The aim of review. To carry out comparative analysis of metabolic pathways of proton pump inhibitors (PPI), to determine the agent with lowest effect on activity of cytochrome CYP2C19 isoenzyme for improvement of safety of combined treatment by pharmaceuticals metabolized by this isoenzyme.

Key points. Pantoprazole is metabolized by CYP2C19 and CYP3A4, however, it has the lowest affinity to these enzymes of all PPIs. The primary metabolite of pantoprazole (the CYP system product 4-hydroxypantoprazole) enters next cytosolic phase of biotransformation i.e. conjugation to sulfate. Second phase of pantoprazole biotransformation does not depend on cytochrome system. It explains lower degree of interaction to CYP2C19 and CYP3A4-metabolized drugs for pantoprazole, in comparison to other PPIs. This is proved by relative safety of clopidogrel to pantoprazole combination in patients with cardio-vascular diseases, demonstrated in clinical studies of the last years.

Conclusion. Data of investigations, available for the present time, in vitro and in vivo allow to consider pantoprazole (Nolpaza) as the most safe drug for application in complex therapy to reduce the drug interaction-associated adverse effects.

The aim of review. To review publications on gastroesophageal reflux disease (GERD) with the accent on data of XVII Russian gastroenterological week, October 10–12, 2011.

Original positions. GERD is one of the most actual problems of modern gastroenterology due to its high prevalence, frequent relapses, and significant deterioration of patients’ quality of life. Difficulties of recognition are quite often related to extraesophageal masks of disease. Delayed diagnostics of GERD and poor efficacy of proposed modes of treatment result in disease progression and development of such complications, as esophageal ulcerative bleeding, strictures of the esophagus, Barret's esophagus, development of adenocarcinoma.

Conclusion. At the present stage there are many unresolved questions of etiopathogenesis, pathomorphology, diagnostics and treatment of GERD that requires further studies, improvement of diagnostics methods, development of new drugs and modes of treatment.

Aim of investigation. To study prevalence of digestive diseases in patients with excessive body weight and obesity.

Material and methods. Retrospective study of diseases of digestive organs prevalence included 1504 patients, who have visited polyclinic department in 2010 : 659 with excessive body weight – body mass index (BMI) 25,0 to 29,9 kg/m2), 610 with obesity (BMI ≥30 кг/м2) and 235 with normal weight (BMI 18,5 to 24,9 kg/m2), the latter made control group. All patients were investigated in polyclinic department and Vasilenko Clinic of internal diseases propedeutics, gastroenterology and hepatology, University clinical hospital #2, State educational government-financed institution of higher professional education Sechenov First Moscow state medical university of the Russian federation Ministry of Health and Social Development.

Results. Every third patient who has visited polyclinic department, had excessive body weight (34,4%), every fourth (25,3 %) was obese. Of diseases of digestive organs the most frequent were: non-alcoholic fatty liver disease (NAFLD) – 83,4 % (r=0,35, p<0,001), non-alcoholic steatohepatitis (NASH) – 13,1% (r=0,14, p<0,001), gallstone disease (GSD) – 41,8 % (r=0,05, p <0,05); steatosis of the pancreas – 86,4% (r=0,20, р<0,001). The rate of patients with insulin resistance (IR) at obesity was 61,3%.

Conclusion. The prevalence of liver steatosis in obesity was 2,7 times, and in NASH – 8 times higher, than in patients with normal BMI. Frequency of GSD, steatosis of the pancreas at obesity was 2-fold higher over the scores of normal BMI group. IR was found in 60% of patients with obesity, that in 4 times higher, than in control group (15,2%). The obesity is modifiable risk factor and application of the respective measures of prophylaxis will promote decreased progression of digestive diseases.

Aim of investigation. To develop diagnostic and prognostic criteria of gastroesophageal reflux disease (GERD) at patients of various age groups on the basis of analysis of clinical and endoscopical, functional and morphological data.

Material and methods. Overall 170 patients with GERD were included in original investigation, of them were of 90 young age (18–23 years) and 80 medium age groups (45–59 years). Patients with chronic H. pyloriassociated gastritis were included to control groups (30 young age, 20 medium age group) and 15 generally healthy patients of young age.

Results. Chronic gastritis and duodenitis were revealed in majority of GERD patients: in patients of young age superficial gastritis prevails; in medium age group gastroesophageal reflux was associated with gastritis accompanying with signs of atrophy. In development of the catarrhal form of GERD in patients of young age it is possible to consider following basic pathogenic factors: chronic H. pylori-associated gastritis; lower esophageal sphincter incompetence closely related to nutritional deficiency; long-term exposure to acidic gastric contents at gastroesophageal reflux due to disorders of motor function of the esophagus on a background of hyperplasia of NO-synthase and endothelin-1-producing stomach cells. The catarrhal form of GERD at middle-aged patients develops on a background of gastritis with signs of atrophy, associated to H. pylori infection, contaminations of distal esophagus by H. pylori and foci of gastric metaplasia, dysfunction of motility of upper regions of the gut on a background of hyperplasia of NO-synthase and endothelin-1-producing cells of the esophagus and the stomach. At the erosive form of GERD same ethipathogenic factors take place, as at the catarrhal form. However, disorder of neurohumoral regulation and pathological acid production, exhausting compensatory potential of the body, play the leading role. It results in more severe damage of esophageal mucosa with development of erosive esophagitis and extraesophageal manifestations. Assessment of patients with erosive form of GERD at endoscopic control during treatment revealed, that epithelialisation of esophageal erosions in medium age group took significantly longer time, than at young patients. GERD develops on a background of significant atrophic and inflammatory changes of gastric mucosa. Changes of antral region initiate and maintain desynchronization in functioning of the lower esophageal sphincter, being the leading cause of GERD.

Conclusions. Published studies indicate that GERD is the disease with primary defect of motor control of gastro-intestinal tract. Its development at patients of all age groups is observed on a background of gastritis with, probably, genetically determined hyperplasia of gastric epithelial cells producing NO-synthase and endothelin-1. Hyperproduction of nitric oxide and endothelin-1 in the stomach antrum causes preconditions for development of motor disorders and reflux that, in turn, lead to inflammatory and dystrophic changes in the esophagus. Thus in age aspect these disorders aggravate and total disturbance of neurohumoral regulation of the upper parts of the gut that determines extraesophageal manifestations of GERD is observed. This provides negative effect on terms of esophageal erosions healing.

The aim of review. To generalize new data on diagnostics, pathogenesis and treatment of autoimmune hepatitis (AIH).

Original positions. AIH is a chronic inflammatory liver disease which is characterized by destruction of terminal plate by mononuclear infiltrate (interface hepatitis) according to histological investigation, hypergammaglobulinemia and production of autoantibodies. Genetic risk factors of AIH development is the presence of DRB1*0301 and DRB1*0401 alleles. Decrease of number and functional activity of CD4+CD25 + (regulatory) Т-cells leads to disorder of immunological homeostasis. Improvement of AIH treatment results is possible at continuation of corticosteroid treatment before normalization of liver tests and histological pattern, at early detection of «difficult» patients and carrying out of long-term maintenance therapy after the first relapse of disease. Alternative medical agents include calcineurin inhibitors, mycophenolate mofetil, and recombinant interleukin-10, abatacept and CD-3 specific antibodies. Liver transplantation is effictive treatment method.

Conclusion. Improvement of corticosteroid treatment allows to determine candidates for alternative treatment. Budesonide is a drug of choice for the patients who were not receiving treatment before. Development of new treatment strategy is possible on the basis of assessment of key defects of immunological homeostasis and antigenic targets.

The aim of review. To describe modern principles of portal hypertension treatment in patients with liver cirrhosis (LC).

Original positions. One of the most significant LC complications is portal hypertension - acute bleeding from varicose veins (VV) of the esophagus and the stomach, ascites, hepatorenal syndrome. VV bleeding is a critical state at which 15–20% of patients die within subsequent 6 wks. Patients with acute episode of bleeding require treatment by vasoconstrictors, antibiotics in combination to endoscopic methods of treatment. For bleeding prophylaxis β-adrenoblockers, endoscopic procedures are used. Hepatorenal syndrome is associated to infections most often. Without treatment or liver transplantation patients with hepatorenal syndrome of the 1st type live for no more than 2 wks. Vasoconstrictors in combination to albumin are drugs of choice for these patients. Prophylaxis requires careful monitoring for other complications of cirrhosis, compensation of liver function.

Conclusion. Patients with liver cirrhosis and portal hypertension are severe patients. Life prognosis most often is determined by infections and associating renal failure (hepatorenal syndrome), esophageal varices bleedings. As the major part of these states peripheral vasodilation, prescription of vasoconstrictors (first of all — terlipressin) is pathogenically justified and results in arrest of acute bleedings from esophageal VV, and in functional recovery of kidneys at renal failure.

Aim of investigation. To determine the effect of bacterial overgrowth syndrome and translocation of bacterial DNA in ascitic fluid on morbidity in liver cirrhosis (LC) and long-term life expectancy.

Material and methods. Overall 42 LC patients were included to original study (Child-Pugh class A – 15 patients, class B – 10, class C – 17). For diagnostics of bacterial overgrowth syndrome in the bowel hydrogen breath test was carried out. Possible bacterial translocation from intestine to ascitic fluid was assessed by the presence of bacterial DNA by PCR method. For 12 months patients were monitored to assess their life prognosis. Data were processed by «SPSS», version 13.0 software.

Results. Bacterial overgrowth syndrome was revealed in 69% (29 of 42) patients with LC (46,7% – class A, 60,0 % – class B and 94,1% – class C, р=0,013). This syndrome was diagnosed mostly in patients with ascites (84,0%) in comparison to those without (47,1%, р=0,017). Correlation between bacterial overgrowth syndrome and stage of varicose dilation of esophageal veins (р=0,001) was revealed. Hypotension and tachycardia, infections were present in patients with positive hydrogen breath test (р<0,036) more often. The survival rate for 12 months in the group of patients with bacterial overgrowth syndrome was lower in comparison to patients without bacterial overgrowth (51,7% vs 84,6% respectively, р<0,042). Among patients with tense ascitis (n=16) bacterial DNA in ascitic fluid was detected in 9 cases (56,3%). Ascitis, resistant to diuretic therapy was more frequent in patients with bacterial translocation (66,7%) in comparison to patients without it (14,3%) [OR 4,667; 95%CI: 0,717–30,353; р=0,036]. All patients with infected ascitis (n=5) had bacterial DNA, though etiological agent was found at culture only in one.

Conclusion. In patients with liver cirrhosis bacterial overgrowth syndrome is associated with portal hypertension, hemodynamic disorders, infections. It acts as one of prognostic factors of low survival rate in such patients. The course of disease in LC patients with tense ascitis and bacterial translocation is complicated by development of diuretic-resistant ascitis and ascitic fluid infection most often.

Aim of investigation. To analyze experience of pegIFN-α 2а (Pegasys®) application at combined antiviral therapy of chronic hepatitis C (CHC) within the framework of the Moscow regional regional program on viral hepatites treatment.

Material and methods. Overall 369 patients underwent treatment since 2008 to 2011, of them 292 patients – with CHC. Male patients prevailed in the studied group – 202 (54,74%), female patients – 167 (45,26%), mean age was 41,1 years. Prior to therapy onset needle liver biopsy was carried out in 88,3% of patients, subsequently liver cirrhosis was diagnosed in 77 patients. In 227 of patients the 1-st HCV genotype was revealed, 2nd genotype – in 24, 3rd genotype – in 41cases.

Results. Sustained virologic response (SVR) after the termination of antiviral therapy was achieved in 70,1% of patients. Statistically significant differences by gender, body mass index, virus genotype were revealed between groups which have achieved and not achieved SVRs. Anemia, leukopenia, thrombocytopenia, thyropathy and depression were marked as the most frequent undesirable treatment effects.

Conclusions. Follow-up of CHC patients, treated by pegIFN-α2а and ribavirin in the Moscow regional hepatological center, testifies its high efficacy and safety profile.

The aim of clinical case presentation. To show features of distal tumor spread at patients with local progression of rectal cancer by original case presentation.

Features of clinical case. At the patient of young age with rectal adenocarcinoma located of 8 cm away from anal edge, clinical stage T3N2M0 has been diagnosed. At repeated investigation after chemoradiotherapy course on a background of significant regression of tumor, development of metastasis in rectovaginal septum was revealed, located 5 cm from the lower pole of neoplasm, that required abdominal-perineal extirpation of rectum instead of initially planned organ-preserving resection. Contrary to the standard opinion on the extremely unfavorable prognosis in patients with severe spread of tumor beyond macroscopicly visible edges, the patient was followed-up for over 3 years without signs of relapse and distant secondaries.

Conclusion. Presented clinical case testifies necessity of careful preoperative investigation of patients with local spread of rectal tumors with obligatory application of magnetic-resonance tomography of small pelvis organs. In the case of prolonged radiological (chemoradiation) therapy careful investigation is required in 6–8 wks after the termination of radiation therapy, before surgical intervention. At a choice of operation risk of residual malignant process in visually unchanged tissues distally from tumor should be taken in account.

Cryptogenic, or common rectal fistulas are one of the most frequent disease in coloproctology. According to established classification, in relation to course of fistula in relation to sphincter muscle fibers, fistulas of rectum are classified to intrasphincteric, transsphincteric and extrasphincteric. The greatest difficulties arise at surgical treatment of extrasphincter fistulas of rectum that is related to high rate of relapse, and at application of ligature method, development of anal incontinence is impending. Today internal fistulous ostium plastic methods become more and more widespread, including those with application of bioplastic implants.

Aim of investigation. To study potential of surgical treatment of extrasphincter fistulas of rectum by creation of inner fistula ostium by bioplastic substance «Collost».

Material and methods. Experience of monitoring of 34 patients who underwent surgery for extrasphincteric fistulas of rectum of various degree of complexity with application of plastic material is presented.

Results. At proctoplasty with application of bioplastic substance «Collost» no intraoperative complications developed, mean duration of surgical intervention was 45 minutes. Morbidity, including urine retention, edema of external hemorrhoids, were observed in 7 patients in postoperative period (20,6 %) and have been resolved conservatively. Complete convalescence was achieved in all patients, no relapses of fistula was observed during follow-up for 1 to 3 years.

Conclusion. Surgical treatment of extrasphincter fistulas of rectum by formation of internal fistulous ostium by bioplastic substance «Collost» is pathogenicly proven. Its application allows to achieve permanent clinical effect, to decrease rate of postoperative morbidity, to reduce terms of rehabilitation of the operated patients.

The aim of review. To generalize the reports submitted at the XIV session of German national college of gastroenterologists.

Original positions. During session most actual issues of diagnostics and treatment of diseases of esophagus, stomach, liver, gallbladder, pancreas and intestine were considered. The statistical data on frequency and prevalence of gastroenterological diseases in Germany were presented.

Conclusion. Acquaintance to data of German national college of gastroenterologists allows to conclude on its similarity to lectures presented at the last session of the Russian national college of gastroenterologists, however there are differences in style data presentation.

The aim of review. To analyze reports of the 19-th United European Gastroenterology Week, devoted to diagnostics and treatment of Helicobacter pylori infection.

Original positions. Prevalence of H. рylori continues to remain high all over the world. Now decrease of the standard triple mode of eradication of infection efficacy, related to growing clarithromycin resistance of H. рylori strains is observed. Overcoming of this resistance is promoted by new modes of eradication: sequential, «concomitant» triple therapy with levofloxacin. The choice of the specific mode depends on level of clarithromycin resistance in this region.

Conclusion. Improvement of treatment efficacy can be achieved by development of new modes of eradication.