Vol 81, No 2 (2009)

Aim. To characterize clinicomorphological manifestations of atrophic process (AP) in gastric mucosa (GM) in chronic atrophic gastritis (CAG) associated and not associated with Helicobacter pylori infection. Material and methods. Clinicoendoscopic and pathomorphological (light microscopy of gastric biopsies, 6 point scale assessment of dysregeneratory alterations) investigations were made in 98 patients aged 16 to 68 years. H.pylori-negative CAG was diagnosed in 52 of them, H.pylori-positive one in 46 patients (groups 1 and 2, respectively). Results. A comparative clinicomorphological analysis has identified 2 variants of AP morphogenesis in GM. Variant 1 is not associated with H.pylori but associated with a combined action of several endogenic risk factors of chronic gastritis or failure of regeneration, with diffuse or diffuse-focal changes with initial prevalence of dysregeneratory changes in a fundal stomach manifesting as a trend to atrophy of the glands. Clinically, this variant is characterized by longer disease, frequent systemic atrophic lesions of gastrointestinal mucosa, prevalent complaints of dyspeptic pain. Variant 2 is associated with a combined action of endo- and exogenic factors, H.pylori infection in particular, pathogenetic components of "chemical" gastritis (duodenogastric reflux, malnutrition), prevalence of dysregeneratory and sclerotic alterations in the antral stomach. Conclusion. GM atrophy is characterized by a significant frequency of concomitant endocrinopathies, undifferentiated connective tissue dysplasia, systemic lesions, structurally - by multidirectional disorders of proliferation and differentiation. First of all, it is the result of impaired regulation of regenerative processes. AP polyetiology and different morphogenetic variants in GM suggest necessity of both individual diagnostic algorithm and pathogenetically sound therapy in each individual case.

Aim. To specify dysfunction of the stomach and duodenum in gastroesophageal reflux disease (GRD) to offer more effective pathogenetic pharmacotherapy of GRD. Material and methods. Fibroesophagogastroduodenoscopy with further assessment of esophageal mucosa condition by Savary-Miller, intragastric pH-metry, dynamic gastroscintigraphy and electrogastrography were made in 150 GRD patients. Results. GRD patients were found to have significant disturbances of a motor-evacuatory function of the gastroduodenal complex. Addition of domperidon and mebeverin to routine combined treatment of GRD raises clinical efficacy of GRD treatment and promotes recovery of gastric and duodenal function though therapeutic efficacy of the above drugs depended on concomitant pathology. Conclusion. Domperidon and mebeverin addition to combined treatment of GRD makes this treatment more effective.

Aim. To determine clinical and cost-effect efficacy of staged (hospital-day hospital-outpatient clinic) treatment and rehabilitation of patients with ulcer disease (UD). Material and methods. Of 160 patients with duodenal ulcer 80 patients (controls) received treatment in hospital and 80 patients (the study group) were treated in hospital and day hospital. Efficacy of the treatment was assessed by clinical data, results of device and cost-effect investigations. Results. Clinical and endoscopic remission of duodenal ulcer was achieved for the same time in both the groups. The cost of the treatment of 1 patient was 23393 and 21163 rub in the controls and in the study group, respectively. Therefore, treatment in a day hospital reduced cost of the treatment. Later, the remission was consolidated by active follow-up in an outpatient clinic. Conclusion. Staged treatment of UD provides good therapeutic and economic effects compared to hospital treatment.

Aim. To analyse a clinical course of hepatic cirrhosis of various etiology in potential recipients of donor liver; to formulate symptom complex which determines life span prognosis in patients with chronic diffuse diseases of the liver (CDDL). Material and methods. We studied 74 recipients of the liver (73 adults aged 15-58 years and 1 boy aged 13 years, mean age at liver transplantation 27.04 ± 1.5 years, 41% males, 59% females). Orthotopic transplantation of the liver (OTL) was made from a live relative donor. All the patients have undergone clinical, biochemical, immunological, virological, ultrasonic, x-ray and other examinations. Severity of the patients condition was assessed according to the Child-Pugh classification. Indications to transplantation of the liver were formulated basing on the syndromal approach. Results. Asthenic syndrome was diagnosed in 34, pruritus - in 25, articular syndrome - in 11, jaundice - in 43, hepatomegaly - in 40, splenomegaly - in 65, ascitis - in 26, peripheral edema - in 8, esophageal varicose veins - in 66, encephalopathy - in 5 patients. Main syndrome manifestations of CDDL involved in formulating indications for liver transplantation consisted in the syndrome of liver cell insufficiency (diagnosed in 77% cases), syndrome of portal hypertension (detected in 100% cases), edemo-ascitic syndrome (41% cases), cholestasis syndrome (95% cases), autoimmune cytopenia syndrome (77% cases), hepatorenal syndrome (5.4%). Most of potential recipients who had liver transplantation were classified as having class B and C by Child-Pugh (66.3%), but often indications for OTL were considered in terms of a combination of various syndromes significant for life prognosis in each patient and in terms of urgency of OTL performance. Conclusion. In determination of indications for OTL syndromal approach seems most adequate. Main syndromes influencing primarily on OTL decision making are portal hypertension with consideration of esophageal varicose veins, syndrome of hepatic cell deficiency, edemoascytic syndrome, hepatorenal syndrome, syndrome of autoimmune cytopenia and cholestasis.

Aim. To study the level of lipoprotein(a) - Lp(a) in the blood serum and incidence of isoforms of apolipoprotein(a) - apo(a) in males and females with cholelithiasis and free of it in population of Novosibirsk; to assess possible correlations between Lp(a) level in the blood, apo(a) isoforms and bile lithogenicity in females with cholesterol cholelithiasis. Material and methods. Examination of the representative samples of 870 females aged 25-64 years and 405 males aged 35-54 years has detected cholelithiasis in 91 females and 19 males. Results. Serum levels of Lp(a) are associated with cholelithiasis. Risk of the latter in males (Lp(a) > 28 mg/dl) and females (Lp(a) > 24 mg/dl) is estimated. It is confirmed that isoforms of apo(a) B, S1 and S2 in females and isoforms of apo(a) B, S2 in males with cholelithiasis occur much more frequently than in individuals free of cholelithiasis while isoform apo(a) S4 is rare. Females with cholesterol cholelithiasis have positive correlation between blood Lp(a) levels, the presence of isoforms apo(a) B, S1 and bile lithogenicity. Conclusion. Males and females with cholelithiasis have more frequent high concentrations of Lp(a) (> 30 mg.dl) while low levels (0-5 mg/dl) are rare. There is a correlation between blood levels of Lp(a), apo(a) isoforms, bile lithogenicity in females with cholesterol cholelithiasis.

Aim. To analyse course of excretory pancreatic insufficiency (EPI) of pancreatic and not origin as well as factors associated with its development. Material and methods. A total of 139 patients with chronic pancreatitis or malabsorption were examined. The pancreatic function was assessed by the results of elastase test - concentration of pancreatic elastase 1 in the feces. EPI was detected in 57 patients (fecal pancreatic elastase 1 under 200 mcg/g); 38 patients had chronic pancreatitis and absolute EPI, 19 patients had relative EPI (the elastase was low, pancreatic pathology was absent, but other gastroenterological diseases were present - enteropathy, Crohns disease, previous surgery). Results. Pancreatic insufficiency in patients with pancreatitis was 36.5%. It was associated with the disease duration. Diarrhial and asthenic syndromes, normal or low lipase levels in the serum were found. Patients with relative insufficiency were significantly younger, had shorter disease duration, more frequent diarrhea, were thinner. Correction of diarrheal syndrome was more successful in patients with absolute insuffuiciency. Pancreatic elastase concentration in the feces persisted for a year in patients with absolute EPI and normalized in patients with enteropaties after etiotropic and pathogenetic therapy.

Aim. To examine content, diagnostic and prognostic role of autologous antibodies in gastrointestinal diseases (GID). Material and methods. Enzyme immunoassay was used to measure content of autologous antibodies to N+/K+ATPase (Aab) of gastric parietal cells, mitochondria, microsomes, tissue transglutaminase in blood serum of 196 patients with gastric, gallbladder, small and large intestinal diseases. Aab relations with heterologous antibodies were studied with kits provided by Bektor-Best (Novosibirsk), DRG-Diagnostics, Orgentec (Germany) and others. Results. In GID high circulation of Aab to parietal cells (Ab-PC) was detected in 42% cases, mean content being 217 ± 32.4 U/ml, 10 U/ml in the control. Maximal concentration (180 = 340 U/ml) occurred in hepatic cirrhosis, celiac disease, atrophic gastritis. In exacerbations of pancreatictis, colelithiasis and duodenal ulcer ab-PC concentration was 190-210 U/ml, in remission - 6-12 U/ml. Minimal concentration (8-38 U/ml) was seen in polyps, gastric cancer, nonspecific ulcerative colitis. For primary biliary cirrhosis more typical was high Aab concentration to mitochondria (in 83%; 200 U.ml), for autoimmune hepatitis - Aab to microsomes (in 81%; 170 U/ml), in celial disease - Aab to tissue transglumaminase (93%, 75 U/ml). High autoantibodies concentration in GID is accompanied with overcirculation of heteroantibodies to infectious-toxic agents confirming their role in development of autoimmune processes. Conclusion. GID are associated with high circulation of autologous antyibodies - markers of systemic humoral autoimmune reactions differing in duration, severity, site of lesion, form, stage, disease duration. Maximal detection rate and concentration of serum autologous antibodies were observed in hepatic cyrrhosis, active hepatitis, celiac disease, atrophic gastritis, exacerbations of cholelithiasis, ulcer, pancreatitis. Estimation of Aab concentration is essential for diagnosis, prognosis of autoimmune diseases, it reflects intensity and duration of autoimmune reactions in GID.

Aim. To investigate antihypertensive efficacy, effects on endothelial, diastolic function of the left ventricule and metabolism of combination of ACE inhibitor quinapril (accupro) with diuretic indapamide SR in patients with hypertension of the second-third degree and type 2 diabetes mellitus (DM) and free of DM. Material and methods. Outpatient treatment was given to 60 patients with AH (mean age 55.3 ± 9.6 years) in combination with mild or moderate DM (group 1) and free of DM (group 2). The patients were observed for 12 weeks. Clinical and biochemical blood tests, ECG, echo-CG, measurements of blood pressure were made in all the patients. Results. Quinapril course (mean dose 23.3 ± 9.8 mg/day) in combination with indapamide (1.5 mg/day) produced a complete hypotensive effect in group 1 (23 patients,76.7%), in group 2 - 25 (83.3%). DM patients demonstrated reduction of fasting and postprandial glycemia and cholesterol, time of isovolumic relaxation reduced in group 1 by 9.1%, in group 2 by 19.8% (p < 0.01). Left ventricular diastolic function improved, endothelium-dependent vasodilation in diabetics rose by 40%, non-endothelium-dependent - by 21.8%, in hypertensive patients free of DM - by 51.9 and 43.2%, respectively. Conclusion. Combination of quinapril with indapamide produces a significant antihypertensive effect in patients with AH of degree II-III associated with type 2 DM, improves carbohydrate and lipid metabolism, left ventricular diastolic function.