The aim of review. To highlight modern aspects of clinical presentation, diagnostics and treatment of gastroduodenal variant of Crohn's disease (GDCD).

Key points. Gastroduodenal involvement at CD is a rare clinical variant of disease and develops in less than 5,5% of cases. By the present time association of GDCD with L1007P mutation of NOD2/CARD15 gene is detected. Epigastric pain, loss of body weight, nausea and — in some cases — vomiting are the most frequent symptoms of this pathology. Endoscopy of the stomach and duodenum with histological examination are the «gold» standard of GDCD diagnostics and quite often have crucial importance in the proof of diagnosis. In difficult cases test for antiSaccharomyces cerevisiae antibodies (ASCA) can be used as additional tool of differential diagnostics. Prescription of proton pump inhibitors in combination to system corticosteroids and azathioprine/6-mercaptopurine if required can be considered as the most successful therapy. Infliximab should be considered as alternati ve drug to other forms of treatment at nonresponding cases.

Conclusion. No matter that GDCD is not the common form of disease, knowledge of the clinical variant is important for its duly recognition.

The aim of review. To demonstrate that esophageal and stomach motility disorders play one of basic roles in pathogenesis of gastroesophageal reflux disease (GERD).

Key points. Gastroesophageal reflux disease is related to the group of acid-related diseases, however esophageal and stomach motility disorders play important role in its development. In patients with GERD disorders of primary and secondary peristalsis of the esophagus, increase of frequency of transient lower esophageal sphincter relaxations and pathologic bile refluxes are common.

Conclusion. Numerous studies are devoted to investigation of gastroesophageal reflux disease. The role of motility disorders of the esophagus and the stomach in its pathogenesis, and origin of symptoms of reflux disease and other gastro-intestinal functional diseases, in particular the functional dyspepsia is actively discussed. At upper gastro-intestinal motility disorders application of prokinetics is effective, e.g. itopride hydrochloride, that reduces frequency of transient lower esophageal sphincter relaxations due to decrease of intragastric pressure, activates propulsive stomach motility and eliminates duodenogastric and duodenogastroesophageal refluxes.

Aim of investigation. To analyze efficacy of heartburn relief and pathological gastroesophageal reflux (GER) elimination as well as dynamics of endoscopic changes at gastroesophageal reflux disease (GERD) under dioctaedric smectite (Smecta) treatment in standard doze as monotherapy and within complex mode of treatment.

Material and methods. Overall 45 case records of GERD patients (25 women and 20 men, mean age 43,06 years) were analyzed. All patients underwent esophagogastroduodenoscopy (EGDS) and 24-hour рН-impedance recording prior to the treatment onset and at the 14-th day of therapy. The first group included patients with erosive esophagitis (EE) of the I–II degree receiving combination of proton pump inhibitors (PPI) and Smecta, the second group included patients with EE, receiving PPI monotherapy, the third group — patients with non-erosive reflux disease (NERD) at Smecta monotherapy.

Results. On a background of treatment by PPI + Smecta relief of heartburn was achieved at the 3rd day in 10 (66,7%) patients, at PPI monotherapy — in 4 (26,7%) patients with EE, at monotherapy by Smecta — in 6 (40%) patients. At the 5th day heartburn has been completely relieved in 11 (73,3%), 9 (60%) and 8 (53,3%), and at the 14-th day — in 13 (86,7%), 11 (73,3%) and 12 (80%) patients respectively. In the first group according to upper endoscopy data healing of erosions was confirmed in 13 (86,7%) patients, in the second — in 10 (66,7%). In the third group cessation of catarrhal signs was revealed in 13 (86,7%) patients. According to 24-hour рН-impedance esophageal recording prior at the beginning of therapy pathological acidic, weakly acidic and weakly alkalinic GERs were diagnosed in 34 (75,5%), 18 (40%) and 12 (26,7%) patients in group as a whole respectively. On a background of therapy by PPI + Smecta acidic refluxes have been eliminated in 14 (93%), at PPI monotherapy — in 11 (73%), at Smecta monotherapy — in 100% of patients. In the first group weakly acidic refluxes disappeared in 2 (67%), in the second — in 1 (50%), in the third – in 9 (69%) cases, weakly alkaline refluxes: in 4 (80%), in 2 (40%) and in 100% of cases respectively.

Conclusions. Addition of Smecta in treatment mode at erosive form of GERD essentially increases treatment response rate, significantly reducing terms of clinical improvement onset. Dioctaedric smectite appears an effective drug as monotherapy of NERD. The chief advantage in treatment of GERD is ability of the drug to stop all reflux types: acidic, weakly acidic, and weakly alkalinic.

Aim of investigation. To study potential of рН-impedance measurement in differential diagnostics of esophageal disorders at irritable bowel syndrome (IBS).

Material and methods. Overall 201 patients with IBS, diagnosed according to Rome-III criteria were investigated. Of them 52 were men, 149 — women, mean age was 41,8±9,5 years. In 70 (35%) of them (21men, 49 women, mean age — 42,3±12,0 years) heartburn, belching, epigastric dyscomfort, non-coronary retrosternal pain were present along with IBS. Methods of investigation included clinical examination, esophagogastroduodenoscopy (EGDS) colonoscopy, X-ray investigation of the upper gut, 13С-urease breath test for Helicobacter pylori, 24-hour combined intraluminal рН-impedance recording with estimation of qualitative and quantitative indicators of refluxes and index of symptom-association probability (SAP). Psychometric components were estimated as well: anxiety and depression scores, scores of alexithymia, associated symptoms, quality of life, degree of hyperventilation, index of visceral sensitivity, degree of pain by visual analog scale. The estimation of the mentioned parameters was carried out separately at IBS with esophageal symptoms (n=70) in comparison to other group of investigated patients with IBS (n=131). Statistical analysis of obtained results was carried out by Statistica 6 software.

Results. In 16 (23%) patients instrumental investigation revealed esophagitis of the II–IV degree by Savary–Miller classification. Clinically 6 of them had heartburn, 1 — belching and 9 — combination of heartburn and belching; according to 13С-urease breath test 5 patients had H. pylori infection. In 49 (70%) patients at EGDS and X-ray investigation non-erosive reflux disease (NERD) was revealed. Clinical presentation in this group included heartburn in 10 cases, belching in 16 combination of heartburn and belching — in 12 and postprandial epigastric dyscomfort — 11; 13С-urease breath test was positive in 15 patients. It is noteworthy that in none of patients non-coronary retrosternal pain was associated to esophageal disorders. According to рН-impedance measurement NERD was diagnosed in 20 (33,3%) patients. Functional heartburn was diagnosed in the other 29 (41%) patients.

Conclusion. Nowadays 24-hour combined рН-impedance recording is considered as the most exact method, allowing to reveal gastroesophagal refluxes. In some cases it allows to carry out differential diagnostics between NERD and functional disorders of the esophagus and the stomach in patients with IBS. Application of рН-impedance measurement allows to recommend its introduction in broad clinical practice.

Aim of investigation. To characterize the systemic immune response at patients various forms of gastroesophageal reflux disease (GERD).

Material and methods. Overall 45 patients with GERD and 10 healthy volunteers were included in prospective study. All patients underwent following investigation: taking complaints and past history, detection of GERD risk factors; esophagogastroduodenoscopy and 24-hour рН-impedance recording. Levels of 7 cytokines were determined by flow cytofluorometry: two antiinflammatory: IL-4 and IL-10, three proinflammatory: IL-8, IFN-γ and TNF-α and two cytokines which can demonstrate both anti-inflammatory and proinflammatory activity in relation to conditions (bivalent) — IL-2 and IL-6.

Results. Patients with erosive and/or ulcerative esophagitis in comparison to patients with non-erosive reflux disease (NERD), Barret's esophagus and healthy patients had increased expression of proinflammatory cytokines. In patients with Barret's esophagus in comparison to others GERD patients and healthy volunteers hyperproduction of anti-inflammatory cytokines was revealed. TNF-α and IL-8 levels correlated to total number of acidic refluxes and exposition of acidic bolus, while IL-4 and IL-10 level — with total number of weakly alkaline refluxes and exposition of weakly alkaline bolus. High level of IL-8 was associated with increased frequency of relapses of erosive esophagitis within 2 years, despite of carried out therapy.

Conclusions. Relation of cytokine levels to the form of GERD was revealed. At erosive and/or ulcerative esophagitis in comparison to NERD and Barret's esophagus production of proinflammatory cytokines IL-8, the IFN-γ and TNF-α prevails, that indicates development of Th1-mediated immune response. At Barret's esophagus expression of anti-inflammatory cytokines IL-4 and IL-10 is increased, that indicates on development of Th2-immune response.

Aim of investigation. To estimate advantages of combined intake of proton pump inhibitor (PPI) and alginate in comparison to monotherapy by PPI in terms of symptom relief in the first days of gastroesophageal reflux disease (GERD) treatment.

Material and methods. Overall 96 patients with GERD were investigated. All patients complained of heartburn, 41 patients had regurgitation. Symptoms were estimated by Likert scale prior to onset of therapy and daily during treatment course. General well-being was evaluated by visual-analog scale (VAS) prior to therapy, at the 7th and 14th days of treatment. The first group (46 patients, 19 males, mean age — 50,2±12,7 years) received combined therapy by pantoprazole 40 mg/day and alginate (Gaviscon DD) 20 ml qid at the 1st and 2nd days of treatment followed by «on demand» mode. The second group (50 patients, 22 males, mean age 51,3±14,4 year) received pantoprazole 40 mg per day. All patients underwent esophagogastroduodenoscopy.

Results. At the 1st day of treatment heartburn has been completely relived in 61% of patients of the first group and in 14% — of the second (р<0,001), at the 2nd day — in 63% and 20% (р<0,001). At the 3rd day (alginate in «on demand» mode) the heartburn was absent in 48% of patients of the first group and in 44% — of the second (р=0,8). Regurgitation at the 1st day of treatment was relieved in 78% of patients of the first group and remained in all patients of the second group, who initially complained of it (р<0,001), at the 2nd day it stopped in 83% and 22% of patients respectively (р<0,001), at the 3rd day — in 67% and 22% (р=0,01). After the 4th day there were no intergroup differences. At the 7th day of treatment according to VAS wellbeing score in the first group increased from 57,3±9,7 to 78,1±11,2 mm (р <0,001), in the second — from 54,9±14,9 to 67,0±15,2 mm (р<0,001). The intergroup differences of the score at the 7th day was statistically significant (р<0,001). By the 14th day difference disappeared (78,8±9,7 mm vs 75,6±12,5 mm, р=0,1).

Conclusions. This study has demonstrated advantages of the combined therapy in the first days of GERD treatment in decreased terms relief of symptoms and improvement of state of health.

The aim of review. To carry out comparative analysis of modern studies, to characterize actual modes of treatment and to define prognosis and features of treatment response at various autoimmune liver diseases.

Key points. Diagnostics and treatment are the most complex and insufficiently investigated aspects of autoimmune liver diseases. Due to large studies, clinicians gain some understanding of approaches to therapy of these patients. Article presents up-to-date management algorithms and new promising agents, demonstrates complexities and alternative variants of treatment of autoimmune liver diseases.

Conclusion. Appropriate and long-term (for 12–24 months) therapy of autoimmune diseases in most cases allows to achieve sustained response and in several folds surpasses efficacy of short courses (6–12 months).

Aim of investigation. To evaluate efficacy and safety of S-adenosyl-L-methionine for treatment of alcohol-induced hepatitis of high severity.

Material and methods. Overall 40 patients with severe alcoholic hepatitis from two medical centers were selected for the study. Patients were randomly divided in two groups. The first group included 20 patients (16 men, 4 women, mean age 46,85±11,89 years). Median daily alcohol consumption — 71 years, 25-th and 75-th percentiles — 45,5 and 92,0 years respectively, duration of intake — 16,85±13,32 year. The mean score of Maddrey index (MI) was 58,5±26,8. The second group included 20 patients as well (11 men and 9 women, mean age — 46,10±10,47 years). The median of alcohol consumption per day was 73,8 years, 25-th and 75-th percentiles — 64,25 and 80,0 years respectively, duration of use — 16,25±5,18 year. The mean MI was 79,6±18,7. Groups were comparable by basic clinical and laboratory features. Patients of the first group received prednisolone 40 mg/day orally, patients of the second group received combination of prednisolone 40 mg/day orally and S-adenosyl-L-methionine (Adomet) 800 mg/day as intravenous infusions for 7 days, followed by 400 mg tid orally up to the 28 day of treatment. Lille index was utilized as treatment response criterion. During statistical data analysis Wilcoxon, Manna– Whitney and chi-square criteria were used. The survival analysis was done using Kaplan–Meyer curve with Breslow and LogRank significance estimation.

Results. Treatment response was higher in the group of patients receiving prednisolone in combination to Adomet (95 and 65% respectively, р=0,018). In this group the trend to increase survival was marked in comparison to the group receiving prednisolone monotherapy (100 and 90%). The rate of adverse events did not differ (р=0,50) significantly between two groups. Hepatorenal syndrome was significantly more frequent in patients receiving prednisolone (20 and 0%, р=0,03).

Conclusions. Prescription of prednisolone and Adomet combination at severe alcohol-induced hepatitis increases the treatment response rate to corticosteroids, promotes decrease of short-term mortality and results in significantly less frequent development of hepatorenal syndrome as compared to standard therapy.

Aim of investigation. To investigate options of improvement of anal sphincter function of defunctioning loop by BFT and tibial nerve stimulation.

Material and methods. Overall 23 patients with preventive stoma were included in original investigation. Diagnostic profilometry and sphincterometry were carried out. Treatment included BFT and tibial nerve stimulation for 10 days. Results. After treatment profilometry revealed statistically significant increase of mean resting pressure, while sphincterometry — at conation as well.

Conclusions. Muscular structures of the defunctioning anal sphincter respond to BFT and tibial nerve stimulation, increasing both tension and force of voluntary contractions.

The aim of review. To discuss effect of certain types of food at irritable bowel syndrome (IBS) and options of reduction of symptom intensity by individual adjustment of ration.

Key points. Undoubtedly, dietary habits in the most cases influence severity of IBS symptoms: pain, flatulence, stool disorders. Most likely, negative action of food substances is realized partly due to fermentation with excessive production of short-chain fatty acids and intestinal gas, partly — because of effect on the microbiota spectrum and enteroendocrine cells, partly - due to elevation of biogenic amine content. Filling of food diary helps to find out relevant food substances. Effect of fermentable oligo-, di- and monosaccharides and sugar spirits (FODMAPs) is most obviously demonstrated, therefore it is necessary to choose products with decreased contents of these components. In some cases negative action is related to products with high gluten content, though whether it is caused by effect of gluten or action of fructans, remains equivocal. Efficacy of functional food products containing bacteria of probiotic strain Bifidobacterium animalis sp. lactis DN-173 010 for treatment of IBS symptoms is demonstrated in clinical trials. At detection of symptoms link to intake of specific products it is necessary to exclude food allergy and enzymopathies (e.g. lactase deficiency), which should be defined as independent diseases under the «mask» of irritable bowel syndrome.

Conclusion. Individually adjusted nutrition is an integral part of treatment of IBS. Progress achieved in studying of food factors contribution to symptom development, forms scientific basis for recommendation to eliminate certain nutrients from the ration and simultaneously promotes better understanding of disease pathogenesis.

The aim of review. To discuss mechanisms of action and results of clinical application of plant-derived drug STW 5 (Iberogast®) for treatment of functional dyspepsia (FD).

Key points. Iberogast® is the combined agent containing extracts of 9 medicinal plants. Mechanism of action includes effect on motility of the stomach and intestine, visceral sensitivity along with anti-inflammatory and cytoprotective effects. Controlled clinical trials have confirmed high efficacy of Iberogast® at treatment of FD (including pediatric practice) as well as good tolerability of the drug.

Conclusion. Results of Iberogast® application allow to consider its as effective agent in multi-target therapy of FD.