18.04.2017 Английские резюме статей "Доктор.ру" Гастроэнтерология № 2 (131), 2017

Treatment and Prevention of Cholelithiasis: Current Concepts

  1. V. Tsukanov, Yu. L. Tonkikh, A. V. Vasyutin

Objective of the Review: To analyze methods used in the treatment and prevention of cholelithiasis.

Key Points: Laparoscopic cholecystectomy is generally considered the leading treatment option for symptomatic or complicated cholelithiasis. Ursodeoxycholic acid (UDCA) has proven effective in dissolving choleliths in patients with asymptomatic cholelithiasis and reducing gallbladder inflammation in people with symptomatic cholelithiasis.

Exercise, losing weight, and dietary changes are important ways to prevent cholelithiasis. Using UDCA as a preventive measure for cholelithiasis is reasonable in patients at risk for this disorder (those with rapid weight loss).

Conclusion: Optimal outcomes in patients with cholelithiasis are achieved through an appropriate combination of surgical, therapeutic, and preventive treatments.

Keywords: cholelithiasis, treatment, prevention, ursodeoxycholic acid.


Current Non-Invasive Methods for Diagnosing Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease

  1. A. Akhmedov, O. V. Gaus

Objective of the Review: To review the data in currently available literature in order to assess the applicability, diagnostic value, and effectiveness of non-invasive markers in the diagnosis of liver fibrosis in patients with non-alcoholic fatty liver disease (NAFLD).

Key Points: Outcomes of NAFLD such as liver cirrhosis and hepatocellular carcinoma are currently among the top ten causes of premature death worldwide. Monitoring the course of NAFLD is one of the most important goals in modern hepatology.

The degree of liver fibrosis reliably indicates the progression of chronic hepatic disorders. Since the use of morphological tests in a broad clinical practice is limited for a number of objective reasons (invasive techniques, the need for highly qualified staff, risk of intraprocedural complications, and risk of false results), the possibility of using non-invasive diagnostic markers of liver fibrosis is a particularly urgent issue.

Conclusion: In patients with NAFLD, a panel of laboratory parameters combined with ultrasound elastography data can be used as reliable non-invasive markers of liver fibrosis.

Keywords: non-alcoholic fatty liver disease, non-invasive markers, liver fibrosis, ultrasound elastography, biopsy.


Autoimmune Hepatitis: How to Avoid Mistakes

Yu. G. Sandler, Ye. V. Vinnitskaya, L. N. Gendrikson, T. Yu. Khaimenova, D. L. Rotin, R. B. Gudkova

Objective of the Review: To summarize current literature on the diagnosis and treatment of autoimmune hepatitis (AIH).

Key Points: AIH is a clinical diagnosis. The following should be considered as diagnostic criteria for this condition: presence of autoimmune markers, hypergammaglobulinemia, and morphological signs of active hepatitis.

Timely diagnosis and immediate initiation of appropriate treatment reduce the risk of complications and death in patients with AIH. This paper also describes a retrospective clinical study, to help raise doctors’ awareness about AIH. This study demonstrates that patients, upon the first signs of liver disease, require thorough and comprehensive examination, and adequate and timely treatment with systemic and topical corticosteroids.

Conclusion: AIH is a chronic liver disease that progresses if not treated properly. Treatment must be started as early as possible, at the precirrhosis stage. When AIH has led to liver cirrhosis (LC), treatment should be given with caution, since it is difficult to assess its efficacy. LC is not always associated with hypergammaglobulinemia and is frequently accompanied by a modest increase in alanine aminotransferase and aspartate aminotransferase levels. Given the high risk of infectious complications, patients should be closely monitored throughout the treatment process. When treatment has no effect, liver transplant is indicated.

Keywords: autoimmune hepatitis, autoantibodies, liver biopsy, immunosuppressive therapy, corticosteroids, azathioprine, budesonide.


Enzyme Activity in the Small-Intestine Mucosa of Celiac Disease Patients on Gluten-Free Diet

  1. V. Akhmadullina, E. A. Sabelnikova, N. I. Belostotsky, A. I. Parfenov, S. G. Khomeriki

Study Objective: To measure intestinal carbohydrase (glucoamylase, maltase, sucrase, and lactase) levels in celiac disease patients following a strict gluten-free diet (GFD).

Study Design: This was a prospective study.

Materials and Methods: Thirty-six patients with celiac disease, aged 18 to 74, were examined; all were strictly following GFD. Levels of intestinal carbohydrases (glucoamylase, sucrase, maltase, and lactase) were measured in mucosa biopsy samples using the Dahlqvist method with Trinder's modification.

Study Results: Deficiencies of lactase, maltase, sucrase, and glucoamylase were detected in 83.3%, 58.3%, 55.6%, and 69.4% of the patients, respectively; 41.7% of the patients were deficient in all of the enzymes under study. Histology of small-intestine mucosa showed that GFD had led to complete restoration of mucosal structure in only 19 of the 36 (52.8%) patients examined. Six of the 19 (31.6%) celiac disease patients with structurally normal small-intestine mucosa had low levels of all the carbohydrases studied.

Conclusion: Deficiency of the enzymes that break down carbohydrates is quite common among celiac disease patients who follow GFD, even in cases of complete mucosal restoration. Such deficits may lead to long-term persistence of clinical symptoms cased by factors other than dietary non-adherence.

Keywords: celiac disease, gluten-free diet, disaccharidase deficiency, lactase deficiency.


Effects of Transfusional Hemosiderosis on Liver and Heart in Patients with Myelodysplastic Syndrome

  1. A. Dudina

Objective of the Paper: To demonstrate the effects of transfusional hemosiderosis on the development of liver fibrosis and heart failure in patients with myelodysplastic syndrome (MDS) and to describe current methods for diagnosing and effectively treating complications of transfusional hemosiderosis.

Key Points: RBC transfusions remain the only treatment for anemic syndrome in patients with MDS. Iron overload associated with chronic blood transfusions causes severe toxic effects. Excessive amounts of this microelement are primarily accumulated in the liver and myocardium. Free iron causes destruction (damage) of these organs, resulting in organ dysfunction.

Understanding the pathophysiological pathways underlying the effects of transfusional hemosiderosis on the development and progression of cardiovascular insufficiency and liver fibrosis significantly expands the current view of how to treat this patient population.

Conclusion: Timely assessment of the severity of iron overload allows action to prevent its toxic effects on the hepatobiliary and cardiovascular systems, through initiation of treatment with iron-chelating agents, which subsequently reduce the risk of fatal hepatic or cardiovascular events.

Keywords: myelodysplastic syndrome, transfusional hemosiderosis, liver fibrosis, cardiovascular insufficiency.


Specific Features of Matrix Metalloproteinase Level Changes in Pancreatic Disorders

  1. V. Vinokurova, G. G. Varvanina, A. V. Smirnova, A. S. Gulyayev, D. S. Bordin, Ye. A. Dubtsova

Study Objective: To analyze changes in serum matrix metalloproteinase 2 (MMP 2) and 9 (MMP 9) and tissue inhibitor of matrix metalloproteinase 2 (TIMP-2) levels in patients with chronic pancreatitis (CP) or pancreatic cancer and to assess their potential value for detecting these disorders.

Study Design: This was a prospective, comparative study.

Materials and Methods: Patients were examined who had a carcinoma of the pancreatic head (n = 15), CP with postnecrotic pancreatic cysts (n = 23), or CP without cystic lesions (n = 37), as well as 13 people who had no pancreatic disorders (control group). MMP 2, MMP 9, and TIMP-2 levels were measured by immunosorbent assay in blood samples collected after fasting.

Study Results: The study showed a statistically significant increase in serum MMP 9 levels in patients with pancreatic carcinoma and those with a six-to-15-year history of CP without cystic lesions, compared to the control group. No statistically significant differences in MMP 2 levels were seen between the groups. Patients with CP and postnecrotic pancreatic cysts had meaningfully lower TIMP-2 concentrations than patients who had CP without cystic lesions.

Conclusion: Long-term CP is associated with increased risk for pancreatic carcinoma. MMP 9 levels can be used as an additional parameter in determining the individual prognosis in CP patients. Changes in MMP 9 levels are greatest in patients with a carcinoma of the pancreatic head. Evaluation of MMP and MMP inhibitor levels is an urgent and clinically significant issue because these parameters can be used as diagnostic and prognostic markers of pancreatic carcinoma and pancreatic inflammatory diseases.

Keywords: chronic pancreatitis, pancreas, matrix metalloproteinases.


Russian Consensus on Diagnosis and Treatment of Chronic Pancreatitis: Treating Abdominal Pain

  1. Ye. Khatkov, I. V. Mayev, D. S. Bordin, Yu. A. Kucheryavyy, S. R. Abdulkhakov, S. A. Alekseyenko, E. I. Aliyeva, R. B. Alikhanov, I. G. Bakulin, A. Yu. Baranovskiy, Ye. V. Beloborodova, Ye. A. Belousova, I. M. Buriyev, Ye. V. Bystrovskaya, S. V. Vertyankin, L. V. Vinokurova, E. I. Galperin, A. V. Gorelov, V. B. Grinevich, M. V. Danilov, V. V. Darvin, Ye. A. Dubtsova, T. G. Dyuzheva, V. I. Yegorov, M. G. Yefanov, N. V. Zakharova, V. Ye. Zagaynov, V. T. Ivashkin, R. Ye. Izrailov, N. V. Korochanskaya, Ye. A. Korniyenko, V. L. Korobka, N. Yu. Kokhanenko, M. A. Livzan, I. D. Loranskaya, K. A. Nikolskaya, M. F. Osipenko, A. V. Okhlobystin, V. D. Pasechnikov, Ye. Yu. Plotnikova, S. I. Polyakova, O. A. Sablin, V. I. Simanenkov, N. I. Ursova, V. V. Tsvirkun, V. V. Tsukanov, A. V. Shabunin

Objective of the Paper: To describe key points of the Russian Consensus on Diagnosis and Treatment of Chronic Pancreatitis (CP), related to treating abdominal pain.

Key Points: Patients with CP require adequate treatment for abdominal pain. In cases of exacerbation, fasting is not mandatory. In patients with CP, pain rating scales should be used for quantitative grading of pain, including when assessing treatment efficacy. The WHO 3-step pain ladder can be used as a guideline for starting and discontinuing medication.

Decisions regarding the duration of treatment with pain medications may be individualized for patients with CP. If a chosen method is not sufficiently effective, the treatment strategy should be regularly reviewed for the addition of endoscopic or surgical interventions if necessary. Octreotide, pancreatic enzymes, montelukast, electroacupuncture, percutaneous nerve electrostimulation, and radiation therapy are not recommended for abdominal pain related to CP. Antispasmodics, proton-pump inhibitors, celiac plexus neurolysis, and thoracoscopic splanchnicectomy may be used for the management of CP-related pain, but evidence supporting the use of these methods is scant.

Conclusion: The Consensus on Diagnosis and Treatment of CP, initiated by the Russian Pancreatology Club, has collected up-to-date information about these issues using the Delphi method. These principles of treatment for abdominal pain, and the related voting results, help in optimizing patient management plans and educational programs for doctors.

Keywords: chronic pancreatitis, consensus, abdominal pain.


Gastroesophageal Reflux Disease in Obese Patients: Clinical, Functional, and Morphological Features

  1. A. Zvenigorodskaya, S. G. Khomeriki, M. V. Shinkin

Study Objective: To study the clinical, functional, and morphological features of gastroesophageal reflux disease (GERD) in patients with abdominal obesity and in non-obese subjects, and evaluate approaches to treating GERD in obese patients.

Study Design: This was a comparative study.

Materials and Methods: Seventy-five patients with GERD and abdominal obesity (main group) and 56 non-obese patients with GERD (control group) were examined. The following data were assessed in all the patients: clinical data, X-ray, esophageal manometry and 24-hour pH monitoring, and esophagogastroduodenoscopy findings, as well as the results of histological examination of the esophageal mucosa.

Study Results: Patients in the main group had atypical GERD: heartburn was not the main complaint; the predominant clinical symptoms were those caused by disturbances in gastric and esophageal motility; and histological examination of the esophageal mucosa showed no dilation of intercellular spaces, expansion of the basal layer of the stratified squamous esophageal epithelium, or inflammatory infiltration of the lamina propria.

Given the specific features found in patients with abdominal obesity, GERD management for these patients should include weight loss and intake of prokinetic agents. In cases of alkaline reflux, ursodeoxycholic acid is justified. In cases of acid reflux, proton-pump inhibitors are the medications of choice.

Conclusion: In patients with abdominal obesity, the clinical manifestations and progression of GERD have several specific features, which should be considered when prescribing treatment.

Keywords: obesity, gastroesophageal reflux disease, motor disturbances, prokinetic agents.


Using Picoprep for Colonoscopy Preparation G. S. Tsaryova, K. Ye. Pchelintsev, A. A. Gladyshev, A. N. Shikhmetov

Study Objective: To assess the tolerability and efficacy of Picoprep for colonoscopy preparation.

Materials and Methods: In a 12-month period 1,372 colonoscopies were performed, of which 954 (69.5%) were done using Picoprep. Quality of colon cleansing was assessed during colonoscopy using the Chicago Bowel Preparation Scale, an internationally recognized scoring system with objective criteria. Tolerability of Picoprep was assessed by patients' subjective feelings.

Study Results: When Picoprep was used, quality of bowel preparation was excellent in 27.3% of the cases, good in 52.8%, fair in 19.7%, and poor in 0.2%. All patients who had previously used other medicines for bowel preparation reported that Picoprep had a good flavor and was well tolerated.

Conclusion: The efficacy of Picoprep is not inferior to other currently available polyethylene glycol-based bowel preparations, and Picoprep is superior to them in consumer qualities (tolerability).

Keywords: colonoscopy, bowel preparation, Picoprep.


Diagnostic Criteria for Serrated Lesions of the Colon

  1. V. Ageykina, O. A. Kharlova, N. A. Oleynikova, P. G. Malkov, M. V. Knyazev, V. A. Duvansky

Objective of the Paper: To describe endoscopic and morphological criteria for diagnosing serrated lesions of the colon.

Key Points: The WHO Classification of tumors of the colon and rectum, published in 2010, first included a classification group of premalignant lesions—serrated lesions, further classified as hyperplastic polyps, sessile serrated adenomas/polyps, and traditional serrated adenomas.

Serrated lesions are considered to be potentially malignant. This paper describes the serrated carcinogenesis pathway. Because of their malignant potential, serrated lesions of the colon should be detected and removed in a timely fashion.

Conclusion: This paper describes the specific features of each type of serrated lesion, which can suggest the nature of the abnormality even during endoscopy. Practitioners, however, often face atypical situations, which present additional diagnostic challenges.

Keywords: colon polyp, serrated lesion, diagnosis, sessile serrated adenoma/polyp, hyperplastic polyp, morphology, endoscopy.


Tribenoside in Combination with Lidocaine for Topical Treatment of Hemorrhoids: Review of Clinical Studies

  1. Yu. Knorring

Objective of the Review: To analyze the published data from studies designed to evaluate the efficacy and safety of tribenoside in combination with lidocaine (T/L) as a topical treatment for uncomplicated hemorrhoids.

Key Points: The T/L combination is used for topical treatment of hemorrhoids; it is available as suppositories or rectal cream. This combination has rapid and comprehensive effects on different hemorrhoid symptoms, providing significant therapeutic benefit. The efficacy and safety of T/L has been studied in numerous high-quality studies, most of which used reference groups whose members received conventional therapies for hemorrhoids.

Conclusion: Analysis of the published data shows that T/L is at least as effective as corticosteroid agents, and sometimes even more effective than either corticosteroids, or tribenoside or lidocaine used as monotherapy. This combination rapidly (within 10 to 30 minutes) relieved symptoms and was very well tolerated.

Keywords: tribenoside, lidocaine, hemorrhoids.


Assessment of Surgical Stress Parameters after Laparoscopic and Open Liver Resection

  1. N. Panchenkov, G. B. Aleksanyan, N. K. Akhmatova, M. G. Yefanov, R. B. Alikhanov, Yu. V. Ivanov

Study Objective: Comparative analysis of surgical stress parameters after laparoscopic liver resection (LLR) and open liver resection (OLR).

Study Design: This was a randomized parallel-group study.

Materials and Methods: Forty chinchilla rabbits were operated on in the experimental stage, and 38 patients underwent surgery in the clinical stage. These animals and patients were divided into groups of those who had laparoscopic surgery (main groups) and those who had open surgery (control groups). In each group, minor (segmental [up to three segments] or atypical) or major (hemihepatectomy) liver resection was performed.

Blood samples were collected before surgery, at 6 and 24 hours post-surgery, and on day 7 post-surgery. The following parameters of innate immunity were evaluated: phagocytic, cytotoxic, and proliferative activity of WBC, WBC subpopulations, Toll-like receptors (TLR), heat shock proteins (HSP), and cytokines.

Study Results: In the experimental stage, phagocytic, cytotoxic, and proliferative activity was higher in the OLR group. In the clinical stage, both groups showed a gradual increase in WBC and WBC subpopulations up to their pre-surgery levels on day 7 after surgery. Cytokines and TLR levels suggested higher reactivity following major OLR. Expression of HSP was significantly higher after OLR than after LLR.

Conclusion: LLR has certain advantages over OLR as confirmed by laboratory and clinical measurements of innate immunity. Compared to LLR, open liver resection causes a more marked increase in parameters of immune response and a more significant activation of innate and acquired immunity effectors.

Keywords: liver resection, laparoscopy, immune response, surgical stress.