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Aim: to analyse the principles of diagnosis and treatment of intrahepatic cholestasis in chronic liver diseases, to present data on the effectiveness of ademetionine in the treatment of chronic liver diseases with intrahepatic cholestasis and the materials of the Expert Meeting held in 2023. Key points. During the Expert Meeting, the problems of diagnostics and treatment of intrahepatic cholestasis in various chronic liver diseases were discussed, the effectiveness of ademetionine was clarified, and optimal regimens for its administration were determined. The relevance of the existing algorithm for diagnosing cholestasis in real clinical practice was assessed. The effectiveness of ademetionine in the treatment of various liver diseases occurring with intrahepatic cholestasis (cholestatic forms of drug-induced liver damage, alcoholic liver disease, non-alcoholic liver disease, primary biliary cholangitis) was demonstrated, manifested by a decrease in clinical and laboratory signs of cholestasis. The anticholestatic mechanisms of ademetionine action were clarified, which consist in normalizing the fluidity of hepatocyte membranes, regulating the activity of Nrf2, a key transcription factor, suppressing lipid peroxidation and the resulting damage to hepatocytes and cholangiocytes. Optimal regimens for prescribing ademetionine for various clinical situations were considered. Conclusions. Ademetionine is an effective drug that, due to its pleiotropic action and favourable safety profile, can be used in various chronic liver diseases accompanied by cholestasis, including as a part of the complex therapy.

The aim of review. Analysis of literature data on the possible causes of fever at patients with disorders of liver function. Article presents pathophysiological mechanisms of development of fever. The algorithm of assessment of patient with disorder of liver function and fever is submitted.Original positions. Fever in patients with liver failure can be caused both by infectious and non-infectious causes. Infections are the most frequent causes of fever at disorder of the liver function, that accounts for immunodeficiency state at this category of patients. An important role in development of fever at patients with liver cirrhosis is bacterial overgrowth syndrome, bacterial translocation processes and, as a consequence, endotoxemia. If the site of infection is not detected, it is necessary to keep in mind the option of development of non-infectious fever within acute phase reaction, neoplastic process or reaction to applied pharmaceutical agents.Conclusion. At development of fever at patients with liver failure carrying out differential diagnostics of the causes of body temperature elevation is necessary that allows more differentiated approaches to treatment.

Aim: to study the metabolic activity of the intestinal microbiota depending on the stage of metabolic dysfunction-associated fatty liver disease (MAFLD). Materials and methods. The study included 85 patients with MAFLD (27 patients with steatosis without steatohepatitis and fibrosis, 42 patients with steatohepatitis, 16 patients with cirrhosis as an outcome of MAFLD, Child — Pugh class A–B) and 20 healthy people who formed the control group. The level and spectrum of short-chain fatty acids (SCFA) were determined by gas-liquid chromatography. Results. It was found that patients with MAFLD at the stage of steatosis and cirrhosis of the liver have unidirectional changes in the metabolic activity of the intestinal microbiota. We established a decrease in the absolute concentrations of SCFA — their total content, the level of acetate, propionate, butyrate, a decrease in the level of isoacids. The SCFA profiles showed an increase in the proportion of acetate and a decrease in propionate and butyrate. Moreover, changes in the named parameters of SCFAs are aggravated with progression to liver cirrhosis. At the stage of steatohepatitis, we identified two subgroups of patients with different levels of metabolic activity of the microbiota. Patients whose microbiota metabolism for SCFA production was high had correspondingly elevated SCFA levels. And, on the contrary, patients in whom the metabolic activity of the microbiota was reduced were characterized by a steady decrease in SCFAs and disease progression to liver cirrhosis. In the study, we showed an inverse correlation between the calculated prognostic indices of NFS and FIB-4, elastography values with the total level of SCFA, the level of acetate, propionate, butyrate. Thus, a decrease in the content of SCFA for patients with MAFLD can be considered as a prognostic marker of an unfavorable course of liver disease.

Aim of investigation. To estimate efficacy and safety of various variants of sclerosing treatment of hemorrhoids at patients with severe concomitant diseases.Material and methods. At 13 patients with chronic hemorrhoids of 2–4 stages sclerosing treatment in combination to ultrasound cavitation, at 14 patients – sclerosing treatment without additional procedures was carried out.Results. Good and satisfactory results of treatment (termination or essential decrease of frequency and intensity of bleedings, decrease of degree of prolapse of hemorrhoids) after a week and month in both groups were identical. In 12 months good result after sclerosing treatment in combination to ultrasound cavitation is ascertained in 58,3% of cases, in the other group – in 15,4% (p

The aim of review. To discuss relation of obesity to phenomena of insulin resistance and lipotoxicity, and to demonstrate main therapeutic directions of their correction.Original positions. The most serious metabolic disorders related to obesity, include non-alcoholic fatty liver disease (NAFLD), diabetes mellitus, systemic hypertension with gradual development of heart failure, dyslipidemia, night apnea, etc. Recently scientists are more involved into the concept of limitation of fat tissue capacity to increase its volume as a factor associating obesity to metabolic syndrome and NAFLD. According to this hypothesis it is possible to explain phenomenon of severe obesity without development of metabolic complications. Within the same concept the role of differences in sets of nuclear receptors expressed in the liver of healthy persons and patients with NAFLD is taken into account. It is possible to explain lipotoxicity phenomenon as follows: in conditions of insulin resistance glucose stops to be an energy source and is substituted by lipolysis, therefore a plenty of free fatty acids is formed, having potential of toxicity and realizing metabolic disorders in target organs: the liver, the pancreas, muscles. New data on pathogenesis of metabolic disorders at obesity assume changes in comprehension of therapeutic actions. In 2008-2009 data on efficacy in treatment of insulin resistance and NAFLD of such pharmacological compounds, as glitazones, metformin, complex silibinin/phosphatidylcholine, ursodeoxycholic acid were published.Conclusion. In most cases the significant decrease of body mass is combined to resolution and better control over concomitant diseases. Recent studies demonstrated, that the visceral fat is in the higher degree associated to insulin resistance and the increased cardio-vascular risk while subcutaneous fat is metabolically more inert. In this aspect it is necessary to focus on glitazones (PPARs ligands), metformin among pharmacological substances, which has no influence on insulin secretion, however it has a lot of extrapancreatic effects by which it reduces increased concentrations of glucose in blood, improves tissue sensitivity to insulin and, thus, increases uptake of glucose by liver and muscles cells. In 2009 results of clinical and experimental researches which show significant efficacy of ursodeoxycholic acid at a dose of 30 mg/kg in treatment of non-alcoholic steatohepatitis and major therapeutic potential of silibinin and silibinin/phosphatidylcholine complex at non-alcoholic fatty liver disease were submitted.

The aim of review. Studying of effect of antiviral therapy on regression of fibrosis in chronic hepatitis B.Original positions. Article presents analysis of the largest investigations estimating effect of interferon α and nucleoside/nucleotide analogues on development of liver fibrosis. Decrease of severity of fibrosis (for prophylaxis of liver cirrhosis and hepatocellular carcinoma development) is one of the basic criteria of efficacy of treatment of chronic liver diseases. Now various strategies of influence on fibrosis are discussed, including elimination of etiological factor, suppression of inflammation and specific antifibrotic therapy.Conclusion. Successful antiviral therapy at chronic hepatitis B (continuous suppression of replication of virus and activity of inflammation in the liver) results in regression of fibrosis, including cirrhotic stage, and is associated with improvement of patients’ survival rate.

Aim: to evaluate the possibility of the MMR-system status, microsatellite instability (MSI) usage in the differential diagnosis of gastric mucosa dysplasia, determination of the gastric adenocarcinoma development risk. Material and methods. The study included gastric mucosa specimens of 75 patients: 25 with high-grade dysplasia, 25 with low-grade dysplasia, 25 were indefinite for dysplasia. Gastrobiopsy specimens were examined histologically, immunohistochemically using mouse monoclonal antibodies (Diagnostic BioSystems, USA) to the MMR system proteins: MLH-1 (clone G168-15, dilution 1:50), MSH2 (clone DBM15.82, dilution 1:100), MSH6 (clone 44, dilution 1:50), PMS2 (clone A16-4, ready to use). MSI was studied with multiplex PCR evaluation of DNA microsatellites (NR-21, NR-24, NR-27, BAT-25, BAT-26) from paraffin sections, their analysis with capillary electrophoresis. The obtained data were processed with the Statistica 10.0 (StatSoft, USA), presented using descriptive, analytical statistics. VOSviewer (1.6.20) was used to visualize the bibliometric analysis. Results. MMR-deficient cases were found in low (2.8 %) and high-grade (2.8 %) dysplasia with the immunohistochemical evaluation of MMR-system proteins in gastric mucosa specimens. In all indefinite for dysplasia cases MMR-system proteins remained unaffected. Three MSI-positive cases (6.5 %) were detected by PCR with two low-grade dysplasia, one high-grade dysplasia cases. All identified cases were also immunohistochemically MSI-positive. Conclusion. Determination of MSI can be used as an auxiliary study within a panel of biomarkers aimed to support the decision-making of a pathologist in the alternative of “indefinite for dysplasia” or “definite dysplasia — obligate precancer”.

Aim: to optimize outcomes of the treatment and prevention of gastrointestinal diseases in adults and children. Key points. The Methodological Guidelines contain sections on the terminology, classification, mechanisms of action, requirements for sale in the Russian Federation, requirements for proving the efficacy and safety of probiotics, prebiotics, synbiotics and metabiotics, as well as functional foods enriched with them. An overview of relevant data allowing to include these drugs and products in the treatment an d prevention of gastrointestinal diseases in adults and children is presented. Conclusion. The clinical efficacy of probiotics, prebiotics, synbiotics and metabiotics depends on the specificity and quantity of their components, the dosage form, the regimen and duration of treatment. Products and functional foods with proven efficacy and safety are recommended for the treatment and prevention of gastrointestinal diseases in adults and children.

Aim: to summarize the literature data of use of laser technologies in the treatment of anorectal diseases. Key points. Lazer intervention technologies in the treatment of anorectal diseases such as haemorrhoids, anal fistula, anal fissure and pilonidal disease makes it possible to significantly reduce the intensity of pain syndrome, shorten the time of wound healing and also reduce the duration of the period of disability of the patient without worsening the quality of life. The main advantages of minimally invasive techniques are the absence of extensive wounds, minimal complications and reduction of the disease recurrence rate, minimally invasive methods are almost as effective as traditional ones. Besides, the use of laser allows to perform minimally invasive interventions under local anaesthesia in a day hospital. Conclusion. It is necessary to further study and improve the use of laser technologies in the treatment of anorectal diseases, and to actively introduce techniques into practice to improve the results of treatment of patients with these nosologies.

Aim: to present data on the involvement of macrophages in the pathogenesis of celiac disease and the development of possible treatment methods for this disease aimed at changing the function of macrophages.Key points. Celiac disease is an autoimmune disease with a characteristic serological (antibodies to tissue transglutaminase, endomysium, deamidated gliadin peptides) and histological profile (inflammatory infiltration of the villous epithelium by lymphocytes and their atrophy, crypt hyperplasia) caused by gluten consumption in genetically predisposed individuals. Macrophages, as key cells that provide a link between innate and adaptive immunity, are of significant importance in the pathogenesis of celiac disease. Gliadin peptides stimulate the activation of macrophages according to the proinflammatory phenotype with the production of cytokines, which causes the immune response of T-helpers 1 and T-helpers 17. The result of these processes is the development of an inflammatory reaction and damage to the intestinal mucosa due to the production of matrix metalloproteinases and reactive oxygen species by macrophages. Therapeutic tactics for celiac disease today include a gluten-free diet, which is not so easy to follow. Of interest is the study of the possibility of using polyphenols in celiac disease, which are capable of precipitating gliadins and inhibiting the polarization of macrophages towards a proinflammatory phenotype, while simultaneously stimulating an increase in the population of macrophages of an anti-inflammatory phenotype associated with a decrease in tissue damage.Conclusion. Impaired macrophage function/differentiation results in either inadequate, excessive immune activation or failure to mount effective protective immune responses against pathogens, which may result in the development of gastrointestinal diseases. Studying the involvement of macrophages at different stages of celiac disease progression is important for the development of new treatments for this disease.

Aim: to present literature data on the importance of intra-abdominal hypertension in the pathogenesis of peritonitis. Key points. Secondary purulent peritonitis is a severe and fairly common form of abdominal infection with high mortality. According to statistics, hospitalization of patients with signs of local or diffuse peritonitis is more than 15 % among patients with acute surgical pathologies. One of the factors in the development of complications and an unfavorable prognosis for this disease is increased intra-abdominal pressure. To measure this indicator, a Foley catheter inserted into the bladder is used in medical practice. According to reference values, the optimal level of intra-abdominal pressure does not exceed 5 mmHg. A persistent increase in pressure of 12 mmHg and above indicates the development of intra-abdominal hypertension. An increase in the level of intra-abdominal pressure indicates the progression of the inflammatory destructive process in the abdominal cavity and contributes to the development of multiple organ failure with subsequent fatal outcome with untimely treatment. With an indicator exceeding 20 mmHg, there is a risk of developing abdominal compartment syndrome. This condition is characterized by increased pressure in two or more anatomical areas, which leads to decreased blood flow and subsequent tissue hypoxia. Intra-abdominal hypertension also increases the risk of developing postoperative peritonitis in patients who have undergone laparotomy. Conclusion. To predict the course of secondary diffuse purulent peritonitis, reduce the risk of complications and mortality, it is necessary to focus on measuring intra-abdominal pressure as a mandatory manipulation in surgical patients. Despite its general availability and ease of implementation, this technique allows assessing the severity of organ dysfunctions.

Aim: Diagnostic criteria for functional disorders of the biliary tract are presented in the materials of the Rome IV consensus, as well as expert councils of Russian and foreign specialists. Episodes of functional biliary pain are caused by a violation of bile outflow through the cystic duct and sphincter of Oddi. It has been suggested that there is a “biliary continuum” in which in some patients’ biliary dysfunction is transformed into cholelithiasis. Key points. Lithogenic bile is considered as the pathophysiological basis for the development of biliary dyskinesia and cholelithiasis. Lithogenic bile provokes inflammation of low grades in the mucous membrane of the biliary tract, decreased contractility of the gallbladder and impaired relaxation of the biliary sphincters, impaired physiological response to cholecystokinin. Changes in motility of the biliary tract may be associated with the influence of hydrophobic bile salts and impaired eicosanoid metabolism. Hyperplasia of the epithelium and muscle layer, hypersecretion of mucin and cholesterol precipitation further impair the outflow of bile. Experimental data and some clinical observations indicate the possibility of transformation of biliary dysfunction into cholelithiasis. Dysfunction of the sphincter of Oddi is one of the possible consequences of cholecystectomy and, in fact, acts as a variant of postcholecystectomy syndrome. The basis for the treatment of biliary dysfunctions are antispasmodics of different classes, which can be combined with ursodeoxycholic acid. The biliary tract-selective antispasmodic hymecromone has shown high effectiveness in relieving biliary pain, which also has a moderate choleretic effect and the ability to prevent the crystallization of cholesterol in bile and can be used both for functional diseases and for cholelithiasis. The domestic drug hymecromone “Odecromone” entered the pharmaceutical market. Conclusion. There is no doubt that the relevance of further study of the patterns of development of biliary dysfunctions and GI is obvious. The study of this problem will contribute to the development of effective preventive approaches, including in the field of nutraceuticals.

Aim: to present the results of the Expert Panel with a discussion of modern concepts of the pathogenesis of functional gastrointestinal diseases and the possibilities of multitarget therapy with trimebutine. Key points. Low-grade inflammation can be considered as a morphological substrate of functional diseases with an increase in activated mastocytes and eosinophils, T-helpers 2 and T-helpers 17 in the gastrointestinal mucosa. In the development in the content of visceral hypersensitivity, the functional connection between mastocytes and TRPV1-positive sensory endings of the vagus nerve is of great importance. Proinflammatory cytokines and matrix metalloproteinases can enter the systemic circulation, provoking the development of systemic manifestations. Increased levels of proinflammatory cytokines are supported by altered intestinal permeability and microbiota. Functional diseases are believed to modify the symptoms and course of concomitant organic diseases of the gastrointestinal tract (for example, functional diseases of the biliary tract may contribute to the development of cholelithiasis, pancreatitis). The peripheral μ-, κ- and δ-receptor agonist trimebutine (Trimedat®) regulates the production of enterohormones, modulates motility throughout the gastrointestinal tract and normalizes visceral sensitivity. The effectiveness of trimebutine in the treatment of functional disorders has been shown in various studies. Trimebutine helps reduce the production of proinflammatory cytokines, including interleukin-6. Conclusion. In the treatment of functional diseases of the gastrointestinal tract, trimebutine can be considered as a multitarget agent, since the drug helps to normalize motility, reduces the degree of visceral hypersensitivity, exhibits anti-inflammatory and neuroregenerative effects, and can also increase the effectiveness of treatment of concomitant diseases.

The aim of review. To present world literature data on epidemiology, features of course and diagnostics of gastroesophageal reflux disease (GERD) at children at different age.Original positions. Now the major attention is given by gastroenterologists and pediatrists to GERD at children, probability of its progression and development of complications in advanced age. Manifestations of GERD at children are different in various age-grades. At the first year of life of GERD manifests by regurgitation and vomiting. In most of the cases these symptoms are regarded to be physiological. However frequent regurgitation in this period of life is related to probability of further development of typical symptoms of GERD in these children. Along with growth, symptoms of GERD in children become more specific and similar to manifestations of disease at adults for whom the heartburn and acidic belching are considered as the most typical complaints. Basic methods of instrumental diagnostics of GERD and its complications at children, as well as at adults, include esophagogastroduodenoscopy and 24-hour esophageal and gastric рН-monitoring. However at children, there is no interrelation of clinical, endoscopic and рН-metrical changes severity.Conclusion. Above mentioned data testifies the absence of clear diagnostic criteria of GERD at children. For more exact diagnostics of GERD at pediatric age complex investigation of the child is required.

Aim of investigation. To study parameters of activity of liver tissue enzymes and blood lymphocytes in children with chronic viral hepatitis B (CVH B).Material and methods. 20 patients with CVH B in the age of 12 to 15 years were investigated: 10 children – with the 2-nd stage of process chronization and 10 – with the 3-rd stage. In liver tissue obtained at guided biopsy, and in lymphocytes discharged from blood activity of metabolic enzymes was determined by bioluminescent method.Results. Metabolic reactions in liver tissue of children depend on stage of chronization of process, at the 3-rd stage the functional lesion of liver cells it is more profound. Metabolism of lymphocytes in children depend on severity of disease as well, thus at children with the 3-rd stage of chronization more severe functional depression of lymphocytes took place.Conclusions. Intensity of reactions of metabolism of liver cells and lymphocytes in 12–15 years old children with CVH B, depends on stage of chronization of infectious process. Lesions of liver cells and lymphocytes are more profound at the 3-rd stage, than at the 2-nd. Pattern of interrelation of enzyme scores of the liver and lymphocytes allows to postulate, that the latter reflect specificity and orientation of metabolic changes in liver tissue.

Aim of investigation. To estimate various variants of surgical treatment of acute biliary pancreatitis at patients of over 60 years old, to develop a method of cholecystectomy at the large Hartmann pouch adherent to biliary tracts, to decrease such complications, as bleeding, bile leakage, damage (intersection) of common bile or common hepatic duct.Material and methods. Patients separated into 3 groups in relation to operative access. The first group – (67 patients) was operated by traditional surgical access. The second group (54 patients) was operated through miniaccess with the help of «Generalpurpose frame wound retractor», of them 34 patients with large Hartmann pouch adherent to biliary tracts, were operated by the proposed method (patent of the Russian Federation #2358663 under application #2008103639, priority 30.01.08; registered on 20.06.2009; bulletin #17). The third group (61 patients) was operated by laparoscopic method. The mean age of patients in groups was 73,1 years. In 100% of cases patients had two and more concomitant diseases. The main type of surgical intervention in groups – was cholecystectomy, drainage of common bile duct by Pikovsky, drainage of abdominal cavity.Results. At traditional cholecystectomy postoperative complications develop at 44,8% of patients: eventration – 7,5%, subphrenic abscess – 6%, suppuration of postoperative wound – 11,9%, pneumonias – 8,9%, pancreatonecrosis – 10,4%. After minilaparotomy in postoperative period at 9,3% of patients following complications developed: incompetence of cystic duct stump and bile leakage – 3,7%, suppurations of postoperative wounds – 3,7%, pneumonia – 1,9%. Conversions were registered in the main group at 5,6 % of patients. After videolaparoscopy complication were observed at 14,8 % of patients: damage of common bile duct, postoperative bile leakage – 3,3%, incompetence of stump of cystic duct – 1,6%, residual choledocholithiasis with accompanying obstructive jaundice – 3,3%, pancreatonecrosis – 6,6%.Conclusions. The proposed method of cholecystectomy at large Hartmann pouch adherent to biliary tracts, allows to decrease such complications as bleeding, bile leakage, excludes damage of common bile duct.

Aim of investigation. To evaluate expediency of testing for carbohydrate-deficient transferrin for diagnostics of alcohol intoxication.Material and methods. For 1996-2007 overall 978 patients with liver cirrhosis (LC) were investigated, including 531 patients with alcoholic LC, 189 patients with HBV-related LC and 258 patients with HCV-related LC. One hundred and three patients taking alcohol (as two subgroups) were tested for carbohydrate-deficient transferrin – a marker of chronic alcohol intoxication. In 56 patients (54,4%) asialoglycoside transferrin was studied, in 47 (45,6%) – all spectrum of sialoglycoside transferrin deficiency: a-, mono-, bi- and three- sialotransferrin deficiency.Results. Growth of alcohol consumption by population in the country resulted in increase of number of patients with alcohol-induced LC. It account for 3,5 times more deaths (78,0%), than all viral LC. Results of these investigations demonstrated, that at testing only for asialotransferrin positive result was obtained only in 3 (5,4%) patients admitted to the hospital with severe manifestations of acute alcoholic hepatitis. At assessment of integral deficiency of transferrin, changes have been found in 36 (76,6%) patients. It confirms high diagnostic capacity of this method in testing for chronic alcohol intoxication.Conclusion. In the last decade the number of patients with alcohol-induced LC with lethal outcome essentially exceeded number of patients, died of viral LC. Assessment of integral deficiency of transferrin is highly informative method of diagnostics of chronic alcohol intoxication.

Aim of investigation. To study at two models of immune hepatitis (Т-cellular and antibody origin) in mice damage of the liver, activity and destruction of its immunocompetent cells, thymus gland and the spleen, as well as the effect of curcumine — inhibitor of NF-κB activation on development of pathological process.Material and methods. An immune lesion of the liver in mice of СВА line was invoked by Т-cellular mitogen concanavalin A and xenogenic anti-liver antibodies. Study was carried out with application of histological, cytological and biochemical methods.Results. In comparative studies features of hepatitis development of cellular and antibody origin were revealed. At Т-cellular hepatitis cytolytic component of liver lesion, primary and secondary cell necrosis, depression of cytophagous activity of macrophages that causes preconditions for enhancement of inflammation were more intensive. At hepatitis of antibody origin, at least at early stages, vascular and immunological reactions are expressed in the liver.Conclusion. Curcumine, the inhibitor of NF-κB activation reduces preconditions for development of inflammatory response at experimental Т-cellular hepatitis, and has protective action for the liver.

The aim of the publication. The case of abnormal elevation of alpha-fetoprotein (AFP) in a patient with autoimmune hepatitis (AIH) of the 1-st type is submitted.Features of clinical case. At a 17 years old female patient AIH of 1-st type debuted by jaundice, severe rise of transaminase activity and level of gamma-globulins. Manifestations of AIH, at first glance were typical, accompanied by over 200-fold elevation of serum concentration of AFP that required differential diagnostics with hepatocellular carcinoma. Achievement of immunosuppressor-induced remission resulted in normalization of AFP level.Conclusion. Derepression of respective gene may serve as the mechanism of serum AFP concentration increase at active hepatitis which, however, in absence of neoplastic proliferation is under control of certain regulatory factors. Over 200-fold elevation of AFP level in presented case, that rapidly decreased up to normal level under the influence of successful immune suppressive treatment, can be hard to explain from traditional point of view. Apparently, it is necessary to take into account specific features of AFP synthesis regulation, manifested at vast destruction of hepatic parenchyma.

Aim: to substantiate the expediency of using a segment of the jejunum on a vascular pedicle in esophagoplasty. Materials and methods. At the National Medical Research Center of Surgery named after A.V. Vishnevsky, 12 patients underwent esophagoplasty with a combined visceral transplant, of which 9 (75.0 %) received a gastrointestinal graft and 3 (25.0 %) — a colon-jejunum one. Esophagectomy with simultaneous esophageal plastic surgery was performed in 10 (83.3 %) patients, in 4 (40 %) of them — in combination with distal gastric resection. The indication for surgery in 3 patients was cicatricial stricture of the esophagus and stenosis of the pylorus, in 2 — achalasia of the cardia of the terminal stage (in one patient — with ulcerative stenosis of the pylorus). Three more patients underwent esophagectomy due to peptic strictures: esophagogastroanastomosis (n = 1), esophagoenteroanastomosis (n = 1) and esophagus after Nissen surgery (n = 1). Cancer recurrence after proximal gastric resection and gastrectomy in 2 patients was an indication for esophagectomy. Also, 2 (16.7 %) patients were hospitalized in the National Medical Research Center of Surgery named after A.V. Vishnevsky with incomplete esophagoplasty: one person — after Dobromyslov — Torek surgery for spontaneous rupture of the esophagus, and one patient — after the unsuccessful Lewis surgery for esophageal cancer performed in other hospitals. Results. The average duration of post-operative stay was 12.7 ± 6.3 days. The postoperative period was smooth in 10 (83.3 %) patients. The failure of the cervical anastomosis was revealed in 1 (8.3 %) patient on day 5 after esophageal plastic surgery with colon-jejunum graft, which was resolved conservatively without repeated surgery. Relaparotomy was required in one patient on day 7 after surgery for bile peritonitis, the cause of which was destructive acalculous cholecystitis with perforation. All 12 patients were discharged from the clinic with full nutrition through the mouth. In the long-term period, 11 (91.7 %) patients remained under observation, 1 (9.1 %) developed an esophagogastroanastomosis stricture 1.5 months after esophageal plastic surgery, which was resolved by 4 courses of bougation during the first 9 months after surgery. No other complications were noted. Conclusion. The segment of the jejunum on the vascular pedicle, used for esophagoplasty, in the condition of a shortage of plastic material, allows not only to complete the reconstruction at once, but also to restore the natural passage of food and prevent bile reflux.

Aim of the review. To present up-to-date management approach to biliary cysts of the liver and polycystosis.Original positions. Opinions of surgeons differ in the issue of whom and when to operate, as well as in the choice of intervention procedure. At polycystosis, patients with the II type liver cysts (by J.Gigot classification) are exposed to treatment. At the presence of cysts of the III type, when the massive lesion of parenchyma takes place (>70%), there is no alternative for liver transplantation. At present there is no uniform medical approach in relation to diameter of cysts that results in application of various methods of treatment. Following variants are defined: 1) percutaneous puncture and drainage of cysts with injection of sclerosing agents; 2) laparoscopic erasion of free walls of cysts with impact on remaining epithelium; 3) erasion of cysts by laparotomic access. Laparoscopic resection of cysts is considered to be the optimal method that is low traumatic, with low frequency of relapses (0–4%) and minimum duration of hospital stay.Conclusion. Only 5–10% of patients with not parasitic (biliary) cysts of the liver are subject to surgical treatment, the others should be observed either by gastroenterologist, or by surgeon of out-patient department.

Aim of investigation. Evaluation of potentials of «dulcolax» for preparation for colonoscopy.Material and methods. Preparation for colonoscopy at versatile hospital was applied by oral intake of macrogol-based preparation (2–2,5 l of solution) in combination to 20 mg of bisacodyl (dulcolax) in 50 patients. Patients of comparison group received a full dose of macrogol (4 l).Results. Preparation quality in clearing of intestine appeared to be comparable in the main and control groups. At the same time patients of a basic group less often had unpleasant symptoms and they had no adverse effects related to intake of main laxative.Conclusion. Dulcolax can be used as additional agent in preparation for colonoscopy to minimize adverse effects related to this procedure, and improvement of its end result.

Aim: to demonstrate the need for a detailed differential diagnosis and selection of therapy in a patient with decompensated liver cirrhosis of combined etiology (HCV infection and primary sclerosing cholangitis). Key points. The patient came to the clinic with complaints of shortness of breath with minimal physical activity, abdominal enlargement, swelling of the legs, yellowness of the skin, and severe weakness. The complaints arose two months after suffering from left-sided focal pneumonia. Laboratory tests revealed signs of systemic inflammation, liver failure, and acute kidney injury. According to the results of instrumental studies, massive hydrothorax was noted in the right pleural cavity. The patient underwent a series of thoracentesis, and a total of about four liters of non-inflammatory pleural fluid was evacuated. Differential diagnosis was based on the presence of dyspnea and respiratory failure. The patient received effective antiviral therapy with drugs using an interferon-free regimen. Subsequently, conservative therapy was carried out, against the background of which the symptoms regressed and the patient’s condition improved. Conclusions. Hepatopleural syndrome is a serious complication in patients with decompensated liver cirrhosis, although it does not always appear secondary to massive ascites. To resolve hepatic hydrothorax, it is necessary to carry out diuretic therapy, replacement transfusion therapy with albumin preparations, and if there is a large amount of fluid in the pleural cavities, therapeutic and diagnostic thoracentesis is recommended.

Aim: to present data on the role of bile acids in the progression of Barrett's esophagus (BE) and the development of esophageal dysplasia and adenocarcinoma and to provide a rationale for the use of ursodeoxycholic acid in addition to basic therapy in patients with gastroesophageal reflux disease (GERD).Key points. The prevalence of GERD in the world is 13.98 %. In the absence of the necessary treatment or non-compliance with the recommended regimens and duration of drug use, complications of GERD develop such as stricture, bleeding, BE, which, in turn, is a risk factor for the development of esophageal adenocarcinoma (EAC). The basic therapy for GERD is proton pump inhibitors (PPIs), but up to 40 % of patients do not fully respond to PPI monotherapy, which indicates the need to consider, among the factors in the pathogenesis of GERD, the persistence of weakly acidic and weakly alkaline refluxes, the presence of which can be diagnosed by performing 24-hour impedance-pH monitoring. It has been proven that refluxate is predominantly acidic in nature in 50 % of patients with GERD, acidic with a bile component in 39.7 %, and 10.3 % of patients have bile reflux. The weaklly alkaline nature of reflux, due to the presence of duodenal contents, significantly increases the incidence of intestinal metaplasia with dysplasia and EAC compared to acidic pH values. Therefore, stopping duodenal reflux may be an important step in preventing the development of EAC. Among the components of duodenal contents that have a damaging effect on the mucous membrane of the esophagus, the role of bile acids has been most studied. The presence of hydrophobic bile acids, namely deoxycholic acid (DCA), is associated with oxidative DNA damage in lesions of intestinal-type columnar cell metaplasia. Ursodeoxycholic acid (UDCA), a hydrophilic bile acid, is a natural competitive inhibitor of DCA and prevents DNA damage and nuclear factor-κB (NF-κB) activation caused by toxic bile acids in BE epithelial cells. The cytoprotective effect of UDCA, aimed at preventing DNA damage and increasing the reparative capacity of cells in the metaplastic epithelium of the BE, allows us to consider this drug as a means of chemoprophylaxis in patients diagnosed with GERD.Conclusion. The addition of UDCA drugs to the basic therapy is pathogenetically justified in patients with GERD in the presence of duodenogastroesophageal reflux. Prescribing complex therapy will reduce the incidence of esophagitis, progression of BE with the development of dysplasia and adenocarcinoma caused by exposure to bile acids.

Aim: to provide the basic points of the Expert Panel of the Russian Gastroenterological Association with discussion of measures to improve diagnostics, treatment and management of chronic gastritis patients.Key points. In the Russian Federation in 2021 more than 30 million patients diagnosed with “Gastritis and duodenitis” were recorded (K29 in accordance with International Classification of Diseases-10). H. pylori incidence rate in the Russian population has reduced and presently is about 40 %. In chronic gastritis pattern H. pylori-associated gastritis has still dominated though gastritis percent after successful H. pylori eradication, reactive gastropathy (including reflux gastritis) and autoimmune gastritis, has increased. Endoscopic and histologic examinations serve as key diagnostic techniques that provide a means for assessing the ethiology of gastritis, topography and degree of atrophic changes, gastritis staging as per OLGA/OLGIM system that properly correlates with the risk of stomach cancer and determines endoscopic examination strategy. H. pylori eradication therapy of gastritis serves as an etiotropic treatment and makes it possible to prevent progression of atrophy and stomach cancer. Conventional triple therapy combined with bismuth tripotassium dicitrate allows for achieving optimal cure rates of H. pylori eradication. Addition of rebamipide to regimens of H. pylori eradication improves their efficiency. Rebamipide arrests symptoms of dyspepsia in the case of chronic gastritis and functional dyspepsia. The administration of rebamipide for chronic gastritis makes it possible to influence the syndrome of increased epithelial permeability and inflammation, which makes it advisable to study it as a means of preventing stomach cancer and the progression of atrophy in various types of chronic gastritis.Conclusion. Members of the Expert Panel has approved the algorithm of diagnosis and treatment of H. pylori-associated gastritis, gastritis after H. pylori eradication and H. pylori-negative gastritis at the diagnostic stage in the case of initial presentation and long-term follow-up when needed.

Introduction. Genetic predisposition in combination with environmental factors and the patient’s psychological and emotional state play a key role in the development of irritable bowel syndrome (IBS). Studies of association between genetic polymorphisms and IBS can help in understanding the key pathophysiological mechanisms. To date, 11 meta-analyses on this issue have been published, however, none of them comprehensively summarize the data on the prevalence of genetic polymorphisms in IBS with predominant constipation (IBS-C).Aim: to summarize the published data on the impact of genetic polymorphisms on the risk of IBS-C.Materials and methods. A literature search was performed in the PubMed and Scopus databases. Identified studies were used for a meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Publications investigating genetic polymorphisms in patients with IBS-C were included in this analysis.Results. A total of 34 studies met the inclusion criteria. The collected data were sufficient to conduct a meta-analysis on polymorphisms of three of the listed genes: SLC6A4 (10 articles), GNB3 (5 articles), ADRA2A (4 articles). No significant association was found between the SLC6A4 (5-HTTLPR) polymorphism, GNB3 c.825C > T (rs5443) polymorphism and either IBS or IBS-C. It was found that ADRA2A 1291C>G polymorphism was significantly associated with both IBS and IBS-C.Conclusions. Our meta-analysis revealed that ADRA2A 1291C>G polymorphism was significantly associated with both IBS and IBS-C in the mixed population. Neither homozygous nor heterozygous variants of the SLC6A4 (5-HTTLPR) polymorphism and GNB3 C825T polymorphism were associated with either IBS-C or IBS as a whole.

Aim: to evaluate the possibilities of endoscopic ultrasonography in the diagnosis of benign stenosis of the major duodenal papilla and improve its results, including by identifying and objectifying the criteria of the disease.Materials and methods. The results of the examination and treatment of 2146 patients treated at the Kursk Regional Multidisciplinary Clinical Hospital in the period from 2015 to 2022, who underwent transpapillary interventions and/or endoscopic ultrasonography on the basis of the endoscopy department, are presented. A therapeutic and diagnostic algorithm for the management of patients with dilation of the common bile duct has been introduced into clinical practice, based on the developed criteria for stenosis of the major duodenal papilla (MDP), for which endoscopic ultrasonography was used in combination with the methodology of synthesis of hybrid fuzzy decision rules.The algorithm was implemented in a group of patients, which included 217 people.Results. Using the developed endosonographic criteria for MDP stenosis and the methodology for the synthesis of fuzzy decision rules, a production decision rule for the diagnosis of MDP stenosis was determined with a decision made according to a threshold set by experts at the level of 0.9. Guided by the selected information sources, 134 (61.7 %) patients with dilated common bile duct were diagnosed with MDP stenosis, requiring minimally invasive treatment aimed at relief of biliary hypertension and indications for endoscopic papillosphincterotomy were determined. In 83 cases of MDP stenosis, it was decided to abandon transpapillary interventions with subsequent follow-up of patients. Minimally invasive treatment using retrograde and antegrade techniques was performed in 134 patients. Complications were noted in 6 (4.4 %) patients, which is comparable to the number of complications with transpapillary interventions performed in patients without MDP stenosis. When monitoring 54 patients for one to three years, 85.2 % of patients showed regression of clinical, laboratory and instrumental symptoms of biliary hypertension.Conclusions. The combination of endoscopic ultrasonography with fuzzy logic technologies based on hybrid artificial intelligence made it possible to objectify the diagnosis of MDP stenosis and optimize indications for transpapillary interventions.

Aim: to evaluate the relationship of body composition components with the development of ascites in patients with liver cirrhosis.Materials and methods. One hundred and ten patients (44 men and 66 women) with the established diagnosis of liver cirrhosis were treated at the University Clinical Hospital No 2 of the Sechenov University. The assessment of the component composition of the patients’ body was carried out using the ABC-01 “MEDASS” device (“MEDASS”, Russia). Ascites diagnosis was performed using ultrasound examination of the abdominal cavity and retroperitoneal space.Results. The values of body mass index (p < 0.001), fat mass (p = 0.002), active cell mass (p < 0.001), and phase angle (p < 0.001) were lower in patients with ascites than without it. Patients with a lower percentage of body fat mass had a more severe ascites severity and vice versa, and the proportion of fat mass was generally higher in women than in men (r = –0.290; p = 0.002). Patients with lower active cell mass had higher ascites severity (r = –0.380; p < 0.001). However, this indicator was lower in women than in men. Significant negative correlations were revealed between fat mass, active cell mass, phase angle (r = –0.395; p < 0.001) and the severity of ascites.Conclusion. Our study confirms the importance of body composition parameters in the development of ascites in patients with cirrhosis of the liver. Insufficient amount of fat and muscle mass, as well as low values of the phase angle according to the results of bioimpedance can become predictors of the development of ascites. Evaluation of these components can be used in prognostic models to identify patients with an increased risk of ascites. Further research in this area will help to better understand the mechanisms of ascites development and develop effective methods of prevention and treatment of this complication in patients with liver cirrhosis.

Aim: to present a clinical case of colorectal cancer in a woman with a long history of smoking and a leading complaint of dry cough.Key points. A 56-year-old patient with a long history of smoking was hospitalized in the pulmonology department of the clinic with a leading complaint of a constant debilitating dry cough during the day, not amenable to the action of drugs, as well as general weakness, sweating and weight loss by 2 kg in 3 months. The examination revealed a moderately differentiated adenocarcinoma of the hepatic bend of the colon with generalized lymphadenopathy and metastatic lung damage, iron deficiency anemia. Surgical treatment was performed at the Sechenov University surgical hospital: right-sided hemicolectomy with D2 lymph dissection (removal of epicolic, paracolic, mesocolic lymph nodes); adjuvant chemotherapy was prescribed. The patient is under the supervision of an oncologist and a coloproctologist.Conclusion. A clinical case of colorectal cancer in a woman with a long history of tobacco smoking and extra-intestinal symptoms is presented, demonstrating the need for cancer caution in relation to patients older than 50 years with iron deficiency anemia and lymphadenopathy. The timeliness of the diagnosis of a malignant neoplasm by primary care physicians is determined by the careful identification of cancer risk factors of this localization and the targeted search for “symptoms of anxiety”, upon detection of which endoscopic, radiation and morphological examination is necessary.

Aim: creation of diagnostic models including electrical, viscoelastic parameters of erythrocytes to distinguish fatty liver disease of mixed etiology (metabolic + alcoholic) from non-alcoholic and alcoholic fatty liver disease.Materials and methods. We examined 46 men with non-alcoholic fatty liver disease (NAFLD), 43 men with alcoholic fatty liver disease (AFLD), as well as 54 men with fatty liver disease (FLD) of mixed genesis (metabolic + alcohol-related); average age of the patients included in the study made 48.4 ± 9.6 years. The diagnosis was established on the basis of liver ultrasound findings and FLI liver steatosis index with a fibrosis grade of F1 or less (FibroScan® 502, Echosens, France). The electrical and viscoelastic parameters of erythrocytes were investigated by the diagnostic technique of dielectrophoresis using an electrooptical cell detection system.Results. The most significant parameters for differentiating fatty liver disease of mixed genesis (metabolic + alcoholic) from NAFLD using the Volcano plot have turned out to be cell polarizability at a frequency of 106 Hz (p = 6.49 ×10-5), erythrocyte cell membrane capacity (p = 0.00077), relative polarizability (p = 0.001), the levels of which were higher in patients with NAFLD. On the contrary, the index of red blood cells destruction at 105 Hz was higher in FLD of the mixed genesis (p = 0.047) and the crossover frequency was shifted to the high frequency range more than in NAFLD (p = 0.0005). The discriminant analysis has additionally revealed the significance of the degree of erythrocyte deformation at 5 ×105 Hz in distinguishing between mixed-genesis FLD and NAFLD. In differentiating FLD of mixed genesis from NAFLD, a diagnostic model incorporating the above red blood cells parameters has provided an AUC of 0.829 (confidential interval: 0.742–0.916), sensitivity of 80.9 %, and specificity of 83.3 %. Two indicators of red blood cells have been established that statistically significantly distinguish the mixed-genesis FLD from the AFLD (Volcano plot); these are the index of red blood cells destruction at a frequency of 5 ×105 Hz, which was higher with AFLD (p = 0.0007), and the capacity of cell membranes, the value of which prevailed in mixed-genesis FLD (p = 0.011). When distinguishing the mixed-genesis FLD from the AFLD, the combined model with the inclusion of three parameters of red blood cells, namely the index of red blood cells destruction at a frequency of 5 ×105 Hz, the capacity of erythrocyte membranes, and polarizability at a frequency of 106 Hz, has shown the highest levels of diagnostic accuracy, namely AUC = 0.751 (confidential interval: 0.611–0.908) with a sensitivity of 79.5 %, specificity of 74.7 %.Conclusion. The electrical and viscoelastic parameters of erythrocytes studied using the diagnostic technique of dielectrophoresis should be considered as promising biomarkers for the diagnosis of diffuse liver disease.

Introduction. As a result of portal hypertension (sequestration of platelets in an enlarged spleen) and liver failure (decreased production of thrombopoietin in the liver) in liver cirrhosis, thrombocytopenia develops, which is associated with the risk of periprocedural/perioperative bleeding complications. There are still unresolved questions regarding risk stratification of bleeding complications, the prognostic role of thrombocytopenia, as well as the need for treatment of thrombocytopenia and its methods.Materials and methods. The Russian Scientific Liver Society selected a panel of experts in the field of therapeutic and surgical hepatology, hematology, transfusion medicine to make reasoned statements and recommendations on the issue of treatment of thrombocytopenia before elective surgery / invasive procedures in patients with liver cirrhosis.Results. Relevant clinical issues were determined based on the PICO principle (patient or population, intervention, comparison, outcome). The Delphi panel made five questions and gave reasoned answers, framed as ‘clinical practice recommendations and statements’ with evidence-based comments. The questions and statements were based on the results of search and critical analysis of medical literature using keywords in English- and Russian-language databases. The formulated questions could be combined into four categories: bleeding risk stratification, the prognostic value of thrombocytopenia, the necessity and methods of thrombocytopenia drug correction, and bleeding risk reduction.Conclusions. The results of experts' work are directly related to high-quality management of patients with liver cirrhosis and thrombocytopenia, who have scheduled invasive procedures/surgery. Thus, this recommendations and statements can be used in clinical practice.

Aim: to analyze the scientific literature on the role of various factors in the mechanisms of development of functional constipation and to summarize the current data on its leading pathogenetic mechanisms.Key points. Constipation occurs in 15 % of the adult population in the world and leads to a significant decrease in the quality of life, and in combination with some other symptoms may indicate the presence of an organic pathology of the gastrointestinal tract. The pathogenetic basis of functional constipation (FC) with slow intestinal transit is a decrease in colonic motor function, which is confirmed by the results of high-resolution manometry. FC is characterized by disturbances in such motor patterns of the colon as low and high amplitude propagating contractions, segmental non-propagating contractions, and general increases in pressure. The main FC mechanisms associated with neurogenic dysregulation include impaired function of the gray and white matter of the brain, as well as an increase in the tone of the sympathetic nervous system with a concomitant decrease in the influence of cholinergic nerves innervating the large intestine. A key role in the FC development belongs to a decrease in the pool of interstitial cells, which play the role of an intestinal pacemaker, due to slowing of their self-renewal. FC-associated changes in the enteric nervous system include a relative excess of the contribution of inhibitory influences and a decrease in the activity of cholinergic and serotonergic neurons that stimulate intestinal motility. A certain role in the occurrence of reduced motor function of the colon may have an imbalance in the production of intestinal hormones synthesized by enteroendocrine cells, namely, a deficiency of motility stimulants, which include motilin, gastrin, ghrelin and cholecystokinin, as well as a relative excess of hormones that suppress motility (somatostatin and vasoactive intestinal polypeptide). Changes in the composition of the intestinal microbiota can also contribute to the FC occurrence, which is associated with a dysfunction of the metabolite profile produced by intestinal bacteria.Conclusions. Functional constipation is a classic multifactorial disease, in the etiology of which the adverse effects of the genotype are combined with multiple acquired risk factors. A more complete understanding of the molecular mechanisms of the FC development can serve as the basis for the emergence of new effective treatments for this common pathology.

Aim: to present the difficulties of the choice of surgical tactics in case of esophagoenteroanastomosis suture failure after gastrectomy.Key points. In patient K., 55 years old, after a planned surgical intervention involving gastrectomy for stomach cancer, leakage of the esophagoenteroanastomosis sutures was noted. An attempt to re-form the esophageal-intestinal anastomosis did not lead to success, despite the early stages of relaparotomy, therefore, in order to relieve purulent complications, it was decided to take the path of “disconnecting” the esophagus, for which the cervical esophagus was transected and brought out in the form of two stomas, and the distal end of the esophagus was sutured tightly. Adequate drainage of the esophageal stump area and disconnection of the esophagus at the cervical level made it possible to avoid purulent complications in the abdominal cavity. The reconstructive stage was performed after 6 months in the amount of a colonic insert between the distal esophagus and the jejunum and plastic surgery of the esophagus using a skin insert in the neck.Conclusion. The chosen treatment tactics was determined by the impossibility of conservative treatment of the suture failure of the esophageal-intestinal anastomosis due to ischemic disorders and necrosis of the small intestine anastomosed with the esophagus. Disconnection of the esophagus after repeated suture failure of the esophageal-intestinal anastomosis seemed to be the only chance to stop the flow of esophageal contents into the abdominal cavity and thereby eliminate the source of purulent complications. The esophagoplasty option used turned out to be the safest and allowed to save the patient’s life.

Aim: in the retrospective study to assess the frequency of various gastritis variants based on the results of morphological examination of gastric biopsies over a 5-year observation period.Methods. The study included 3162 individuals who underwent esophagogastroduodenoscopy with biopsy collection between 2017 and 2022. Pathological examination of biopsies was conducted using the updated Sydney system, determining the histological variant and, when possible, the etiology of gastritis. In some cases, chronic gastritis was assessed using the OLGA/OLGIM system.Results. The most frequently diagnosed type was active H. pylori-associated gastritis (36.7 %), followed by chronic atrophic gastritis with intestinal metaplasia in cases where H. pylori infection was not detected (28.4 %), including immunohistochemical examination, classified as gastritis after successful H. pylori eradication. Atrophic forms of chronic gastritis constituted 34.8 %. Minimal or mild changes close to normal histological characteristics were оbserved in 19.2 % of patients. Reactive gastropathy was present in 7.6 % of cases. Autoimmune gastritis ranked fourth in frequency, with a relatively high percentage of observations (8.6 %).Conclusion. According to the analysis of gastric biopsies in the Russian population, a high frequency of H. pylori-associated gastritis was observed, and autoimmune gastritis is not uncommon. The high prevalence of atrophic gastritis emphasizes the importance of dynamic patient monitoring within cancer prevention programs.

Aim: to assess the composition of the microbiota of the mucous membrane of the body and the antrum of the stomach.Materials and methods. Sixty patients with dyspeptic symptoms were included into the study. Two biopsy samples of the gastric mucosa (from the body of the stomach and the antrum) were obtained from each patient. The presence of H. pylori infection was confirmed by PCR; RNA was isolated and then libraries were prepared for metatranscriptomic analysis of the 16S rRNA gene. Sequencing was performed on MiSeq (Illumina, USA) using MiSeq Reagent Kit v3 (600-cycle) (Illumina, USA).Results. The bacterial diversity decreases with the predominance of Helicobacter pylori species in H. pylori-positive patients. These results were confirmed by the Shannon index, the average value of which was 3.6 in the H. pylori-positive group and 5.4 in the H. pylori-negative group. In H. pylori-negative patients an increase in the representation of Streptococcus, Prevotella and Alloprevotella genera was observed. The level of H. pylori contamination of the gastric mucosa varies in the antrum and body of the stomach, in some cases reaching a 3.5-fold difference. Representation of other bacteria in the body and antrum of the stomach does not differ significantly.Conclusion. The bacterial composition of the stomach is dependent on the presence of H. pylori. H. pylori leads to the decrease of the bacterial diversity with the predominance of H. pylori in gastric microbiome.

Aim: to discuss current views on the clinical significance, diagnostic opportunities, and therapeutic approaches in the treatment of small intestinal bacterial overgrowth (SIBO) as an important component in the gut microbiota function assessment, to assess the awareness of physicians and the opportunities in the diagnosis and treatment of this disease in patients in the Federal districts of the Russian Federation, as well as to present the proceedings of the Expert Council held on December 16, 2023 in Moscow.Key points. SIBO is a common syndrome often associated with irritable bowel syndrome, liver cirrhosis, asthma, and congestive heart failure, being also a predictor of early death in the elderly. Today, in many regions of the Russian Federation, there are limitations for instrumental diagnosis of this disease — lack of awareness among doctors, unavailability of gas analyzers for diagnosing SIBO, lack of information about the need to diagnose SIBO in the standards of compulsory health insurance. Rifaximin is the first-line treatment due to the highest therapeutic efficacy. One of the ways to increase the efficacy of SIBO treatment is to include strain-specific probiotics in the treatment regimen. Saccharomyces boulardii CNCM I-745 is thought to be the most studied, promising probiotic. The review also presents statistical data on the issues in the diagnosis and treatment of SIBO in the regions of the Russian Federation.Conclusion. Optimization of approaches to the diagnosis and treatment of SIBO, the development of domestic gas analyzers, increasing the awareness of physicians in all regions of the Russian Federation, as well as the development and optimization of clinical recommendations appear to be necessary measures to increase the effectiveness of medical care, the duration and quality of life of the Russian population. These goals can be achieved within the framework of Federal programs under the supervision of specialized reference centers of the Ministry of Health of the Russian Federation.

In 2019, on the eve of Vladimir Ivashkin’s 80th birthday, we conducted our first interview with him. Now, on the eve of his 85th birthday, Professor Ivashkin again kindly agreed to talk with us and share his thoughts, emotions and impressions about the key events of the past five years.

Aim: localization of the new nomenclature of steatotic liver disease in Russian clinical practice.Key points. In 2023, international consensus decided to introduce a new nomenclature for steatotic liver disease. The article discusses the reasons for the change in nomenclature and the new terms adopted: steatotic liver disease, metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction and alcohol associated steatotic liver disease. Adapting new terms to Russian healthcare poses a certain problem. The results of voting by Russian doctors on the introduction of new terms and their optimal translation are presented. A comparison of existing classifiers with new terms was carried out and the formulation of diagnoses was discussed taking into account the new nomenclature.Conclusions. Adaptation and implementation of new nomenclature into clinical practice is an important and complex task, in which it is necessary to maintain a balance between a progressive concept and the interests of practical healthcare.

Aim: to present a clinical observation of a patient with Whipple's disease, demonstrating the difficulties in diagnosing the disease.Key points. A clinical observation of Whipple's disease in a 61-year-old man is described. The onset of the disease was manifested as polyarthritis three years before diagnosis. The further course of the disease occurred during the pandemic of a new coronavirus infection COVID-19, which made the diagnostic search difficult. Clinical manifestations of fever, arthralgias, diarrhea, lymphadenopathy, anaemia and weight loss raised suspicion of Whipple's disease. Key to the diagnosis were endoscopic studies with multiple small bowel biopsies, which allowed histological identification of PAS-positive macrophages in the small bowel mucosa. Therapy with ceftriaxone for 14 days, therapy with trimethoprim-sulfamethoxazole (160 mg/800 mg twice a day) for 14 months resulted in positive clinical dynamics, improvement of laboratory parameters, disappearance of PAS-positive macrophages in the small intestinal mucosa, indicating remission of the disease.

Aim: to evaluate, using the “GastroPanel®”, the frequency of detection of H. pylori infection and associated gastric diseases among doctors and medical staff of the National Medical Research Radiological Centre of the Ministry of Health of the Russian Federation, Moscow.Materials and methods. Employees of three branches of the National Medical Research Radiological Centre (n = 434, mean age — 48.5 ± 0.6 years) were examined using laboratory tests “GastroPanel®” (Biohit Oyj, Finland). The test results make it possible to identify infection of the stomach with H. pylori, hypo- and hyperacid conditions, as well as atrophic gastritis of the antrum and body of the stomach, as its precancerous conditions. Esophagogastroduodenoscopy (EGDS) for suspected atrophic gastritis was performed with an Olympus GIF-HQ190 video endoscope (Japan) in a narrow-spectrum mode with close focus (NBI Dual Focus).Results. The absence of pathological signs detected by “GastroPanel®” was established in 23.3 % of cases, hyperacid state — in 18.4 %, and hypoacid state — in 5.2 %. These disorders are classified as functional. Consequently, the conditional norm in total was identified in 46.9 % of observations. An increased level of antibodies to H. pylori was found in 43.3 % of those examined. Atrophic gastritis in the body of the stomach according to the results of the “GastroPanel®” was detected in 4.8 % of cases (median age — 59 years), in the antrum (or increased secretion of hydrochloric acid) — also in 4.8 % of cases (median age — 52 years). Within two months after laboratory diagnostics, EGDS was performed for 10 out of 15 patients examined at the P. Hertsen Moscow Oncology Research Institute in whom, based on the results of the “GastroPanel®”, the presence of atrophic gastritis in the antrum (or increased secretion of hydrochloric acid) was suspected. In 6 out of 10 cases, atrophic gastritis of the antrum was confirmed (in two of them, the atrophy extended to the body of the stomach and was assessed as severe). Of the 11 people with the “GastroPanel®” conclusion “Atrophic gastritis of the body of the stomach,” an endoscopic examination was carried out in 7 persons, and in all these cases the diagnosis was confirmed, and in two people the conclusion was made of severe atrophic pangastritis.Conclusion. “GastroPanel®” confirmed its high significance in identifying H. pylori infection and precancerous atrophic changes in the gastric mucosa. Regarding the occupational risks of infection among medical workers, we consider it advisable to conduct such screening without selecting an asymptomatic population.

Aim. Given the potential for physiological alterations in the gastrointestinal tract following appendix removal, which may influence carcinogenesis, we embarked on a systematic review and meta-analysis to explore the possible association between appendectomy and the subsequent risk of colorectal cancer (CRC).Methods. Our systematic investigation utilized sources including the Cochrane Library, Embase, PubMed, ClinicalTrials.gov, and Web of Science, covering research up to February 1, 2023. We assessed the impact of appendectomy on colorectal cancer, employing a random effects model to calculate the pooled hazard ratio (HR) for developing CRC post-appendectomy and its 95 % confidence interval (CI).Results. This review and meta-analysis incorporated a total of 10 studies, comprising 1,001,693 cases of appendectomy and 39,463 instances of CRC. The meta-analysis revealed a pooled HR of 1.04 (95 % CI: 1.0–1.08) for developing CRC following appendectomy. Notably, the HR for CRC development increased to 1.20 (95 % CI: 0.69–1.69) when considering only cases with more than 10 years of follow-up.Conclusion. The findings indicate a marginally increased risk of colorectal cancer in cases without a specified follow-up period. However, this elevated risk did not persist over the long term (exceeding 10 years). The heterogeneity of the included studies appears to have influenced our results. Nevertheless, it is advisable for physicians to weigh the potential benefits of alternative therapies and consider the future complications that may arise from an unnecessary appendectomy.

Aim. The guidelines set out the modern methods of diagnostics and treatment of peptic ulcer and are created for gastroenterologists, primary care physicians, general practitioners, surgeons, endoscopists.Key points. The clinical guidelines contain modern views on the etiology and pathogenesis of peptic ulcer, its clinical features, methods of laboratory and instrumental diagnostics, the main approaches to conservative and surgical treatment. They include the criteria for assessment of the quality of medical care, the algorithm of the doctor's actions, as well as information for the patient.Conclusion. Knowledge of modern methods of diagnostics and therapy of peptic ulcers will contribute to improving the results of its treatment.

Aim: to improve methods of diagnostics of esophageal mucosal forms of metaplasia and dysplasia in patients with complicated forms of gastroesophageal reflux disease (GERD) using multidisciplinary approach.Material and methods. Overall, 131 patients aged 18 to 84 years (mean age — 55.8 ± 16.7 years) with confirmed diagnosis of GERD complicated by development of metaplasia of mucosa of distal esophagus were included in retroand prospective study. At the prehospital stage the patients' complaints were estimated, anamnesis was taken. At the first stage of the diagnostic program all patients underwent detailed esophagogastroduodenoscopy in high resolution with white light. The region of esophageal mucosa with signs of metaplasia and determination of its prevalence was examined and evaluated with special attention. Ultrashort segment was revealed in 26 patients, short segment — in 47 patients, long segment of mucosal metaplasia was revealed in 58 patients. Then to reveal the signs of dysplasia we used specifying endoscopic methods: the structure of pitted and microvascular pattern was estimated in narrow spectral mode using BING classification system. If an irregular type of metaplasized epithelium structure was detected in the process of BING assessment, the areas suspicious for dysplasia were marked, followed by aim forceps biopsy from them. The next stage was staining of the metaplasized segment with 1.5 % ethanic acid solution — acetowhitening. PREDICT classification system was used to evaluate the stained mucosal sections with metaplasia. Targeted forceps biopsy was performed from the altered areas that most quickly lost their coloring. The final stage of the diagnostic program in all patients was a forceps biopsy of the mucosa of the metaplasic segment according to the Seattle protocol, which requires increasing the number of fragments as the metaplasic segment lengthens in a “blind” biopsy. The biopsy material was stained with hematoxylin and eosin, and periodic acid Schiff reaction was performed in combination with alcyanine blue according to the standard technique.Results. Endoscopic examination in white light and evaluation of metaplasia extent revealed ultrashort segment ( 3 cm) — in 58/131 (44.3 %) patients. Among the diagnostic techniques used, the BING and PREDICT classifications had the highest accuracy, sensitivity, and specificity (accuracy — 88.9 and 95.3 %, sensitivity — 90.5 and 91.3 %, and specificity — 86.7 and 100 %, respectively), which significantly exceeded the Seattle protocol also used in this work. The results showed a low level of specificity (31.2 %), accuracy (54.5 %), and sensitivity (76.8 %) of the Seattle protocol. The use of BING and PREDICT classifications provided marking of compromised zones, allowing targeted histological sampling.Conclusions. The original study demonstrated the greatest sensitivity, specificity, and accuracy of PREDICT and BING methods in the diagnosis of metaplasia with signs of dysplasia in patients with complicated GERD. It is also important that the use of BING and PREDICT classification systems allows to reduce the number of biopsy samples in comparison with their unreasonably large number according to the Seattle protocol, thereby reducing mucosal and submucosal trauma of the esophagus and the risk of complications.

Aim of the study: evaluate the role of normalization of humoral immunity to address dose reduction or discontinuation of immunosuppressors in patients with autoimmune hepatitis (AIH).Patients and methods. The data of 47 patients with AIH who received immunosuppressive therapy from April 2001 to August 2023 were analyzed: 10 men (21 %), 37 women (79 %); the average age was 37 (17–66) years. The follow-up period was 10–180 months. Type 1 AIH was diagnosed in 37 patients, type 2 AIH — in 7 patients, seronegative AIH — in 3 patients. The diagnosis was established according to the IAIHG point system. To confirm the diagnosis, a liver biopsy was performed in 17 patients, a histological picture of AIH was detected in all of them. The most used combination was prednisolone and azathioprine — in 25 patients (53.2 %), as well as methylprednisolone and azathioprine — in 8 patients (17 %).Results. In some patients, when the immunosuppressive therapy decreased below the recommended dose, a relapse of the disease developed (Group 1), and in others, remission persisted (Group 2). The concentration of гамма-globulins in patients of Group 1 was 22.5 mg%, in Group 2 — 17.95 mg% (p = 0.00055). IgG level after achieving remission in Group 1 was 1709.7 mg/dL, in Group 2 — 1381.7 mg/dL (p = 0.000001). The terms of ALT normalization in Group 1 were 2.14 months, in Group 2 — 1.47 months (p = 0.037); AST normalization in Group 1 made 2.22 months, in Group 2 — 1.48 months (p = 0.026).Conclusions. Normalization of humoral immunity, as well as rapid normalization of ALT and AST can be considered as markers of maintaining AIH remission when immunosuppressor doses are reduced below standard doses, and in individual patients — the possibility of immunosuppressive therapy withdrawal. This will reduce the risk of adverse events and increase adherence to the therapy. We propose introducing the term “immunological remission” into the clinical lexicon, which, along with biochemical and histological remission, acts as a predictor of persistent remission of AIH.

Introduction. In cirrhotic patients, hyperammonemia develops due to impaired ammonia detoxification and portosystemic blood shunting and is most commonly associated with hepatic encephalopathy and sarcopenia. Currently, there are questions regarding the diagnosis of hyperammonemia and the effect of ammonia-lowering therapy on disease outcomes.Materials and methods. The Russian Scientific Liver Society selected a panel of seven experts in liver cirrhosis research and management of patients with this disease to make reasoned statements and recommendations on the issue of diagnostic and prognostic value of hyperammonemia in patients with liver cirrhosis, hepatic encephalopathy and sarcopenia.Results. The Delphi panel identified the most relevant topics, in the form of PICO questions (patient or population, intervention, comparison, outcome). The Delphi panel made six questions relevant to clinical practice and gave reasoned answers, framed as ‘clinical practice recommendations and statements’ with evidence-based comments. The questions and statements were based on the search and critical analysis of medical literature by keywords in Englishand Russian-language databases. The formulated questions could be combined into four categories: hepatic encephalopathy, sarcopenia, hyperammonemia, and ammonia-lowering therapy.Conclusions. The results of the experts' work are directly relevant to the quality management of patients with liver cirrhosis, and their recommendations and statements can be used in clinical practice.

Introduction. The standard volume of removed groups of lymph nodes for right colon cancer (RCC) has not been determined. According to Japanese clinical guidelines, it is necessary to perform D3 lymphadenectomy in all cases, except stage I, while according to European and Russian clinical guidelines, the standard scope of surgical intervention includes only D2 lymphadenectomy. There are no long-term results regarding differences between D2 and D3 lymph node dissection in RCC; therefore, it is relevant to conduct studies to improve the long-term results of treatment of patients with RCC.Aim: to comparatively evaluate the results of treatment of patients with RCC who underwent laparoscopic right hemicolectomy at A. Tsyb Medical Radiological Research Center.Materials and methods. Conducted from 2018 to 2023, the study included 174 patients with stage I–III RCC: in 106 patients, laparoscopic right hemicolectomy with D2 lymph node dissection was performed, in 68 patients — with D3 lymph node dissection. When assessing the homogeneity and comparability of the groups, according to input parameters, such as clinical stage, gender, age, body mass index and tumor location, their heterogeneity was noted, which did not allow a direct comparative assessment of both groups. To eliminate heterogeneity and adequately select groups, a pseudorandomization technique was used, after which the groups (n = 68) became statistically comparable in all main clinical parameters.Results. Statistically significant differences were obtained in the median duration of surgical intervention, which was longer in the group of patients with D3 lymph node dissection — 150 (60–393) and 213 (70–390) minutes (p < 0.001), and in the median time of flatus passage — 2 (1–4) and 3 (1–9) days, respectively (p = 0.042). Postoperative complications in accordance with the Clavien — Dindo classification occurred in 16 (23.5 %) patients in the group with D2 and in 15 patients (22.1 %) in the group with D3 lymph node dissection (p = 0.999); III–V grade complications were noted in 2 (2.9 %) cases in each group (p = 0.999). Postoperative hospital stay was 6 days for patients in both groups (p = 0.369). During pathomorphological assessment of the removed specimen, the median number of examined lymph nodes was significantly higher in the group with D3 lymph node dissection: 14 (1–52) and 19 (3–59) lymph nodes, respectively (p < 0.001). Involvement of apical lymph nodes (groups 203, 213, 223) was noted in 2 (3 %) patients. In the group with D2 lymph node dissection, distant metastases were recorded twice as often as in the group with D3 lymph node dissection — in 8 (11.8 %) and 4 (5.9 %) patients, respectively (p = 0.365). Local recurrence was not established in any case. The three-year overall and disease-free survival rates were 94.8 ± 3.0 and 100 % (p = 0.149) and 80.5 ± 5.8 and 88.7 ± 5.8 % (p = 0.177), respectively.Conclusions. The experience of using total mesocolonectomy with D3 lymph node dissection for RCC indicates the safety of this surgical intervention in comparison with traditional surgical techniques, while we did not obtain statistically significant differences in patient survival. To definitively determine the role of D3 lymph node dissection in the treatment of patients with RCC, large multicenter randomized studies are certainly needed.

Aim: to provide data on the pathogenesis of functional biliary pain and provide rationale for the use of trimebutine for this indication.Key points. Biliary pain is one of the most frequent reasons for patients to see a doctor. The diagnosis of functional disorder of the gallbladder and Oddi's sphincter is legitimate only after the exclusion of organic causes from both the gastrointestinal tract and other organs and systems. The initial appeal to surgeons with a complaint of pain in the epigastrium or right hypochondrium may lead to unjustified surgical intervention that does not bring relief to the patient's suffering. The consequences of cholecystectomy also have an anatomical and physiological justification for the occurrence or preservation of biliary pain. Currently, two main hypotheses are being considered to explain its cause: increased intraluminal pressure due to morphological and functional obstacles to bile outflow and visceral hypersensitivity. In the multilevel system of regulation of the gallbladder and sphincter apparatus, the opioid system occupies a special place. The agonist of peripheral receptors of the enkephalinergic system, trimebutine, in clinical studies led to the relief of biliary pain in more than 80 % of patients with functional biliary disorders, while a significant decrease in the severity of diarrhea, dyspeptic, and constipation syndromes was revealed.Conclusion. The prescription of the peripheral receptor agonist of the enkephalinergic system, trimebutine, is pathogenetically justified for functional biliary pain.

Background. Some studies have shown that resveratrol may prevent, delay, or treat liver damage. This study aimed to provide up-to-date evidence regarding the effect of resveratrol on the liver enzymes (ALT & AST) in NAFLD patients. We conducted a systematic review and meta-analysis to evaluate the effect of resveratrol on liver enzymes in patients with NAFLD by searching various databases for published RCTs.Methods. A systematic search in PubMed, Scopus, and Web of Science was performed up to September 2023. This systematic review and meta-analysis included all the RCT studies assessing resveratrol supplements on serum AST and/or ALT in NAFLD patients. The effect was presented as a mean difference and 95 % confidence interval (CI) in a random-effects model.Results. Finally, six eligible randomized controlled trials consisting of 256 patients were found. Resveratrol had no significant effect on serum ALT (Mean diff = 3.30 IU/L; 95 % CI: –2.34, 8.94; p = 0.25) and AST (Mean diff = 0.07 IU/L; 95 % CI: –2.96, 3.10; p = 0.96) concentrations. Moreover, subgroup analysis revealed that neither resveratrol dose nor intervention duration had any significant effect on the serum ALT and AST levels.Conclusion. The current evidence shows that resveratrol supplementation did not affect liver enzymes in NAFLD patients.

Aim: to evaluate the efficacy and safety of the new prokinetic drug acotiamide in the treatment of functional dyspepsia.Key findings. Acotiamide is an antagonist of inhibitory muscarinic receptors of type 1 and 2 and a reversible inhibitor of acetylcholinesterase activity. In patients with functional dyspepsia acotiamide normalizes the accommodation of the fundal part of the stomach and accelerates delayed gastric emptying. The conducted studies have confirmed the higher efficacy of acotiamide compared to placebo in reducing the severity of such symptoms of functional dyspepsia as a feeling of epigastric postprandial fullness and bloating, early satiation. The advantage of acotiamide in comparison to other prokinetics (in particular, metoclopramide and domperidone) is the high safety of use and the absence of influence on the duration of the Q-T interval.Conclusion. The high efficacy and safety of the application makes it advisable to use acotiamide in the treatment of patients with functional dyspepsia.