains and serotypes both in vivo and in vitro. It was revealed that lyophilizate of this strain (PylopassTM) blocks adhesion of H. pylori to epithelial cells as well. Clinical trials demonstrate the effect of PylopassTMon gastric mucosa colonization by H. pylori according to the 13C urea breath test data and as well the increase in H. pylori eradication rate when the productis added the to triple therapy modes. Conclusion. Potential of PylopassTM combination to various H. pylori eradication therapy modes is a subject offutnet multicenter randomized clinical trials for assessment of optimal combination to antibiotic drugs, treatment duration and adverse effect rates. The value of monotherapy by this metabiotic at chronic H. pyloriassociated gastritis is a subject of further studies.

Aim of investigation. To study dynamics of morbidity gastrointestinal tumors in Kabardino-Balkar Republic for 25-year period, to compare to the Russian and world wide epidemiological data. Material and methods. Annual reports of oncological dispensary of Kabardino-Balkar Republic Ministry of healthcare for 1990, 1995, 2000, 2005, 2009-2014, along with archive of biopsies and postoperative specimen of Bureau of pathology for 2009-2012 are studied and statistically analyzed. Intensive (raw) scores for gender and age, annual average gain rates of oral, esophageal, stomach and colonic neoplasms incidence rate were calculated. Results. In Kabardino-Balkar Republic in contrast to all-Russia and world data decrease in oral and oropharyngeal and especially (more than double) esophageal cancer was noted. Decrease in incidence of colorectal cancer and growth - of the stomach cancer in Kabardino-Balkar Republic correspond to similar trends in other regions, but exceed them in rates. Incidence of oral and oropharyngeal cancer cases, stomach and colonic neoplasms in urban and lowland population is higher (1.4-2 times) as compared to rural and mountainous population, while for esophageal carcinoma, on the contrary, the prevalence is higher in the mountain part (almost double) both for the town and country populaiton. Conclusions. Establishment of epidemiologic and morphological features of malignant tumors gives clinicians a chance to take effective measures for early diagnostics and effective treatment, whereas healthcare administration may develop prophylactic actions.

Aim of investigation. To analyze the data of patients with gastrointestinal stromal tumors (GIST) in the retrospective study that was carried out in hospitals of Chita and central regional hospital of Transbaykal region. Material and methods. In original study overall 116 patients with stromal tumors of gastrointestinal tract according to the records of Chita and Transbaikal Regional pathological bureau were analyzed Results. Nine (7,7%) patients had tumor location in the esophagus, 69 (59,4%) - in the stomach, 3 (2,5%) - in duodenum, 16 (13,7%) - in jejunum and ileum, 10 (8,6%) - in the colon, 3 (2,5%) - in the rectum. Retroperitoneal location of the GIST was revealed in 3 (2,5%) patients, pancreatic - in 2 (1,7%), liver - in 1 (0,8%) patient. The tumor was complicated by development of gastro-intestinal bleeding in 51 (44,8%) patients, in 3 cases (2,5%) it was lethal. Patients underwent organ-preserving operations without lymphadenectomy. In the remote period after surgery one patient died due to tumor metastasis, in 7 patients GIST was primarily diagnosed at the autopsy. Targeted therapy by tyrosine kinase inhibitors was carried out for 14 patients. Histological investigation of tumors revealed the mixed type in 8,62% of patients, and approximately equal proportion for spindle-cell and epithelioid (46,4 and 44,8%) variants. Extraorgan tumor growth especially in the cases of gastric location, commonly led to diagnostic errors when GIST was misdiagnosed for pancreatic pseudocyst, leiomyoma, schwannoma and other tumors. Conclusions. GIST can develop in any segment of gastrointestinal tract and features extraorgan growth in most of the patients, intraluminal growth of pedunculated tumor is rarely diagnosed. Bleeding from a tumor is the most frequent complication which can which can be lethal.

Aim of investigation. To evaluate the prevalence of clinical manifestations and variants of progression for ulcerative colitis (UC) and Crohn’s disease (CD) in population of the Russian Federation. Material and methods. The present investigation was designed as population-based one-stage observational study. The clinical data, treatment methods, laboratory tests results and the rate of adverse effects for patients with inflammatory bowel diseases (IBD) from 8 gastroenterological centers were obtained. Severity grade was estimated by a doctor. Encoding of concurrent therapy, complications and systemic manifestations was carried out according to MedDRA. Results. Original study included overall 1000 patients (667 UC patients, 333 CD patients). Most of the study patients were diagnosed to have chronic relapsing (53.1% for UC; 45.0% for CD) or chronic persistent (32.8% with UC; 39.65 with CD) course of disease, mild attack was revealed in 51.3% of UC patients and 52.3% of CD patients, moderate attack in 46.6 and 47.3% respectively. Systemic manifestations and complications of the disease were found in 33.5% of patients. At the moment of enrollments to the study patients received maintenance therapy, most frequently - by the drugs containing 5-aminosalicylic acid (72.0% for UC, 59.5% for CD) and immunosuppressors (28.0% for UC, 42.6% for CD); biological agents are prescribed rarely (11.75% for UC, 20.4% for CD). Previous surgical intervention was present in the past history of 43.8% CD patients and 5.7% - UC patients. The median (range) hospital admissions was 1 (1-10) in those with UC and 1 (1-24) in those with CD. Conclusions. High complication rate, previous surgical intervention and changes of therapeutic tactics demonstrates that treatment approaches to this cohort of IBD patients in the Russian Federation are not optimal enough.

Aim of publication. To present the guidelines on diagnostics and treatment of biliary dyskinesia to practical doctors. Summary. The gallbladder dyskinesia and sphincter of Oddi dyskinesia are defined as the diseases of functional origin caused by motility and visceral sensitivity disorders. The pathogenesis of these disorders is not completely understood. Development of sphincter of Oddi dysfunction is related to previous cholecystectomy. Contractility disorders along with increased lithogenicity followed by cyclooxygenase-2 overactivation in biliary tract tissue play significant pathogenic role; putative change in bile acid composition may be involved as well. Diagnosis of biliary dyskinesia requires first the careful analysis of pattern of pain and compliance of symptoms to biliary pain criteria; second, instrumental tests that exclude organic origin of biliary disease. Estimation of the type of biliary dysfunction is established on compliance of the detected symptoms to proposed criteria. Conclusion. Biliary dyskinesia pathogenesis is not studied well. Development of attacks of biliary pain (according to established criteria) and lack of organic disorders evidence, may help to suspect the presence of biliary dyskinesia. To exclude organic biliary diseases with confidence, informative modern diagnostic tests of biliary tract visualization should be applied. Therapeutic approach should include correction of diet and lifestyle modification, administration of antispasmodic medications and agents modulating the state of nervous system, in selected cases the option of papillosphincterotomy should be considered.

Aim of review. To present modern options of comprehensive infusion therapy at various liver diseases, indications and contraindications for application of basic blood substitute groups, and pathogenically justified approaches for their use. Summary. Chronic and acute liver diseases are associated to end the genius intoxication, electrolyte disorders, shift of acid-base state, tissue and cellular hypoxia. Infusion therapy with application of modern plasma substitute solutions provide increase in treatment efficacy for this group of patients. Application of basic group infusion solutions along with complex anti-hypoxia agents helps to correct water and electrolyte imbalance as well as disorders of acid-base state, carry out body detoxication, normalize blood pressure, treat edema and ascites syndrome, protein-energy malnutrition, prevent renal value and other complications in liver cirrhosis patients. Comprehensive treatment of liver diseases includes application of modern infusion agents (anti-hypoxia/anti-oxidation) containing pharmacologically active metabolic substances that include succinate-containing drugs developed on the basis of succinic acid and its salts. Succinic acid is presumed to act as the paracrine agent produced by damage hepatocytes (e.g. at ischemia), affecting pericytes (Ito's cell) in the liver through SUCNR1receptors. It results activation of pericytes providing synthesis of extracellular matrix components that are involved in metabolism and regeneration of liver parenchyma cells. Conclusion. Addition of succinic acid-based medications to infusion therapy program for chronic liver diseases provides alleviation of basic clinical syndromes (intoxication, asthenic and autonomous nervous disorders, dyspeptic, cholestatic), and at patients with hepatocellular failure improvement of protein-synthetic liver function.

The aim of clinical case presentation. To analyze the options of autonomous intestinal neuropathy treatment in critical state patients. Key points. The clinical cases of autonomous intestinal neuropathy of various etiology are presented. Patient A., 19-year-old patient presented with constipation for up to 3 days, progressive feeling of abdominal distention and general weakness. In the past history patient underwent surgery for chronic left-side achillobursitis. In postoperative period antibacterial treatment was prescribed that included first-generation cephalosporin. At the 4thday after onset of antibiotic treatment the patient developed chronic abdominal pain that increased progressively, diarrhea up to 10 times per day and fever of 39 °C. Subsequent investigation revealed positive stool test for C. difficile toxins A and B. Urgent colonoscopy detected pseudomembranes at colonic mucosa. Histological examination of biopsy specimens from affected sites demonstrated focal cystic dilation of crypts with epithelium desquamation, severe edema of lamina propria. Pseudomembranous colitis was diagnosed and vancomycin 125 mg qid in combined to metronidazole 500 mg tid for 10 days were prescribed. At the background of treatment stool frequency gradually decreased up to 2 times per day, hematochezia stopped. However at the 7-8th days patient developed constipation, feeling of abdominal distention and progressive general weakness. The state was regarded as development of C. difficile toxin-associated autonomous intestinal neuropathy. Patient I., 54 year-old admitted to the hospital; presenting complaints included flatulence, constipation for up to three days and severe general weakness. According to the past history in 2014 patient was diagnosed to have adenocarcinoma of the right breast gland with subsequent right-sided radical mastectomy followed by radiation therapy and chemotherapy. In May 2017 patient developed boring pain in the right lumbar area, frequent small-volume urination, febrile fever and progressive general weakness. Laboratory and instrumental investigation revealed obstructive right-sided abscessing pyelohephritis with development of sepsis; antibacterial therapy included meropenem in daily dose of 3.0 g along with correction of hypoalbuminemia and detoxication therapy. At the 3rd day of treatment patient noticed improvement in the state of health: decrease in right-sided lumbar pain and general weakness, decrease in body temperature up to subfebrile level. Catheter-collected urine sample contained no admixture of pus. However in the same day patient developed constipation along with progressive abdominal distention. The most likely cause for development of ileus in this case is development of autonomous intestinal neuropathy associated to severe intoxication. Basic mechanisms for development of autonomous intestinal neuropathy are discussed: suppression of smooth muscular contractility by C. difficile toxins A and B (in the first of presented cases) and combined autoimmune neuronal damage by immune cells due to expression of proteins by neoplastic cells (in the second case). Therapeutic approaches including prescription of prokinetic drug prucalopride and multistrain probiotic containing bifido-and lactobacilli are presented (Bifidobacterium bifidum, B. longum, B. infantis, Lactobacillus rhamnosus). Prescription of prucalopride and multistrain probiotic provided resolution of neuropathy and recovery of adequate intestinal motility due to resumption neuromuscular intestinal complex activity and correction of intestinal microbiota spectrum. Conclusion. Combination of prokinetic drug (prucalopride) and multistrain probiotic medication (Bifidobacterium bifidum, B. longum, B. infantis, Lactobacillus rhamnosus) can be effective in the treatment of autonomous intestinal neuropathy in critical care.

Aim of clinical case presentation. Choice of optimal surgical approach for treatment of intestinal intussusception. Key points. Intestinal intussusception is a rare condition, especially in adults, which can develop due to both benign and malignant neoplasms. Commonly intestinal intussusception is an accidental diagnostic finding, however cases of clinically severe intussusception resulting in impaired passage of intestinal content are described in the literature. Ultrasound investigation and endoscopy contribute significantly to diagnosis of this pathology; however in certain cases computer and magnetic-resonance tomography are required. Surgical approach in intestinal intussusception varies widely from conservative reposition of intussuscepted loop to expanded resection of intestinal segment. Clinical case of ileocecal intussusception caused by melanoma metastasis to the ileum is presented.

Aim of the case presentation. To demonstrate the rare case of extranodal lymphoma with primary extensive liver involvement which caused difficulties at diagnosis verification. Despite of rapid disease progression with development of severe liver failure, that resulted in poor prognosis, patient demonstrated significant response to high-dose chemotherapy and achieved long-term remission. Summary. Male 38-year-old patient developed acute symptoms: sweating, general weakness, febrile fever, weight loss (50 kg for 4 months), abdominal pain combined to hepatomegaly and multiple focal lesions in the liver according to abdominal US, with 5 unsuccessful attempts for 6 months to receive informative tissue sample. Laboratory tests revealed progressive signs of liver failure at normal level of alpha-fetoprotein and carcino-embryonic antigen; clinical signs included progressive manifestations of liver encephalopathy, skin hemorrhages, severe edema, ascites, pruritis and excoriations. Empirical therapy by prednisolon resulted in no responce and was complicated by development of steroid diabetes. The diagnosis of diffuse B-macrocellular lymphoma was established only via open liver biopsy. Four sessions of high-dose polychemotherapy according to mNHL-BFM-90 program resulted in rapid reduction of liver size, recovery of consciousness, resolution of encephalopathy signs, however the liver and the spleen remained enlarged with focal parenchimatous lesions that required laparoscopy with biopsy of the pathological foci, the latter revealed no remaining neoplastic cells. During 10 years of patient follow-up liver function remains compensated, focal lesions in the liver and the spleen are undetectable, that indicates achievement of 113-months complete tumor remission. Conclusion. Presence of multiple focal lesions in the liver and signs of progressive liver failure at normal level of tumor markers requires taking into account primary liver lymphoma in the spectrum of possible etiologies. Potentially poor life prognosis in similar clinical situations at detection of primary liver lymphoma can flip to favorable due to high efficacy of modern chemotherapeutic agents.