The aim of review. To illuminate state-of-the-art of issue of ischemic heart disease and reflux-esophagitis combination and options of treatment of comorbide patients.

Original positions. Ischemic heart disease (IHD) and reflux-esophagitis (RE) are one of the most frequent diseases of cardio-vascular and alimentary systems. Common risk factors play important role in high prevalence of comorbide course of IHD and RE. Close anatomic position and common innervation of the heart and the esophagus trigger effect of gastroesophageal reflux on coronary vasoconstriction and disorders of heart rhythm at patients with IHD. Present studies show treatment effect, aimed on RE, at patients with IHD: decrease in number of myocardial ischemia and arrhythmia attacks. Application of prokinetics in complex treatment of RE at IHD patients is pathogenically proven. Combination of diseases requires long treatment, dictates necessity of choice of the safe agent, having no negative effect on the course of IHD.

Conclusion. Mutual effect on development and progression of symptoms of cardio-vascular and alimentary diseases causes not only certain diagnostic difficulties, but also necessitates search for improvement of diagnostic and treatment methods in comorbide patients with IHD and RE.

The aim of review. To present experimental and clinical data on enzyme-ergic regulatory coupling of exocrine pancreatic secretion and evacuatory activity of gastroduodenal complex.

Original positions. Intraduodenal injection of pancreatin or trypsin as model of exocrine pancreatic secretion of enzymes accelerates gastric evacuation of chymus to the duodenum and decreases pancreatic secretion in dose-dependant w ay. Both effects result from inhibition of endogenous cholecystokinin release which is the main stimulant of pancreatic enzymes secretion and inhibitor of gastric evacuation, suppressing antral motility, reducing brake efficacy of duodenoantral reflux.

Conclusion. Enzymatic, acid-base and nutrient properties of duodenal chymus link parameters of pancreatic exocrine secretion and gastroduodenal evacuatory activity.

Aim of investigation. To determine, which mechanism of dipeptide transport is realized under experimental conditions: PEPT1-mediated transport of the intact dipeptides or transport of the amino acid formed as a result of membrane hydrolysis of dipeptides through transport systems for free amino acid.

Material and methods. Amplitudes of short circuit current (SCC) response reflecting rate of Na+-dependent absorbtion of nutrients on addition of dipeptides and amino acids to washing solution at different pH were registered in isolated fragments of the small intestine of rats. Results. Higher efficacy of dipeptide transport (SCC responses to dipeptides were more intensive, than responses to amino acids mixture) was observed at рН 8,5. On the contrary, at рН 5,5 is inverse ratio: stronger SCC responses to amino acid mixture than to dipeptides was revealed. Thus, the explorer, working at рН 5,5, will find, that absorbtion from mixture of aminoacids is more effective, than from dipeptide solution.

Conclusions. Increase of sodium-dependent component of stimulating effect of easily hydrolyzed dipeptides along with рН is caused by membrane digestion. Decrease of sodium-independent dipeptide transport component along with рН is related, apparently, to functioning of proton-dependent PepT1 in enterocyte apical membrane. We believe, that such serial «incubation» of gastric contents at increasing рН at gastro-intestinal transit (from the stomach to the large intestine) results in well-timed diversion of two mechanisms of oligopeptide absorbtion and respectively to their optimal digestion.

Aim of investigation. To study parameters of lipid composition of liver cells and peripheral blood lymphocytes at children with chronic viral hepatitis B, as well as the relation of these parameters to the stage of disease chronization.

Material and methods. Overall 25 children aged 12 to 15 years with chronic hepatitis B were investigated: 14 – had the 2nd stage of hepatitis chronization and 11 – the 3rd stage. Lipid composition parameters were determined by thin-layer chromatography in Silufol with extraction of lipid fractions from cells of liver tissue obtained at guided biopsy, and lymphocytes extracted from venous blood.

Results. Metabolic changes in liver tissue of children depend on the stage of chronization of disease, at the 3- rd stage functional lesions of cells are more profound. Metabolism of lymphocytes depends on disease severity as well, thus the 3rd stage is characterized by more severe functional depression of lymphocytes.

Conclusions. Intensity of metabolic reactions in liver cells and lymphocytes at 12–15 year old children with chronic hepatitis B depends on the stage of chronization of infectious process and at the 3rd stage more profound changes of investigated parameters were revealed, than at the second. Interrelation pattern of lipid parameters of liver cells and lymphocytes indicate, that the latter mirror specificity and trend of metabolic changes in liver tissue.

Aim of investigation. To study the results of complex investigation of patients with postcholecystectomy syndrome for the sake of diagnostics of functional disorders of the sphincter of Oddi (SO) and targeted treatment.

Material and methods. Overall 70 patients mainly with biliary colic after cholecystectomy were included in original study. The complex investigation, that included laboratory methods, ultrasound investigation, including that with test meal, endosonography, endoscopic cholangiopancreatography excluded organic changes of pancreatobiliary system. Successful SO manometry was executed in 27 of 32 patients.

Results. Functional SO disorders (spasm of papilla of Vater, hyper- and hypokinetic dyskinesia, increased frequency of contractions, local stenosis of papilla of Vater in combination to sphincter dysfunction) were diagnosed in all patients, who underwent endoscopic SO manometry. Treatment was prescription was differential, spasmolytic and prokinetic drugs were applied.

Aim of investigation. To study clinical features of chronic pancreatitis in patients with severe mesenteric atherosclerosis (calcification of celiac trunk).

Material and methods. Overall 290 patients with chronic pancreatitis have been investigated. According to alcoholic and biliary etiology of disease, signs that was revealed at computer tomography with bolus contrast injection (calcification of ostium of celiac trunk and superior mesenteric artery), 43 patients were selected to the group with «ischemic component».

Results. Patients of this group were characterized by series of features: older age, lower intensity of pain, higher frequency of ischemic heart disease and systemic hypertension. Gastroduodenal erosions with relative resistance to drug treatment were more frequently diagnosed in these patients.

Conclusion. At elderly patients with chronic pancreatitis and calcification of mesenteric blood vessels, with respect to frequent constipation tablet pancreatin agents (Mezym® 10000) have high efficacy in treatment of abdominal pain.

Aim of investigation. To evaluate potentials of various noninvasive procedures for treatment of severe acute pancreatitis.

Material and methods. Treatment results of 110 patients with acute destructive pancreatitis by various noninvasive methods were analyzed. At early terms of disease the main aim of interventions was debridement and drainage of abdominal cavity and/or localized retroperitoneal fluid collections as a method of surgical detoxication at failure of conservative treatment (endovideosurgical or percutaneous puncture draining procedures were used). Revealing of the infected pancreatonecrosis, peripancreatic abscesses acted as absolute indication to their drainage which was carried out by percutaneous or lumboscopic approach. At inefficacy of noninvasive procedures traditional open interventions were carried out.

Results. Of 110 patients with destructive pancreatitis treatment by noninvasive procedures was effective and sufficient in 97 cases (88,2 %).

Conclusions. Adequate debridement and drainage of pathologic foci along with little surgical aggression at access in noninvasive interventions provide advantage in comparison to traditional methods.

The aim of the publication. Issues of drug interaction, side effects development at patients with combined diseases, requiring eradication treatment, are taken into account.

Original positions. Being based on literature data and own experience, authors demonstrated, that drug interactions are observed in vast majority of cases at simultaneous prescription of five drugs and more. As eradication therapy implicates addition to treatment of at least 3 pharmaceuticals of which antibiotics are strictly specified, it is extremely desirable to choose proton pump inhibitor (PPI) with lower affinity to cytochrome Р450. Pantoprazole conform to these requirements, and surpasses all other PPIs in this respect.

Conclusion. Authors believe, taking into account available data on drug interactions, that at patients with multiple morbidity pantoprazole is preferable to other antisecretory agents.

The aim of review. To share experience of application of topical steroids (Budenofalk®) in children with hormone – dependent inflammatory bowel diseases (IBD) and severe side effects on a background of systemic corticosteroids (CS).

Original positions. Etiopathogenesis of IBD represents the cascade of self-maintaining pathophysiological reactions: adaptive microcirculational, hypoxicmetabolic, autoimmune inflammatory and dysbiotic disorders emerging on a background of genetic features of the body under the effect of unfavorable environmental factors. Anti-inflammatory treatment aimed to destruction of «vicious circle» of inflammatory responses occupies the main place in the treatment of IBD. CS are agents of choice of the second line. Prescription of CS is indicated at high severity of disease, active extraintestinal manifestations, absence of response to 5-aminosalicylic acid or dangerous side effects. At the same time CS application is associated to high risk of side effects and complications caused by their systemic action, and hormone-dependence. Introduction of topical steroids (Budenofalk®) to IBD treatment in some cases allows to resolve these problems. Experience of topical steroids application in the treatment of IBD in pediatrics is rather limited. On the basis of the Nizhny Novgorod scientific research institute of pediatric gastroenterology Budenofalk® was applied in 5 cases of IBD with severe cushingoid syndrome on a background of systemic CS and/or hormone-dependent course of disease to overcome dependency for CS and decrease of steroidrelated side effects. The article presents description of clinical case of successful application of budesonide according to determined goal.

Conclusion. Budenofalk® can be a drug of choice in patients with hormone-dependent IBD, and at high risk of complications and severe side effects of systemic CS. 

The aim of the publication. To present clinical case of Cushing disease, with resistant large stomach ulcer.

Original positions. Hypercorticoidism is one of the causes of treatment-resistant stomach ulcers that is due to increase in gastric secretion and depression of collagen formation under the effect of hydrocortisone. Since 2009 we follow up the patient (female, 47 years old) who for the first time addressed to the doctor with complaints of pain and muscle weakness, mainly — of lower extremities, and also hip, ankle joints pain, which essentially complicated locomotion capacity. Initially these symptoms were inaccurately attributed to osteoarthrosis, thus patient received nonsteroid anti-inflammatory drugs (NSAID) and high doses of Kenalog. Later classical symptoms of hypercorticoidism - characteristic changes of the face, visceral obesity, striae, systemic hypertension and diabetes mellitus became obvious. Within over half a year patient had large antral ulcer of the stomach (periodically turning to giant) with signs of occult bleeding. Chronic ulcer was characterized by complete absence of granulations and striae-shaped changes of surrounding mucosa. During the further investigation: low-dose dexamethasone suppression test, magnetic-resonance tomography (MRI) and computer tomography (CT) of the brain and abdominal cavity data, favoring the Cushing disease (ACTH-producing pituitary adenoma), was obtained. Pathogenesis of chronic stomach ulcer is complex: effect of H.pylori infection, drugs (NSAID, steroids) and hypercorticoidism. Antihelicobacter eradication treatment, complete cancellation of NSAID and steroids, treatment by high doses of proton pump inhibitors, Н2-blockers, bismuth subcitrate did not result in ulcer healing. In January, 2010 the ulcer bleeding developed (Forrest stage IIс), that was stopped by conservative treatment. Intravenous injection of esomeprazole allowed to decrease the size of ulcer and promoted its further healing. After transsphenoidal adenomectomy improvement of general well-being, weight loss, decrease of muscle weakness, improvement of parameters of glucose metabolism and blood pressure were marked; the stomach ulcer did not recur.

The aim of publication. To show difficulties of differential diagnostics and prescription of adequate treatment in patient with abdominal pain and nutritional disorders.

The main contents. Patient C., female, 58 years old, admitted the clinic in the spring of 2008. Symptoms included epigastric pain, sometimes belt-like, not related to food intake, posture or defecation, sensation of bitter taste, fever up to 37,2–37,4 °С without relation to time of day, physical activity or pain intensity. Symptoms started in childhood, onset of disease patient associated to irregular and improper nutrition. From 18-years of age almost permanently receives conservative treatment for abdominal pain, underwent three surgical operation without definite indications (cholecystectomy, Roux stomach resection, Bilroth I stomach resection). Conservative and surgical treatment did not result in pain relief. At examination presence of nutritional insufficiency draw attention. BMI was 15 kg/m2. The aim of investigation was to define the cause of abdominal pain, and to determine treatment approach. According to the results of investigation in the patient with tesselated personality disorder somatoform disorder was diagnosed (generalized somatoform pain). Treatment included drug therapy along with repeated conversations with the patient, that resulted in relative stabilization of her state.

Conclusion. Estimating presented clinical case it is possible to draw conclusion on involvement of various departments of nervous system, including emotional component into the mechanism of abdominal pain. Thus, the key moment in investigation of the patient presenting complaints of pain, besides laboratory and instrumental tests is careful analysis of symptoms, past history and family history. The choice of an agent for treatment abdominal pain depends on the level of its generation.

The aim of review. Analysis of up-to-date approaches to treatment of acute anaerobic paraproctitis (AP).

Original positions. The majority of researchers agree that anaerobic directivity of inflammatory process at AP is determined by high load and virulence of the infectious agent on a background of decrease of immune resistance of the body. Unsatisfactory results of treatment are related to the delayed encounter of the majority of patients (81,8%) for specialized aid, and also to late diagnostics. High mortality and morbidity at anaerobic paraproctitis are caused by rapid generalization of process, development of septic states and multiorgan failure.

Conclusion. Ways of improvement of treatment results at AP – perfection of tactical and technological level of surgical interventions, improvement of preoperative preparation, methods of anaestesia, prevention of acute cardiopulmonary failure. In postoperative period antibiotic therapy by carbapenems or last generation penicillins in maximally allowed doses, treatment of organ dysfunction, control of regenerative processes in the vast wounds formed after radical operations is recommended.

Aim of investigation. To study clinical and genetic characteristics of the attenuated form of familial adenomatosis of the colon. Material and methods. Overall 123 patients with familial adenomatosis of the colon, underwent clinical and genetic investigation. Results. Of all patients 60,2 % had classical form of disease, 24,4% – aggressive, 15,4% – attenuated. At attenuated form mutation in АРС gene occurred within 450 and 510 codons and on the edges of this gene that allows both to reveal disease at preclinical stage, and to identify the attenuated variant. For this variant of adenomatosis absence of metabolic disorders and development of cancer after 50 years is typical that requires onset of treatment by endoscopic polypectomy with subsequent extensive resections of the colon if necessary.

Aim of investigation. To discuss potential of highenergy 970 nm laser radiation for radical ablation of sessile polyps of the rectum.

Material and methods. Laser scalpel «LS-0,97- IRE-Poljus» (Russia) was used as a source of highenergy laser radiation. Polyp erasion was implemented by «Olympus CF-EI» colonoscope (Japan). The contact laser photocoagulation was applied in continuous mode using quartz monothread 600 microns in diameter. Totally 16 polyps of the rectum at 11 patients over 45 years old were removed by laser ablation.

Results. Radical erasion of 16 sessile rectal polyps 0,4 to 1,0 cm in size was carried out. No complications during laser photocoagulation procedure and in postoperative period were observed. At control endoscopy 6 to 12 months after erasion no relapse of polyps was revealed.

Conclusions. The procedure of laser photocoagulation by 970 nm radiation allows to remove sessile polyps of rectum of the small size in out-patient conditions. Special investigation is required for evaluation of safety of this procedure for ablation of flat polyps of the colon.

S.V.Rychkova – Quality of life of children of school age and effect of chronic gastroduodenal diseases.