Carbohydrate intolerance

Aim of review. To present the modern concept on etiology and pathogenesis of food intolerance, to analyze the modern strategy of diagnosis and treatment of carbohydrate intolerance. Key points. Patients, who presented with abdominal pain, diarrhea, flatulence at the absence of organic diseases should be investigated to exclude intolerance of nutritional components, first of all - carbohydrates. If food intolerance was confirmed, high performance treatment methods should be applied including dietary modification with elimination of intolerable food products, addition of specific enzyme preparations to the treatment mode. Conclusion. Carbohydrate intolerance results in abdominal pain, flatulence and diarrhea in generally healthy population and patients with functional gastrointestinal diseases. Early detection of integrated agentт and its elimination from the ration will provide significant decrease in symptom severity

Diagnostics and treatment of Clostridium difficile-associated disease: Guidelines of the Russian gastroenterological association

Aim of publication. To present with clinical guidelines of the Russian gastroenterological association on Clostridium difficile-associated disease management to practical doctors. Summary. Clostridium difficile-associated disease develops at disorders of intestinal microbiome with excessive colonization of C. difficile which toxins cause colonic inflammation and damage. C. difficile toxins A and B are major virulence factors causing damage of intestinal wall and inflammation due to damage of intestinal epithelial barrier, induction of proinflammatory cytokines, apoptosis and a necrosis of epithelial cells. Current epidemiologic trends of C. difficile-associated disease are characterized by growth of both inpatient and community-acquired morbidity, expansion of risk groups, increase in number of more severe cases including those, caused by more virulent BI/NAP1/027strain, tendency to relapsing, increase in lethal outcomes. C. difficile infection is the most common cause of intrahospital diarrhea leading to significant mortality. Risk factors of C. difficile-associated include antibacterial therapy, hospital admission, elderly age, comorbidity and immunosuppressive treatment. At the present time several laboratory methods for diagnosis of Clostridial infection exist: fecal ELISA test for toxins A and B, PCR, test for C. difficile glutamate dehydrogenase. Detection of densely adhered to underlying mucosa greenish or creamy deposits (pseudomembranes) is the endoscopical marker of severe C. difficile-associated disease i.e. pseudomembranous colitis. C. difficile-associated disease treatment includes vancomycin and metronidazole, the choice of drug and dose depends on disease severity. Significance of sorbents and probiotics in patient management is under discussion. Prophylaxis requires rational application of antibiotics, decrease, whenever possible, of terms of hospital stay, timely diagnosis and observance of sanitary and epidemiologic rules in medical institutions. Conclusion. Epidemiologic growth, risk of significant morbidity made C. difficile-associated disease a socially important disease. The present guidelines direct the doctor to correct diagnosis and adequate treatment of C. difficile infection

Diagnostics and treatment of biliary dyskinesia: clinical guidelines of the Russian gastroenterological Association

Aim of publication. To present the guidelines on diagnostics and treatment of biliary dyskinesia to practical doctors. Summary. The gallbladder dyskinesia and sphincter of Oddi dyskinesia are defined as the diseases of functional origin caused by motility and visceral sensitivity disorders. The pathogenesis of these disorders is not completely understood. Development of sphincter of Oddi dysfunction is related to previous cholecystectomy. Contractility disorders along with increased lithogenicity followed by cyclooxygenase-2 overactivation in biliary tract tissue play significant pathogenic role; putative change in bile acid composition may be involved as well. Diagnosis of biliary dyskinesia requires first the careful analysis of pattern of pain and compliance of symptoms to biliary pain criteria; second, instrumental tests that exclude organic origin of biliary disease. Estimation of the type of biliary dysfunction is established on compliance of the detected symptoms to proposed criteria. Conclusion. Biliary dyskinesia pathogenesis is not studied well. Development of attacks of biliary pain (according to established criteria) and lack of organic disorders evidence, may help to suspect the presence of biliary dyskinesia. To exclude organic biliary diseases with confidence, informative modern diagnostic tests of biliary tract visualization should be applied. Therapeutic approach should include correction of diet and lifestyle modification, administration of antispasmodic medications and agents modulating the state of nervous system, in selected cases the option of papillosphincterotomy should be considered

Diagnostics and treatment of biliary dyskinesia: clinical guidelines of the Russian gastroenterological Association

Aim of publication. To present the guidelines on diagnostics and treatment of biliary dyskinesia to practical doctors. Summary. The gallbladder dyskinesia and sphincter of Oddi dyskinesia are defined as the diseases of functional origin caused by motility and visceral sensitivity disorders. The pathogenesis of these disorders is not completely understood. Development of sphincter of Oddi dysfunction is related to previous cholecystectomy. Contractility disorders along with increased lithogenicity followed by cyclooxygenase-2 overactivation in biliary tract tissue play significant pathogenic role; putative change in bile acid composition may be involved as well. Diagnosis of biliary dyskinesia requires first the careful analysis of pattern of pain and compliance of symptoms to biliary pain criteria; second, instrumental tests that exclude organic origin of biliary disease. Estimation of the type of biliary dysfunction is established on compliance of the detected symptoms to proposed criteria. Conclusion. Biliary dyskinesia pathogenesis is not studied well. Development of attacks of biliary pain (according to established criteria) and lack of organic disorders evidence, may help to suspect the presence of biliary dyskinesia. To exclude organic biliary diseases with confidence, informative modern diagnostic tests of biliary tract visualization should be applied. Therapeutic approach should include correction of diet and lifestyle modification, administration of antispasmodic medications and agents modulating the state of nervous system, in selected cases the option of papillosphincterotomy should be considered

Diagnostics and treatment of chronic constipation in adults: clinical guidelines of the Russian gastroenterological association

Aim of publication. To present the modern concept on etiology and pathogenesis of constipation, its classification, basic diagnostic and treatment methods to general practitioners. Summary. The prevalence of constipation in general population is quite high and averages 12 to 19%. Two types of constipation are usually distinguished: primary (functional) and secondary that is related to mechanical obstruction of the intestinal passage of bowel content, neurologic and endocrine diseases, systemic diseases of connective tissue, intake of drugs etc. At diagnosing of functional constipation early detection of «alarm symptoms» which require thorough patient investigation is important. Moreover, insufficient treatment response require step-by-step instrumental diagnostics. Constipation treatment has to be comprehensive and include general recommendations (intensification of physical activity, increase in dietary fiber in daily ration etc.), intake of psyllium, laxatives, including first of all of polyethyleneglycol, at insufficient response enterokinetic agents. Conclusion. Successful treatment of constipation requires correct detection of its cause, following essential dietary recommendations and stepwise application of pharmaceutical agents

Diagnostics and treatment of peptic ulcer: clinical guidelines of the Russian gastroenterological Association

The aim of publication. To present modern concept on etiology and pathogenesis of the peptic ulcer (PUD) to general practitioners, to acquaint them with modern diagnostic methods and main treatment approaches of this disease. Summary. The PUD continues to remain one of the most widespread digestive disease. Despite a tendency to decrease of hospital admission rate of patients with uncomplicated PUD, increase in complicated forms of disease rate is noted that it is related mainly to the growing intake of non-steroidal anti-inflammatory drugs (NSAID). Helicobacter pylori infection has a leading role as PUD ethological factor. None H. pylori-associated gastroduodenal ulcers may be caused by NSAID intake or may develop within the other nosological entities (symptomatic stomach and duodenal ulcers). PUD diagnosis includes obligatory testing for H. pylori infection and carrying out eradication in the case of positive takes. At the present time the first line of antihelicobacter therapy includes standard triple clarithromycin and amoxicillin-based therapy, as well as quadrotherapy with bismuth drugs. The second line eradication therapy includes quadrotherapy with bismuth drugs and triple levofloxacin-based therapy. The third line therapy modes should be chosen after assessment of individual antibiotic sensitivity of H. pylori strains. The efficacy control of antihelicobacter treatment should be carried out not earlier than 4 weeks after the end of eradication. Conclusion. Strict conformance of diagnostic algorithm for this category of patients as well as the eradication therapy protocol allows to decrease considerably the risk of recurrence of PUD and its complications

Diagnostics and treatment of gastroesophageal reflux disease: clinical guidelines of the Russian gastroenterological association

Aim of publication. To present the latest data on adequate diagnostic methods, treatment approaches and features of rational pharmacotherapy of gastroesophageal reflux disease (GERD) based on the principles of evidence­based medicine to general practitioners. Summary. The prevalence of GERD occupies the first place of other gastroenterological diseases. The heartburn that is a leading GERD symptom is present at 20-40% of the population of developed countries. The prevalence of GERD in Russia ranges 18­46%. Diagnosis of GERD early stages is based on the primary appealability and clinical presentation evaluation. Esophagogastroduodenoscopy (EGDS) gives the chance to define the presence of reflux esophagitis, to estimate severity grade, to reveal development of esophageal epithelium columnar metaplasia. At the refractory course (lack of conclusive clinical and endoscopic remission within 4-8 wks of treatment by standard dose of proton pump inhibitor - PPI), and development of complications (strictures, Barret's esophagus) examination within specialized hospital or gastroenterological clinic is required, including their out­patient departments. Under certain indications the patient should undergo EGDS with esophageal biopsy and histological examination of biopsy specimens to rule out the Barret's esophagus, esophageal adenocarcinoma and/or eosinophilic esophagitis; intraesophageal 24­hour pH­metry or pH­impedance measurement; high resolution esophageal manometry; X­ray study of the esophagus and stomach. The treatment of GERD has to be individualized according to the pattern and severity of clinical symptoms. The goal of treatment is symptom relief, at erosive esophagitis - healing of erosions and complication prevention, at Barret's esophagus - prophylaxis of disease progression and dysplasia and adenocarcinoma development. Nowadays PPIs are considered as the most effective and safe agents for GERD treatment. PPIs are applied for the long­term baseline treatment (no less than 4-8 wks) and maintenance therapy (6-12 months). Intake of alginates is pathogenically reasonable therapeutic approach for reduction of «acid pocket» and acid neutralization in the area of gastro­esophageal junction in GERD patients by formation of mechanical barrier raft which prevents reflux of the stomach content into the esophagus. Antacid monotherapy is recommended for the cases of rare heartburn which is not accompanied by esophagitis and in complex modes of GERD treatment for achievement of rapid symptom relief. Adsorbents are applied as monotherapy at non­ erosive reflux disease, and as a component of comprehensive GERD treatment, especially of the cases of mixed (acid + biliary) refluxes. Prokinetic drugs promote recovery of a normal physiological state of the esophagus, controlling the pathogenic mechanisms of GERD, reducing the number of transient lower esophageal sphincter relaxations and improving esophageal clearance due to stimulation of the lower gastrointestinal motor function. Prokinetics can be applied as a component of comprehensive treatment of GERD along with PPI. Anti­reflux surgery is indicated in complicated cases (recurrent bleeding, peptic esophageal strictures, development of Barret's esophagus with high­grade epithelial dysplasia, frequent aspiration pneumonias). Surgical treatment of GERD is more effective in patients was typical manifestations and positive treatment response to PPIs. Conclusion. Implementation of clinical guidelines can promote improvement of healthcare quality for GERD patients and prevent complications, in particular if terms of treatment will be observed, at active outpatient follow­up for certain groups of patients

The Role of Lactobacillus reuteri DSMZ17648 for Helicobacter pylori eradication therapy

Aim of review. To analyze the options of application of Lactobacillus reuteri DSMZ17648 (Pylopass™) within Helicobacter pylori eradication. Summary. H. pylori eradication therapy is considered as one of the optional spheres for clinical application of probiotic medications. According to available data certain strains of probiotics are effective in decreasing of gastrointestinal adverse effects rates, associated with eradication therapy while the other can potentiate the efficacy of H. pylori eradication itself. L. reuteri strain DSM17648 which was chosen from over 700 wildtype strains of Lactobacillus spp. possess the ability for selective adhesion to H. pylori in vivo in the gastric media. DSM17648 strain of L. reuteri form coaggregates with various H. pylori strains and serotypes both in vivo and in vitro. It was revealed that lyophilizate of this strain (PylopassTM) blocks adhesion of H. pylori to epithelial cells as well. Clinical trials demonstrate the effect of PylopassTMon gastric mucosa colonization by H. pylori according to the 13C urea breath test data and as well the increase in H. pylori eradication rate when the productis added the to triple therapy modes. Conclusion. Potential of PylopassTM combination to various H. pylori eradication therapy modes is a subject offutnet multicenter randomized clinical trials for assessment of optimal combination to antibiotic drugs, treatment duration and adverse effect rates. The value of monotherapy by this metabiotic at chronic H. pyloriassociated gastritis is a subject of further studies