The aim of review. To present basic mechanisms of pain at pancreatitis and determine main management approaches in pain-predominant cases.

Summary. Direct toxic action of damaging factors (first of all — alcohol), pancreatic enzyme deviation phenomenon, parenchymal damage by overflow of free radicals, elevation of intraductal pressure, damage of nerves (neuropathic pain) and compression of adjacent organs play primary role in development of pain. Enzyme supplements at chronic pancreatitis can be indicated not only as replacement treatment, but also as addition to complex treatment of patients with severe abdominal pain. Proton pump inhibitors, spasmolytics or prokinetics are recommended as additional therapy. At absence of desirable results application of nonsteroid anti-inflammatory drugs and analgetics, in resistant pain — non-narcotic opiates or pregabalin are indicated. Efficacy of analgetics can be increased by coadministration of psychotropic agents, most often — tricyclic antidepressants. In severe cases intractable pain at a chronic pancreatitis itself can become indication to surgical intervention.

Conclusion. Treatment efficacy in each given case depends on duly establishment and adequate treatment of complications, motivation for abstain of alcohol intake and smoking; strict diet restriction for relapse period, and functional rest for the pancreas.

The aim of review. To characterize features of autolysis-induced digestion dynamics at breast feeding of infants.

Key points. At child breast milk nutrients are hydrolysed in natural conditions by milk enzymes, secretions of digestive glands and secretory intestinal epithelial cells as autolytic-induced digestion with subsequent addition and advance of autologous digestion. Characteristic features of human milk enzyme activity during one-year lactation are adjusted to hydrolytic potential of infant’s digestive system.

Aim of investigation. To estimate effect of probiotics and enterokinetic agents on severity of clinical symptoms, presence of bacterial overgrowth syndrome (BOS) and quality of life of patients with constipation variant of irritable bowel syndrome (IBS-C).

Material and methods. Comparative analysis of effect of probiotics, enterokinetic agents and placebo on dynamics of main clinical symptoms, intestinal microflora state and quality of life in IBS-C patients was carried out. Investigation of Florasan-D probiotic, composed of Bifidobacterium bifidum, Bifidobacterium longum, Bifidobacterium infantis, Lactobacillus rhamnosus, enterokinetic agent Resolor (prucalopride) and placebo was carried out in 50 patients with IBS-C, conforming Rome III criteria without organic diseases according to results of present investigation. Overall 8 men (16%) and 42 women (84%) with mean age of 35 years [33,7; 41,1 years] were investigated. Patients received probiotic Florasan-D 250 mg bid, placebo — in a similar mode; patients received Resolor 2 mg as a single-dose in the morning. Intensity of abdominal pain and meteorism were estimated by visual analog scale (VAS), stool consistency — by Bristol stool form scale, frequency of defecation — by calculation of number of defecations for every week of treatment. BOS was assessed by lactulose hydrogen breath test, quality of life — by The Short Form-36 (SF-36) questionnaire. Treatment was carried out for 28 days.

 Results. In the group of IBS-C patients efficacy of Florasan-D probiotic in relation to basic symptoms reduction, improvement of quality of life, normalization of hydrogen breath test scores was comparable to those at Resolor application.

 Conclusions. Probiotic of Florasan-D and enterokinetic Resolor at application in patients with IBS-C for 4 wks possess similar efficacy in main symptom reduction, relief of BOS, improvement of quality of life. Florasan-D is better tolerated by patients due to gradual increase of stool frequency during treatment course.

Aim of investigation. To determine ultrasound characteristics of gastro-intestinal tract (GIT) at combined trauma.

Material and methods. Data of ultrasound investigations (US) in 48 patients with combined trauma (36 men, 12 women, aged 20–50 years) with disorders of gastro-intestinal function were analyzed. Combined trauma (of chest, abdomen, pelvis, spine, extremities) was diagnosed in 41 patients, in 7 cases closed craniocerebral trauma prevailed. All patients underwent US to rule out damage of abdominal organs at hospital admission. Patients have been divided into two groups: patients of the first (n=27) had no damage of abdominal organs, no surgery was carried out, patients of the second group had combined trauma and closed injury of abdomen (n=21) and subsequently abdominal surgery was performed. Investigation of abdominal organs was carried out by medium class ultrasound devices with convex (3,5 mHz) and linear (7,5 mHz) probes. Abdominal organs were examined according to the standard protocol for signs of traumatic damage, presence of free fluid, retroperitoneum was examined as well. Resected portions of the small intestine with adjacent damaged mesentery were subject to comparative histological examination at closed abdominal injury cases.

Results. In 27 patients of the first group US revealed signs of ileus in posttraumatic period. In 22 patients US-signs of dynamic ileus were revealed on a background of retroperitoneal hematoma, in 7 cases dynamic examination revealed its enlargement, in the other 7 cases retroperitoneal hematoma was small with tendency to spontaneous resolution. In 6 cases mesenteric hematoma of the small intestine, extending to retroperitoneum was found out. In 2 patients with pelvic bones fracture hematoma of sigmoid colon mesentery was visualized. Five patients had spinal trauma. In posttraumatic period in 19 of 27 first group patients with onset of multiorgan failure dynamic US demonstrated liver, spleen and kidney enlargement. In 8 patients gastric stasis was revealed at the 9 day after trauma, in 3 cases — on the 10–14 day signs of pseudomembranous colitis were found out. In the second group at the 3rd day after surgery disorder of motor and evacuatory function of GIT was found. At US control in 11 patients with small intestine mesentery trauma signs of dynamic ileus were revealed, in 4 of them after resection of intestinal segment signs of mesenteric circulation disorder at the early postoperative period were found out. As a result of conservative therapy paresis of the gut was eliminated. In 2 patients after operation for splenic rupture and in 2 patients with urinary bladder trauma dynamic smallintestinal ileus was diagnosed with subsequent resolution according to clinical and ultrasound data after conservative treatment. In 2 of 6 patients with intestinal trauma after suture application pharmaceutical therapy resulted in resolution of intestinal paresis. In 1 of 4 patients with resection of small intestine and signs of dynamic ileus intestinal function was restored under conservative treatment. Three patients with mechanical smallintestinal obstruction on a background of abdominal adhesions were operated.

Conclusions. The dynamic ultrasound investigation in posttraumatic period after combined trauma helps to differentiate dynamic and mechanical smallintestinal obstruction and determine indications to surgical intervention in early terms. Application of this method allows to reveal intestinal posttraumatic changes on background of dynamic smallintestinal obstruction that may require revision of treatment approach. US in postoperative period at hematomas of smallintestinal mesentery without disorder of integrity of intestine, reveals disorders of gastrointestinal motility and development of paresis of intestine which aggravates circulation disorders in intestinal wall and can result in irreversible changes. Color Doppler flow mapping mode of ultrasound investigation at extensive hematomas of mesentery helps to detect thrombosis of mesenteric veins, occlusion of stem arteries that provides surgeons with essential information to choose treatment tactics, and in some cases to predict course of disease.

The aim of review. To keep doctors and population in the picture of alcohol abuse issues and to acquaint with treatment approach at alcoholic disease, to prove necessity of primary and secondary prophylaxis.

Key points. Alcoholism control efforts should be directed first of all on prevention of this disease. Primary prophylaxis is necessary for decrease or stop of alcohol consumption. It is required to educate population and to unveil myths about safe, and the more so useful dozes of alcohol. Secondary prophylaxis includes application of specific therapy with application of metabolic agents (hepatoprotectors).

Conclusion. Alcohol is the main etiological factor of liver cirrhosis in Russia. Prompt change of situation with alcohol abuse is required for reduction of morbidity and mortality. Preventive actions should be directed on change of embedded stereotypes of doctors and population in relation to alcohol intake.

Aim of investigation. An estimation of metabolic disorders related to chronic course of hepatitis C.

Material and methods. Total homocysteine (tHCy), total cysteine (tCys), total glutathione (tGSH) and free aminoacids (Asp, Asn, Glu, Gln, Tau, Ser) levels were measured by high-performance liquid chromatography in plasma of 55 hepatitis C patients and 14 healthy volunteers.

Results. Total statistical data processing at hepatitis C revealed: hyperhomocisteinemia (2,5 times increase in tHCy level), hypercysteinemia (1,5 times increase in tCys level), glutamate excitotoxicity (2,75 times increase in Glu level on a background of relative decrease of levels of tGSH and Gln), deficiency of taurine (level was decreased 1,4 times), increase of Gln, Asp, Asn, Ser levels 1,56, 1,75, 1,32, 1,4 times respectively. Data processing by nonnormal histogram plotting of substances plasma levels in hepatitis C patients revealed heterogeneity of pathochemistry of hepatitis C for tGSH, tCys and Gln. However in sets both with relatively low and high levels of these substances content of tHCy, Glu and Asp remains increased and reflects hyperhomocisteinemia and glutamate excitotoxicity phenomena. In patients with high content of tGSH and Gln in blood glutamate excitotoxicity was less expressed — levels of tHCy, Glu and Asp were increased to lesser degree, strong positive correlation between tGSH, Gln, tCys and Ser was marked.

Conclusion. Metabolic therapy can essentially decrease negative effect of metabolic disorders and increase efficacy of PEG-IFN-α in combination to ribavirin at hepatitis C treatment.

The aim of review. To present new data on a role of molecular genetic disorders of innate immunity at Crohn's disease (CD), and to demonstrate the role of adherent-invasive Escherichia coli (AIEC) as the microorganisms potentially involved in CD development.

Summary. According to modern concept, etiology of CD has complex nature and is determined by genetic predisposition, infectious agents and environmental factors. Alteration of autophagy process (defects of NOD2/ CARD15, ATG16L1, IRGM genes) is one of genetically determined disorders of innate immunity typical for CD. Besides that intestinal dysbiotic disorders associated with elevation of quantity of microorganisms, possessing pathogenic potential, in particular AIEC is characteristic for CD. This phenotype of microorganisms has capacity of adhesion to mucosal epithelial cells, invasion, and active replication inside macrophages. In patients with genetic predisposition AIEC replication in macrophages at reduced clearance of microorganisms due to alteration of autophagy process can induce the unsound immune response with development inflammatory changes characteristic for CD.

Conclusion. Intestinal dysbiosis associated with elevation of quantity of microorganisms, possessing pathogenic potential (AIEC), as well as genetically — determined defects of innate immunity (autophagy alteration) lay in a basis of up-to-date model of CD development. Undoubtedly, such model is most likely relevant only for selected part of CD patients, nevertheless for the present moment it is the basic for the further studying of CD etiopathogenesis.

The aim of review. To analyze modern approach to pathogenesis of Crohn's diseases (CD), to determine effect of individual immunogenetic factors on development and progression of disease, in particular, in relation to HLA profile.

Summary. Series of the population studies, confirming association of HLA antigens with human diseases were carried out. Main histocompatibility complex (MHC) plays the leading role in immune response as well as in development of CD, therefore occurrence of disease is related to changes at genetic level. Many studies indicate relation of Crohn's disease to specific genes of HLA-system. Hence, scientists of USA, Canada, Spain, Finland confirmed association of HLA-DRB1*0103 allele with development of CD, as well as with course of inflammatory bowel diseases and their complications. Important role in development of Crohn's disease in different countries is played by specific groups of alleles. In Israel interrelation of CD with DR15, in Germany — with HLA-DRB1*0701, in China — with HLA-Cw*12, in Japan — with HLA-DRB1*0405 and 0410 was established. Associations with clinical forms of disease was found, in particular in Italy presence of DRB1*0304, DRB1*0305, DRB1*0307, DRB1*0309 is linked to total involvement of the large intestine, in Spain presence of HLA-DRB1*07 — with terminal ileitis at CD, HLA-DRB1*0103 — with colitis. It has been demonstrated, that certain HLA-haplotypes have stronger association with Crohn's disease. For example, in Japan presence of Cw*1202-B*5201-DRB1*1502 haplotype reduces the risk of CD development. In Russia these studies are less concerned and were carried out by serological HLA typing methods. So, development of Crohn's disease was associated with B14, DR3 and DR5.

Conclusion. Presented ambiguous results are caused, first of all, by ethnic differences and different frequency of some alleles in different populations. Thus, assessment of predisposition and resistance to Crohn's disease requires detection of HLA-markers in each specific population group.

The aim of review. Assessment of optimum surgical method for organic incompetence of anal sphincter (US).

Summary. Review of literature demonstrates significance of fecal incontinence issue, as well as the history of operative treatment of anal incontinence, its advantage and shortcomings. The variety of surgical methods used in global practice reflects absence of clear concept of preferable and most effective surgical intervention.

Results. Both fundamental and modern data of Russian and foreign studies on application of various surgical techniques for anal incontinence were used at review. The analysis of efficacy of proposed surgical interventions as well as comparative analysis of both early and late postoperative complications was carried out.

Conclusion. Treatment of anal incontinence is significant challenge with no established optimal tactics, that requires further development and introduction of new effective methods of surgical treatment.

Aim of investigation. To demonstrate unusual clinical symptoms and difficulties of diagnostics of disseminated tuberculous process.

Material and methods. The 25 year-old patient, who was managed for 10 years for liver cirrhosis of nonspecified etiology, was investigated. The careful analysis of clinical presentation of disease, data of physical examination, results of radiological and other methods of diagnostics was carried out.

Results. It was possible to suspect and subsequently to confirm disseminated tuberculosis with involvement of the lungs, the heart, pericardium, pleura, mesenteric lymph nodes, the liver; chronic right-sided tubercular pleurisy with pleurocirrhosis; constrictive pericarditis with signs of right ventricular failure; cardiac liver fibrosis (Pick's pseudocirrhosis); mixed portal hypertension.

Conclusion. The detailed analysis of clinical presentation of disease, physical data and application of complex of visual and other methods of investigation expand potential of diagnostics of disseminated tuberculous process.

The aim of publication. Analysis of clinical cases demonstrating differentiated management approach at chronic H. pylori-associated gastritis with stomach epithelium dysplasia.

Key points. Detection of high grade (severe) dysplasia is associated to high risk of early, invasive stomach cancer or its rapid development. In presented clinical case adenocarcinoma has been found in 60 year-old male patient with deep submucosa invasion simultaneously with high grade dysplasia. According to comprehensive endoscopic investigation endoscopic treatment option was considered impossible and patient underwent distal subtotal stomach resection with Roux-en-Y anastomosis and D2 regional lymph node dissection. At low grade (mild) dysplasia complex endoscopic investigation is recommended to identify local premalignant lesions of the stomach mucosa, and at ruling them out — to determine adequate therapy. So, in presented clinical case H. pylori eradication therapy in 45-year old patient has led to disappearance of changes suspicious to epithelial dysplasia. The term «indefinite for dysplasia» is applied to atypical changes which can be characterized as of premalignant or reactive nature. It is provisional conclusion which requires specifying endoscopy with guided biopsy and repeated histological conclusion.

Conclusion. Prognosis and management approach in the cases with histological conclusion of stomach epithelium dysplasia should be determined according to comprehensive multimodal endoscopic investigation with guided biopsy.