Vol 21, No 8 (2019)
Articles
Eosinophilic esophagitis diagnostics and treatment: review of the 2017 European guidelines
Abstract
Eosinophilic esophagitis is a chronic immune-mediated disorder of the esophagus that is characterized by esophagus dysfunction symptoms and severe eosinophile infiltration of the organ mucosa. The aim of the present review article was to present Russian medical practitioners the main points of diagnostics and treatment of eosinophilic esophagitis that are specified in 2017 European guidelines.
Consilium Medicum. 2019;21(8):9-14
9-14
Phenotypes of Gastroesophageal Reflux Disease in real clinical practice
Abstract
Aim. To define the epidemiological, clinical and endoscopic features of GERD, factors for development of erosive esophagitis (EE) and predictors of the effectiveness of PPI therapy in patients of a megapolis. Materials and methods. The study included 1433 patients with GERD from Moscow, Moscow region and St. Petersburg. There were 595 (42%) men and 838 (58%) women with the average age 48±16 years (from 7 to 91 years) among the examined patients. The study design included 3 visits with an interval of 4 weeks, during which complaints and anamnestic data gathering, anthropometry, upper endoscopy, tests for Helicobacter pylori infection and adherence evaluation were performed. For acid-suppression rabeprazole was prescribed for most of the patients (1333, 96%). Results. Among the male patients, the most common was the age group of 30-39 years (30%), among women - 60-69 years (23%). In patients with the duration of GERD for more than 5 years, the chance of having a high degree of changes in the esophagus mucous (erosive esophagitis B-D) was significantly higher than in patients with the disease duration for less than 5 years (OR 1.85). The proportion of patients with overweight and obesity dominated among the examined (904 patients - 62.7%). At visit 1, in 614 (47.8%) patients EE was found, and in 618 (48.1%) - NERD. In patients with EE infected with H. pylori, B-D stages were observed 1.3 times more often than among patients with EE without H. pylori (p<0.05, 95% CI 1.02-1.54). Previous PPI therapy was not effective enough in 288 (34%) patients with EE and in 559 (66%) patients with NERD. At visit 3, the results of the GERD questionnaire were significantly higher in the group of patients with obesity and in the group of smokers compared with patients with normal BMI and non-smoking patients. The lowest percentage of mucous healing after 4 weeks of PPI therapy was observed among patients with EE stage D. Among patients with high adherence to therapy, remission was achieved in 95% of cases. PPI rabeprazole was effective in relieving symptoms of the disease in 81.2% of patients and in healing of the esophagus mucous - in 79.6%. Conclusion. Excess body weight and obesity, waist circumference above normal values, duration of GERD for more than 5 years, H. pylori, the presence of comorbid pathology and concomitant drug therapy increases the risk of EE development. The effectiveness of PPI therapy is significantly influenced by smoking, the severity of EE, the choice and duration of PPI treatment, and patient adherence to the therapy.
Consilium Medicum. 2019;21(8):15-22
15-22
Gastroesophageal reflux disease and diabetes mellitus: pathophysiological mechanisms of comorbidity
Abstract
This article covers a very important material about etiology and pathology of the gastroesophageal reflux disease with which most commonly suffer people with the diabetes mellitus type 2. It is well known fact that, on the one hand, hyperglycemia leads to the diabetic neuropathy. Neuropathy is the most common reason for motor disorders of the digestive system. On the other hand, patients who suffer from diabetes mellitus type 2 have an increased body mass index and obesity, which are associated with the increased abdominal pressure, the decreased lower esophageal sphincter pressure and increase of transient relaxation of the lower esophageal sphincter and lead to the pathophysiological reflux. In addition, such a decreased level of grelin in patients with obesity also leads to the pathophysiological reflux.
Consilium Medicum. 2019;21(8):23-28
23-28
The role of alterations in permeability of the intestinal mucosa in the genesis of functional gastrointestinal disorders
Abstract
The intestinal mucosa is a kind of barrier that provides a protective function by preventing the passage of intraluminal antigens into the body internal milieu. Currently more and more of scientific information is accumulating on the role of an alterations in permeability of the intestinal mucosa in the genesis of functional gastrointestinal (GI) disorders, including irritable bowel syndrome (IBS) and functional dyspepsia (FD). In these functional GI disorders, alterations in the intestinal mucosa barrier function is described. This is linked to compromising proteins of tight contacts of intestinal cells, which leads to an increase in the permeability and to the passage of various intraluminal factors into the deep mucosa, and, consequently, to an activation of immunocompetent cells. Activation of mast cells in the small and large intestines mucosa plays a key role in a pathogenesis of IBS, and an activation of mast cells and eosinophils in the duodenal mucosa - in a pathogenesis of FD. These effector cells of the immune response produce a number of cytokines, which affect a sensitivity of nerve endings in the mucosa, thereby inducing the phenomenon of visceral hypersensitivity and alteration in the motility and tone function of the gastrointestinal tract, which leads to characteristic symptoms. Thus, increased permeability of the gastrointestinal mucosa is currently potentially one of the priority therapeutic targets in the treatment of IBS and FD.
Consilium Medicum. 2019;21(8):29-34
29-34
Use of standard triple therapy in the treatment of Helicobacter pylori infection in adult
Abstract
Aim. Compare the efficacy of Helicobacter pylori eradication and tolerance of 10-day and 7-day standard triple therapy of H. pylori infection in adults. Materials and methods. In total, 136 H. pylori-infected subjects participated in the randomized clinical trial. 68 patients of the first group received a 10-day standard triple therapy: esomeprazole (20 mg 2 times a day), clarithromycin (500 mg 2 times a day) and amoxicillin (1000 mg 2 times a day). 68 patients of the second group - 7-day standard triple therapy: esomeprazole (20 mg 2 times a day), clarithromycin (500 mg 2 times a day) and amoxicillin (1000 mg 2 times a day). H. pylori stool antigen was performed to check for eradication. Results. The efficacy of H. pylori eradication, according to ITT-analysis, in patients of the first and second groups was 82.4% and 64.7% (p=0.020), and according to PP-analysis - 87.5% and 66.7% (p=0.010). Adverse events were reported in 25% of the first group and 36.8% of patients in the second group. There were no statistically significant differences of adverse events in both groups (p>0.05). Conclusion. 10-day standard triple therapy appears to be more effective than 7-day without increasing frequent adverse events. It is not recommended to use 7-day standard triple therapy in the treatment of H. pylori infection in adults in the Smolensk region due to the low frequency eradication of H. pylori. The use of a 10-day standard triple therapy has extremely acceptable efficacy and can be recommended as a therapy for the first line of H. pylori infection.
Consilium Medicum. 2019;21(8):35-41
35-41
Irritable bowel syndrome: what do we know about symptoms today?
Abstract
In the modern concept pathogenesis of irritable bowel syndrome, the central role is assigned to "brain-intestinal" interaction. Visceral hypersensitivity is the primary mechanism for the development of abdominal pain and motor dysfunction of the intestine. Important links are also "low degree" inflammation of the intestinal wall, increase in the permeability of the epithelial barrier, impaired microbiota composition. This review summarizes and presents current information on the pathogenetic factors formation of clinical manifestations irritable bowel syndrome. This is necessary to develop individualized therapeutic approaches that provide effective control over the disease, depending on the severity of abdominal pain and the type of motor disorders.
Consilium Medicum. 2019;21(8):42-48
42-48
Enteropathy with impaired membrane digestion and rebamipide
Abstract
The article describes enteropathy with membrane digestion disturbance (EMDD). At the basis of the disorder underlies a decrease of disaccharides and other membrane enzymes of small intestine mucous membrane (SIMM) activity. It can be caused by genetically determined and acquired enterocyte damage. EMDD clinical symptoms are presented with alimentary intolerances (stomach discomfort and pain, stool disturbances, and bloating). The diagnosis is based on SIMM enzymes biochemical study. Differential diagnosis should be performed between intestinal tract functional disorders, among which EMDD occurs frequently. The treatment is based at dieting with limitation of badly tolerated foods, the use of cytoprotector rebamipide that increases enzymes activity and intestinal antiseptics that inhibit bacteria growth in small intestine.
Consilium Medicum. 2019;21(8):49-57
49-57
Probiotics in Helicobacter pylori eradication regimens: current data and results of our own research
Abstract
The article presents the results of currently available studies on the composition of the gastric microbiome and changes in the microbial ecosystem of the stomach due to infection with Helicobacter pylori. It was shown that there is two-way interaction of microbial communities, both with the host and with each other, and some types of bacteria exhibit high antagonistic effects and can inhibit the growth of H. pylori. Treatment for infection is still a challenge for clinicians. Attention is paid to the role of probiotics in reducing the incidence of gastrointestinal adverse events during eradication therapy of H. pylori infection, as well as their positive effect on H. pylori eradication. The possibilities of using Lactobacillus reuteri DSMZ17648 (Pylopass™) in the eradication therapy of H. pylori infection are considered separately. The results of our own research carried out as part of the educational project "Real Clinical Practice for the Treatment of Acid-Dependent Diseases" on the inclusion of Pylopass™ and other probiotics in the eradication regimen are presented.
Consilium Medicum. 2019;21(8):58-64
58-64
Pleiotropic effects of ursodeoxycholic acid in non-alcoholic fatty liver disease and metabolic syndrome
Abstract
Aim. To study the effect of therapy on Ursosan that insulinoresistense and dyslipidemia, the stage of liver steatosis and liver fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) obesity and metabolic syndrome against the background of life style modification. Materials and methods. The study included 70 patients (36 men), mean age - median (Me)=45,6 with NAFLD on the background of overweight - Body Mass Index >30 kg/m2 (Me=32) with the syndrome of cytolysis >2 norms and/or liver fibrosis and liver steatosis ≥1 stage (FibroScan 502 TOUCH with ultrasonic sensor for fat patients and software CAP). The stigma of the lipid spectrum, insulinoresistense, inflammation. All patients were prescribed a diet combined with daily aerobic activity for 24 weeks, and patients of the main group (n=50) were additionally prescribed Ursosan in daily dose 15 mg/kg. Results. Both groups showed a decrease in Body Mass Index (-4.9% in the main group and -4.8% in the comparison group). Revealed a decrease in Me alanine transaminase by -24% (p<0.001) of group 1 and -11% (p<0.05) of group 2; a decrease in aspartate transaminase by -32% (p<0.001) and -13% (p<0.05), respectively; gamma-glutamyltransferase - -33% (p<0.001) and -22% (p<0.05), respectively; glycated hemoglobin -17% (p<0.05) and -10% (p>0.05), respectively; HOMA-index -15% (p<0.04) and -7% (p=0.1); total cholesterol -12% (p<0.05) and -5% (p=0.15); triglycerides -21% (p<0.05) and -9% (p>0.05); low-density lipoprotein - -21% (p<0.05) and -9% (p>0.05); high-density lipoprotein - +28% (p<0.05) and +5% (p=0.7); liver steatosis (DV/m2) - -26% (p<0.01) and -7% (p<0.05); liver fibrosis reduction by stage 1 (METAVIR) in 40% of patients of group 1. Conclusion. The use of Ursosan 15 mg/kg/day in patient with NAFLD, obesity and metabolic syndrome against the background of diet and exercise therapy can significantly reduce the stigma of inflammation, insulin resistance and dyslipidemia, liver steatosis compared with non-drug therapy.
Consilium Medicum. 2019;21(8):65-70
65-70
Gastrointestinal complications in patients receiving antiplatelet and anticoagulant therapy
Abstract
Gastrointestinal complications of medicinal therapy remain relevant in practice of internal diseases within several decades. If earlier, drug, then the last years were most often mentioned as the main adverse agents Nonsteroidal anti-inflammatory drugs, in connection with change of a portrait of the comorbid patient on the first positions anticoagulant and antiagregant tratment. It is connected with increase in life expectancy and also introduction in daily practice of intervention methods of treatment of patients. At present moment antithrombotic and anticoagulant therapy is widely used at patients with cardiological pathology. At the same time gastrointestinal bleedings are one of the most serious complications of such therapy. In article data on mechanisms of risk of development the gastrointestinal bleedings at the persons accepting antiagregant and anticoagulants treatment are generalized.The data indicating a number of features of emergence of such changes at reception of separate groups of anticoagulant and antiagregant tretment are provided. The emphasis about need of development of clinical recommendations for real clinical practice taking into account stratification of all risks as cardial, ischemic, and gastrointestinal is placed.
Consilium Medicum. 2019;21(8):71-73
71-73
Course of gallstone disease in persons with metabolic disorders
Abstract
Aim. To identify factors affecting the course of gallstone disease (GD) in persons with metabolic disorders. Materials and methods. 103 patients with GD aged 23 to 65 years were examined. All patients were examined in accordance with the purpose and objectives of this work with the analysis of clinical, instrumental and laboratory data. Anthropometric indicators (height, weight, body mass index, waist volume) were taken into account; biochemical data - total cholesterol, high density lipoprotein cholesterol, triglycerides, glucose; Ultrasound of the abdominal organs. The verification of metabolic disorders was carried out on the basis of the criteria of JIS metabolic syndrome (MS), 2009. Results. In patients with gallstone disease accompanied by acute cholecystitis (GDAC), metabolic disturbances and MS were more common. Statistically significant influence on the course of GDAC was rendered by triglycerides, high density lipoprotein cholesterol as well as MS. Conclusion. MS and its individual components can be considered as risk factors for acute cholecystitis in patients with gastrointestinal tract. Further research is needed to clarify the clinical importance of this Association in the near and trimmed perspective and the possibility of drug lytic therapy with bile acids and preventive measures related to the normalization of weight, high density lipoprotein cholesterol and triglycerides.
Consilium Medicum. 2019;21(8):74-77
74-77
Drug-induced liver injury is one of the important problems in the comorbid patient
Abstract
Drug-induced liver injury are an actual problem of modern medicine, as they account for 10% of all adverse reactions associated with the use of drugs. Drug-induced liver injury does not have any specific manifestations and covers the symptoms that occur in a variety of liver lesions, from asymptomatic increase in transaminases to the development of fulminant liver failure. The need for early diagnosis, difficult differential diagnostic search, the lack of specific laboratory tests make this pathology quite difficult for the practitioner. The wide distribution and availability of dietary supplements makes a significant contribution to the development of drug-induced liver injury. Treatment of drug-induced liver injury is based on the abolition of the drug that caused the defeat of the organ, and the appointment of specific and symptomatic therapy. Preventive measures are reduced to compliance with the dose, multiplicity, ways of drug administration, the absence of polypragmasia, careful collection of medical history, analysis of risk factors before prescribing drugs and monitoring the patient in the dynamics.
Consilium Medicum. 2019;21(8):78-83
78-83
Early detection, differential diagnosis and prevention of complications of chronic inflammatory bowel disease
Abstract
The article discusses the possibility of early detection of prevention of the development of complications of chronic inflammatory diseases and tumor processes of the intestine. At the moment, there is a tendency to intensify scientific research and practical use of complex diagnostics and therapy of patients with inflammatory bowel diseases both in our country and abroad. Improvement of local control indicators and prevention of tumor processes in inflammatory bowel diseases is possible only if the criteria of succession of all parts of medicine are met and effective protocols of early diagnostics are included in the protocols, such as computer tomography and magnetic resonance imaging, which allow differential diagnosis and predict the development of complications.
Consilium Medicum. 2019;21(8):84-87
84-87
Influence of preoperative oral carbohydrate loading on perioperative period (a pilot study)
Abstract
Objective. To evaluate influence of preoperative oral carbohydrate loading on perioperative surgery results. Materials and methods. The prospective study included 51 patients in whom routine abdominal and retroperitoneal surgeries were performed. The patients were divided into 2 groups: study group and control group. In both groups surgeries were performed in identical conditions. In preoperative period control group (n=27) patients kept to a traditional protocol of preoperative fasting that meant consumption of solid food no later than 6 hours before the surgery and consumption of clear transparent liquids no later than 2 hours before the surgery. The patients in study group (n=24) consumed a carbohydrate drink before surgery (33.5 g of carbohydrates and 4 g of hydrolyzed protein in 100 ml): 400 ml in the evening before surgery and 200 ml 2 hours before surgery. Results. No differences in perioperative glycemia levels were observed, intraoperative infusion volume was lower, hemodynamic parameters were more stable, and the number of patients with organ dysfunction was significantly lower in the study group in comparison with control group. Conclusion. Preoperative carbohydrate loading resulted in decrease of infusion volume and more stable hemodynamic parameters in the intraoperative period as well as in decrease of organ dysfunction manifestations.
Consilium Medicum. 2019;21(8):88-92
88-92
Cholecystectomy as a risk factor of non-alcoholic fatty liver disease progression
Abstract
Association between non-alcoholic fatty liver disease (NAFLD), cholelithiasis, and cholecystectomy is a research subject for biochemists, pathophysiologists, morphologists and clinical physicians. Association between cholelithiasis and NAFLD is mostly presented by insulin resistance. Although in present years solid evidence have emerged showing that not so much cholelithiasis as cholecystectomy has an important role in NAFLD progression. It is determined by endocrine balance and bile acids signal function disturbance as well as by small bowel bacterial overgrowth syndrome development. Further study of these interrelations not only will allow holding from unreasonable surgeries, but will also offer perspectives for development of new treatment methods.
Consilium Medicum. 2019;21(8):93-97
93-97
Anoplastic in the treatment of the chronic anal fissure
Abstract
Aim. To determine the effectiveness of simple anoplastic therapy, in the treatment of patients with chronic anal fissures. Materials and methods. From January 2013 to December 2016, 56 patients with chronic anal fissure were treated, including 37 (66.1%) men and 19 (33.9%) women. The average age of the patients was 44.3±7.9 years. The duration of the disease is from 3 to 12 months. The treatment was conducted in a "one-day" hospital. The anoplasty was performed by a sliding flap according to J. Musiari (1954). To normalize the tone of the internal sphincter in the postoperative period for 6 weeks, 0.3 percent nifedipine ointment Results. The average duration of the operation was 28.9±2.8 min. The hospitalization time is 23±1.9 hours. The pain syndrome for the first time on the VAS scale was 45.3±5.03 (40-50) mm, which required an average of 26.4±4.8 (20-30) mg of Ketorolac tromethamine. By the 7th day, the pain syndrome according to the VAS scale was 27.3±5.2 (20-40) mm, which required an average consumption of 12.8±5.9 (0-30) mg of analgesic. The average period of incapacity for work was 12.8±1.8 (10-14) days. Complications developed in 5 (9.0%) patients. Retraction of the flap occurred in 3 (5.4%) and 2 (3.6%) wound suppuration occurred, which required local treatment for 6 weeks. Within a period of up to 12 months, all patients were tracked; there was no recurrence of the anal fissure. No incontinence was detected. Conclusion. Anoplasty with a flap is a simple, safe and sphincter-saving operation for the treatment of a chronic anal fissure that does not respond to conservative treatment.
Consilium Medicum. 2019;21(8):98-101
98-101
Modern methods for the prevention of thromboembolic complications in the postoperative period
Abstract
Despite active prevention, venous thromboembolic complications following surgery significantly complicate the patient's recovery and continue to occupy aggressive positions on fatal outcomes. In the early postoperative period, in general surgery profile patients their proportion reaches 11%. In most cases (up to 70-75%), venous thrombosis is asymptomatic and is detected either by ultrasound or after clinical signs of pulmonary embolism become evident. The likelihood of thromboembolic complications depends on a nature of nosology and a type of surgical intervention, as well as on the patient's individual pathophysiological features that lead to hypercoagulation, damage to the vessel wall as a complication of the underlying disease, concomitant diseases, history of thrombosis and genetic mutations. Based on an identification of predisposing factors and a determination of risk groups, modern schemes for the prevention of venous thromboembolic complications include a complex of pharmacological and mechanical procedures, which in most cases prevent thrombosis. However, given a significant impact of urgent surgical pathology which is often accompanied by a endotoxicosis development, on the vascular wall and microvasculature, the possible supplementation of the complex of prevention procedures with phlebotropic drugs in patients with concomitant varicose disease and limited mobility in the postoperative period is considered.
Consilium Medicum. 2019;21(8):102-107
102-107
Tuberculous peritonitis. Identification difficulties
Abstract
Aim. To study forms of the course of the disease, variations of clinical and morphological manifestations and diagnostics of tuberculous peritonitis with determination of optimal examination and surgical tactics algorithm. Materials and methods. In the period from 2009 to 2018 in the Tuberculosis surgery department of the Moscow Research and Clinical Center for Tuberculosis Control 58 patients with tuberculous peritonitis were examined and operated. Among the hospitalized patients, males prevailed (males - 39; 67.2%, females - 19; 32.8%), while the patients' age ranged from 20 to 63 years (median - 37.2 years). The complex examination of patients included diagnostic radiology methods (MSCT and ultrasonography) of the abdominal cavity and chest, diagnostic video laparoscopy, laboratory and morphological methods. Results and discussion. According to the clinical and morphological picture of peritoneal tuberculosis, all patients were divided into three groups: patients with the predominant syndrome of fluid accumulation in the abdominal cavity (37, 63.8%), patients with the prevailing enterocolitis syndrome and intestinal obstruction (19, 32.8%), patients with symptoms of peritonitis and abdominal sepsis (2, 3.4%). Anamnestic data on the timing of occurrence and course of the disease allowed to speak of the extreme variability in the course and duration of tuberculous peritonitis. Non-invasive diagnostic radiology methods showed a high level of informativeness in visualization of free fluid in the abdominal cavity (more than 90% positive results), but its detection with MSCT or ultrasonography can only serve as indirect evidence of tuberculous peritonitis, as it is observed in a wide range of diseases. Accumulations of fluid in the abdominal cavity in the presence of thickened and layered areas of the peritoneum, as well as signs of partial or complete small bowel obstruction detected with MSCT may be markers of peritoneal tuberculosis in 81% of cases, but laboratory confirmation of the process etiology is always required. The examination of exudates in only one third of cases allowed to identify the pathogen with PCR (29.3%), bacteriological examination showed bacterial growth of the MBT after 8-9 weeks in only 8.6% of patients. Only a peritoneal biopsy with bacterioscopic and histological examination of the biopsy specimen showed the highest confidence rates in the detection of Acid-Resistant Mycobacterium (74.1%) and specific granulomas (93.1%) or their equivalents in cases of HIV infection. Conclusion. With all the variety of clinical and morphological pictures of tuberculous peritonitis, the only highly informative diagnostic method is surgical involvement with a peritoneal biopsy followed by bacterioscopic and histological examination of biopsy specimen.
Consilium Medicum. 2019;21(8):108-115
108-115
Clinical efficacy of the electret’s electrostatic field in the surgical treatment for hip joint osteoarthrosis
Abstract
Background. Along with impaired local microcirculation, functional joint overload, metabolic disorders and changes in energy metabolism, alterations in bioelectric processes in chondrogenic and osteogenic structures play an important role in the pathogenesis of coxarthrosis. Effective correction for bioelectric processes in structures of the affected joint on the basis of electrophysiological principles is pathogenetically justified and appropriate. Aim. Assessment of the efficacy of the electret’s electrostatic field effect in the surgical treatment for hip joint arthrosis. Materials and methods. The article provides a retrospective analysis of the results of surgical treatment for stage 1-3 coxarthrosis in 92 patients aged 26 to 80 years with the electret’s electrostatic field. An electret stimulator of osteoreparation based on tantalum oxide, was implanted into the affected joint. The treatment efficacy was evaluated by the dynamics of the clinical and functional WOMAC index, data from comprehensive clinical and laboratory screening and radiation diagnostic methods. Results. The beneficial effect of the electret’s electrostatic field in hip joint arthrosis manifested as a decrease in a severity of disease symptoms severity, an improvement in patients’ functional activity, slowing progression of degenerative changes in the joint, and an increase in the quality of life during follow-up period. The effect of the electrostatic field is associated with an activation of reparative chondro- and osteogenesis, which allows a restoration of altered osseocartilaginous structures in coxarthrosis. Conclusions. The clinical efficacy and safety of the electret’s electrostatic field effect in the surgical treatment for coxarthrosis have been proven. It was noted that the positive effect increases to 3rd month and reaches a maximum at 6th month after surgery.
Consilium Medicum. 2019;21(8):116-122
116-122