The aim of review. To present up-to-date data on the causes of proton pump inhibitor-refractory gastroesophageal reflux disease (GERD) development.

Summary. The prevalence of GERD reaches 20–30% of population, and approximately 40–50% of patients do not respond to standard treatment by proton pump inhibitors (PPI). There is a disorder of the immune response as a disbalance between cellular and humoral components of immunity at GERD, that can be determined as phenotype of macrophages (М1 or М2), and other immune and non-immune cells.

Conclusion. For the present moment it becomes clear, that low compliance of patients to PPI treatment, cytochrome Р450 isoenzyme CYP2C19 polymorphism and other known reasons are unable to explain growing number of refractory GERD cases. Therefore, studying of disease at cellular and tissue levels in relation to type of refluxate can disclose new mechanisms of refractory GERD and to increase treatment efficacy.

Aim of investigation. Acute obstructive jaundice developed on background of malignant pancreatobiliary neoplasms is one of the most complex and dramatic problems of modern abdominal surgery. At surgical interventions at the climax of obstructive jaundice and/ or cholangitis, postoperative period of these patients is characterized by high severity and is accompanied by high postoperative mortality. Due to this in the last decades the increasing number of researchers prefer endoscopic retrograde approach of biliary drainage for treatment of obstructive jaundice.

Material and methods. From January, 2007 to July, 2013 overall 3269 endoscopic retrograde interventions on major duodenal papilla (MDP) have been executed in the Scientific-educational center of abdominal surgery and endoscopy, Moscow city clinical hospital #31. Endoscopic stenting of biliary tract have been carried out in 523 cases, of them 418 (79,9%) procedures were carried out in 287 patients with jaundice of neoplastic origin (148 women, 139 men). Patients were in the age of 32 to 94 years (mean 68,2±9,3 year). With the help of the comprehensive diagnostic program providing ultrasound investigation, computer tomography, endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography, it was possible to determine in 207 (72,1%) cases the distal block of biliary tract due to tumors of MDP, terminal CBD portion, distal part of common bile duct and pancreatic head, and the proximal block in 80 (27,9%) cases at lesions of gallbladder, hepatico-choledochal duct, lobar hepatic ducts or compression of proximal biliary tree by lymph nodes of hepatoduodenal ligament.

Results. Bilioduodenal stents at 272 (94,8%) patients were installed after preliminarily endoscopic papillosphincterotomy (EPST). Adequate drainage of biliary tracts after biliary stenting was achieved in all patients. At the same time in 48 cases stenting of biliary tract failed. The reasons of failure were mainly due to duodenal stenosis caused by malignant involvement and extended and convoluted neoplastic deformation of the bile duct. Complications after endoscopic interventions, including acute pancreatitis, cholangitis, bleeding from EPST zone, perforation of wall of duodenum and stent migration, occurred in 22 cases (5,3%). Postoperative mortality was 3,5%. Thus almost in all cases death occurred after achievement of endoscopic biliary decompression. After bilioduodenal stenting in all patients jaundice was resolved or has essentially decreased. In 230 (80,1%) of them endoscopic aid was final treatment method of late-stage neoplastic process in inoperable patients. At relapse of jaundice endoscopic sanitation or stent replacement was performed. In other patients (19,9%) after resolution of jaundice surgical decompression interventions have been carried out.

Conclusion. According to authors data, at malignant pancreatobiliary tumors in 85,7% of cases endoscopic retrograde drainage of the biliary tracts is possible and effective in treatment of obstructive jaundice. This method allows to prepare patients with obstructive jaundice for surgical interventions, including radical treatment, or may be a final method of treatment in inoperable patients. Morbidity rate after endoscopic retrograde interventions on MDP for acute obstructive jaundice of neoplastic origin is almost same as at those after standard retrograde interventions and according to our results equals to 5,3%.

Aim of investigation. To establish interrelation of intercellular interaction mediators with histological changes at chronic viral liver disease.

Material and methods. Blood contents of immunoglobulins superfamily and selectin molecules was investigated in 101 patients with chronic viral liver diseases. Scores of ICAM-1, VCAM-1, Е-selectin, L-selectin and the Р-selectin were determined by enzyme-linked immunoassay method and were compared to values of Knodell histological activity index and Desmet fibrosis score as well as to E.M. Brunt hepatic steatosis levels.

Results. At chronic viral hepatitis ICAM-1 and selectins blood contents increase whereas in patients with liver cirrhosis elevation of all adhesin levels was marked. Concentration of ICAM-1, VCAM-1, Е-, L-and Р-selectin at chronic viral liver diseases was increased along with increase of severity of inflammation and severity of hepatic fibrosis and had positive correlation with histological activity indexes (HAI) and liver fibrosis. Positive correlation of ICAM-1, VCAM-1 and Е-selectin with degree of liver steatosis was found. Level of immunoglobulin superfamily and selectin molecules were characterized by sufficient accuracy in detection of HAI over 8 points and detection of moderate/severe degree of fibrosis.

Conclusions. Association of morphological signs with mediators of intercellular interactions indicates their important role in development and progression of chronic viral liver disease.

The aim of review and clinical case. To bring modern standards of antiviral therapy (AVT) of chronic hepatitis B (CHB) and possible mistakes at assessment of medical tactics to focus of general practitioners.

Summary. Chronic hepatitis B still remains one of the most actual problems in hepatology. The main aim of treatment is improvement of patients quality of life and prognosis of disease that can be achieved at permanent suppression of virus replication. The modern modes of AVT have several variants: treatment for the limited term by interferon-alpha or nucleotides/ nucleosides analogues and long-term treatment by nucleotides/nucleosides analogues. The major factor decreasing nucleotides/nucleosides AVT efficacy is virus resistance development. At application of pegilated interferon (PEG-IFN) resistance does not develop, however frequency of adverse events is high. The low level of virologic response at of PEG-IFN treatment should be mentioned as well. Nowadays detailed international and Russian guidelines on with chronic hepatitis B patient management are developed. Despite of them general practitioners quite often experience difficulties at choice of medical approach. This article reviews in brief up-to-date modes of CHB treatment, clinical case demonstrating the basic AVT stages is presented: decision-making on its onset, monitoring of the patient during treatment, rules of choice and substitution of antiviral agents, criteria of treatment response assessment and indications for its termination.

Conclusion. The adequate choice of drug at definition of antiviral treatment approach allows to suppress virus replication effectively, reduces risk of resistance development and rate of side effects while violation of international standards can result in fatal outcome. The presented clinical case evidently shows possible mistakes at chronic hepatitis B patient management and their consequences.

Aim of investigation. To study prevalence of diffuse liver diseases in the Russian Federation by the example of large industrial city with application of screening tests. Material and methods. Overall 5000 Moscow inhabitants age 18 to 75 years, chosen randomly within the «the liver check up» project, have been included in prospective population study. All patients underwent following investigation: physical examination, filling of nutrition diary, CAGE and AUDIT questionnaires, taking occupational history, anthopometrical examination, US of abdominal organs, clinical and biochemical blood tests, assessment of HCVAb and HBsAg. In the case of abnormal liver tests preliminary diagnosis was determined according to certain algorithm and these patients were recruited for further investigation and specifications of diagnosis in department of hepatology, University clinical hospital N 2, State educational government-financed institution of higher professional education «Sechenov First Moscow state medical university». Results. Abnormal liver functional tests were revealed in 30,6% of industrial city inhabitants — in 1461 of 4768 cases (232 patients were excluded from the study due to partial data loss), significantly more frequently in men in comparison to women, i.e. 49,7 and 25,5% respectively (p<0,001). Prevalence of diffuse liver diseases in the studied sample (n=4768) was following: non-alcoholic fatty liver disease —7,4% (n=352), alcohol-induced liver disease — 6,9% (n=329), hepatitis C — 6,7% (n=322), hepatitis B — 1,9% (n=91), drug-induced liver disease — 0,82% (n=39), cholestatic liver diseases — 0,69 % (n=33), autoimmune hepatitis — 0,78% (n=37), others — 5,4% (n=258). Conclusion. Risk factors for diseases, defined by one-way ANOVA test, were: male gender (p<0,001), excessive body weight and obesity (body mass index >25 kg/m2 (p<0,001)), hyperglycemia (p<0,001), hypertriglyceridemia (p<0,001). By more strict estimation at multifactorial analysis major risk factors were determined: age 30 to 59 years (p<0,001), intake of alcoholic beverages in harmful dozes (over 16 points of AUDIT questionnaire, p=0,04), hypercholesterolemia (p=0,016). Relative weight of those, requiring etiological and pathogenic treatment after specification of preliminary diagnosis, of patients with abnormal liver tests, revealed at screening stage, was 80,3%.

The aim of review. To discuss modern concepts on interaction of bacterial cells with human body, and disorders of micro-and macroorganism interaction at inflammatory bowel diseases (IBD).

Summary. Quantitative and qualitative changes of intestinal microflora are revealed in patients with IBD, with tendency to increase of opportunistic and pathogenic microorganisms contents. The capability of bacteria contact with immune cells is provided by capacity of bacterial cells to adhesion and invasion, competence of mucus layer covering mucosa of gastro-intestinal tract, detaining and fixing microbic cells, competence of intercellular epithelial contacts function, density of signal receptors, level of antimicrobic peptides expression, completeness of autophagy process. Disorder of barrier function of intestine at IBD patients, in combination to prevalence of opportunistic and pathogenic microorganisms in intestinal biome, results in essential overload of innate and adaptive immune system.

Conclusion. At IBD, all mechanisms providing interaction of bacterial cells with the host body are malfunc tioning to some extent, that, in combination to genetic predisposition to this disease, results in development of clinical symptoms and morphological changes.

The aim of review. To analyse modern concepts on antibiotic-associated diarrhea, to determine its place in the pattern of total morbidity.

Key points. Wide antibiotic application in all sections of medicine along with beneficial action has series of essential side effects, including antibiotic-associated diarrhea. Its extreme and most severe manifestation is pseudomembranous colitis, caused by toxin-producing Clostridium difficile strains. This etiological agent in modern world has got significant association with hospitals and assisted-care facilities, therefore it can spread in out-patient conditions as well at the present time. Mutations resulting in antibiotic resistance, increasing toxin production or promoting sporulation, considerably increase virulence and prevalence of these opportunistic microorganisms.

Conclusion. The further studies on development of effective prophylactic and treatment methods of antibiotic-associated diarrhea are required, especially for most severe complication — pseudomembranous colitis. It is necessary to limit application of antibiotics, develop strict indications to their application.

The aim of review. To analyze accumulated world data on human fecal microbiota transplantation (FMT) at treatment of digestive diseases.

Summary. Review highlights basic problems of fecal microbiota transplantation — i.e. new and, probably, promising trend in treatment of many diseases, where traditional methods do not provide due results. Main results of FMT received by the present time at certain digestive diseases are discussed. At the same time clinical application of FMT is related to the ethical φ-factor and lack of microbiologic studies.

Conclusion. Progress in understanding of clinical value of faecal microbiota will transform concept of pathogenesis and treatment of set of diseases.

The aim of review. To present literature data on application of prokinetics at gastroesophageal reflux disease and functional dyspepsia.

Summary. Gastroesophageal reflux disease and functional dyspepsia are considered to be the most common gastroenterological diseases. Motility disorder of gastroesophageal zone plays a leading part in pathogenesis of these diseases that assumes application prokinetics as a baseline therapy. Itopride hydrochloride has advantage over other prokinetics by three key parameters: double mechanism of action, absence of drug interactions and serious side effects.

The aim of publication. To present potential of ultrasound investigation (US) in diagnostics of pancreatic tumors (PT).

Summary. Morphological verification of PT and estimation of stage of their progression are the basic factors of treatment planning. Traditionally «the gold standard» in detection of tumor and estimation of vascular invasion is computer tomography. In world practice US at PT is used only at the stage of primary diagnostics, as a rule, application at specifying diagnostics stage is limited because the method is operator-dependent and storage of study data is complex. However US can be carried out in various planes and positions of the patient’s body, that in some cases helps to receive additional information. Though morphological verification is the leading factor in assessment of prognosis and treatment approach at oncologic diseases, its necessity and ways of tissue sampling at PT is discussed up to now.

Conclusion. Potential of US in morphological verification and assessment of vascular invasion of PT is demonstrated by the clinical case example, that has allowed to carry out radical surgical treatment to the patient.

A.P. Schyokotova — Clinical and laboratory parameters and endothelial dysfunction at liver diseases, their diagnostic, prognostic value and potential of application for treatment response rate rating

A.A. Kurbatova — Pathogenic and clinical value of cytokine and claudin system at irritable bowel syndrome

Ye.N. Baranova — Liver cirrhosis: prognostic value of clinical and autonomous nervous system parameters

V.L. Mel'nikov — State of the gut in HBsAg carriers and its correction by nonpharmacological methods (clinical, functional, morphological study)