Vol 44, No 6 (2016)

The most controversial provisions of the Russian Consensus on Diagnosis and Treatment of Chronic Pancreatitis (hereinafter, the Consensus) are presented. The debate has been initiated by the Russian Pancreatic Club and performed with the use of the Delphi system, based on interdisciplinary approach with participation of leading gastroenterologists, surgeons and pediatricians. This paper is the first in the series of the Consensus-related publications. Here we discuss the most controversial issues of Chapter 5 "Treatment of acute episodes" and Chapter 8 "Strategies of pain syndrome management". While discussing the conventional recommendation of a period of starvation for patients with clinical symptom of exacerbation of chronic pancreatitis, it was noted that for a long time it had been virtually the only way to provide functional rest for the pancreas. However, patients with chronic pancreatitis are frequently in malnutrition, therefore, starving may aggravate nutritional deficit that significantly affects the prognosis; therefore, early nutritional support is indicated. To alleviate functional strain of the pancreas, it is reasonable to use enteral nutrition elemental and semi-elemental formulas. The transition from formulas to conventional nutrition should be accompanied by administration of adequate pancreatin doses. The role of pancreatic enzymes, spasmolytics and proton pump inhibitors in the management of pain syndrome was also controversial.

Background: Epidemiological characteristics of chronic hepatitis C virus (HCV) infection presented in the literature are not representative for the real situation with its incidence and prevalence in the Russian Federation. In the Moscow Region, which is the second largest population in the Russian Federation (7.2 million people), the Moscow Regional Registry of patients with hepatic disorders has been continuously maintained since 2010, as well as screening programs for anti-HCV positive individuals. Analysis of this data allows for generalization of the results obtain to the general population and for description of the prevalence of the infection among adult population of the Russian Federation. Aim: To analyze the epidemiological situation with chronic hepatitis C in the Moscow Region. Materials and methods: We analyzed data from the Moscow Regional Registry of patients with hepatic disorders as per April 2016, as well as the results of large scale screening of the population of the Moscow Region with oral express test for anti-HCV antibodies (OraQuick HСV Rapid Antibody Test). Based on the registry, we assessed the following parameters of the patient cohort with chronic HCV infection (n = 17 182): age, gender, HCV genotype, grade of liver fibrosis, allele variants of interleukin 28В. Within the large scale screening program among the population of the Moscow Region, 1447 individuals from 6 districts of the region were screened for anti-HCV antibodies. Results: As per April 2016, the proportion of patients with chronic viral hepatitis in the Registry was 75.3% (n = 12 938 of 17 182). The vast majority of them (80.3%, or n = 10 393) had chronic hepatitis C, with 84% (n = 8726) of referrals were patients of productive age (from 20 to 50 years). 8.4% (n = 873) of all HCV infected patients had liver cirrhosis. Although the proportion of patients with cirrhosis was negligibly low (< 1.5%) in patients below 30 years of age, it was progressively increasing with age, with a maximum of 23.8% in those above their 50-es. As far as the HCV genotype distribution is concerned, it was as follows: genotype 1, 54.1% (n = 5622) of patients, genotype 2, 7.2% (n = 747), genotype 3, 38.4% (n = 3990). According to the results of assessment of IL28B genetic polymorphisms (n = 3212), СС rs12979860, which is associated with the most favorable sensitivity to interferon α, was found in 27.5% (n = 883), СТ allele, in 58.4% (n = 1876), and ТТ in 14,1% (n = 453). Prevalence of HCV infection in the Moscow Region, assessed by the screening program, is 1.38% of adults, or 77 200 anti-HCV positive persons, whereas estimated number of patients with chronic hepatitis C may amount to 54 000 to 61 700. Conclusion: HCV infection is the most prevalent among other viral hepatites in the Moscow Region (80.3%), and the largest numbers of infected individuals are of productive age. Almost three quarters of these patients are referred for medical care at the stage of minimal liver injury, and antiviral therapy can be used on an elective basis. Knowing the proportion of patients with liver cirrhosis (8.4%) allows for planning of the need in emergency treatments. The true prevalence of HCV infection estimated from the results of the screening program is at least 5-fold higher than that in the Registry. This indicates the necessity to upgrade the system of primary assessments. In particular, it seems reasonable to include detection of anti-HCV antibodies into the list of obligatory screening laboratory tests.

Despite the existence of effective prophylactic vaccines, chronic hepatitis B remains a major public health problem, with more than 350 million people infected   worldwide.  Chronic  infection   increases the  risk of serious  liver diseases  such  as cirrhosis and  hepatocellular carcinoma.  Available therapies for chronic  hepatitis  B  have  limited  efficacy and require  long-term   continuous  treatments;  that  is why the  development of therapeutic vaccines has been  investigated as  promising  approach.  In this sense, a novel  vaccine  formulation  called ABX203 (HeberNasvac), based  on  the  combination of the hepatitis B virus nucleocapsid and surface antigens, was developed. ABX203 has been studied in phase I, phase II and phase III clinical trial in treatment-naïve chronically infected  patients  in Bangladesh  and  in healthy  volunteers  in Cuba with promising  results. In the present work we reviewed the main preclinical and   clinical  results  of  ABX203 development. Altogether, the data demonstrates safety and immunogenicity of ABX203 vaccine and support  its use as a novel and competitive treatment alternative for chronic hepatitis B. The vaccine has been granted marketing authorization in Cuba.

Systemic glucocorticosteroids are widely used in the treatment of inflammatory bowel disease, and despite the introduction of new anti-inflammatory drugs, remain the first-line therapy for induction of remission in moderate and severe ulcerative colitis and Crohn's disease. However, in some patients steroid resistance is observed when glucocorticosteroids are not effective enough. The paper gives a detailed discussion of the criteria of steroid resistance, possible mechanisms of it's development, including secondary resistance resulting from complications of ulcerative colitis and Crohn's disease and associated opportunistic infections. Special attention is paid to the modern treatment of steroid-refractory inflammatory bowel disease.

At present, there is no "golden standard" of diagnosis of inflammatory bowel disease. Each and every individual case requires a thorough analysis of clinical symptoms in their association with endoscopic, histological, radiological and laboratory data. This review paper analyzes both conventional and novel methods of radiological investigations. Some of them have changed their significance from the "golden standard" to rare and limited application and from promising, then frequent and currently sporadic use of small bowel enema. Traditional ileocolonoscopy maintains its diagnostic potential, especially as a tool for follow up of patients with colonic and ileac disorders. The state-of-the-art non-invasive (ultrasound examination) and limitedly non-invasive (computerized tomography and magnetic resonance imaging) procedures are considered to be the most accurate methods for assessment of inflammatory bowel disorders in patient with already confirmed diagnosis and those with suspected cases of Crohn's disease and ulcerative colitis. The paper describes preparation of patient for each method, assessment technique, advantages and limitations for use, diagnostic criteria for intestinal wall thickness, accuracy of methods and discusses the perspectives of their use. The main sign of inflammatory bowel disease is thickening of intestinal wall. Usually its mean thickness in Crohn's disease (11 to 13 mm) is higher than that in ulcerative colitis (7 to 8 mm). This may provide a diagnostic key during differential diagnosis of an isolated colon disease. The amount of the contrast cumulated by the intestinal wall directly correlates with inflammation activity. Intensive contract cumulation in the intestinal wall after intravenous contrast enhancement is a symptom of active inflammatory process. However, despite progression in the technologies, initial signs of inflammatory bowel diseases are quite superficial and remain hardly visible, being below the resolution ability of any diagnostic investigation.

Cirrhotic cardiomyopathy is a syndrome, which includes systolic and diastolic dysfunction and electrophysiological abnormalities in patients with liver cirrhosis in the absence of any cardiac disease. Several mechanisms seem to be involved in the pathogenesis of cirrhotic cardiomyopathy, such as impaired signaling of beta-receptors, altered trans-membrane ion currents and excess production of vasodilators. Clinical manifestation of cirrhotic cardiomyopathy is non-specific and is usually masked by the symptoms of cirrhosis. Despite frequent regression of cirrhotic cardiomyopathy after liver transplantation, myocardial dysfunction may lead to cardiac complications during transplantation surgery and post-operatively. Severe myocardial dysfunction may affect liver transplantation outcomes with an increase in cardiovascular mortality. Therefore, timely identification of cirrhotic cardiomyopathy is crucial for assessment of candidate patients for liver transplantation. At present, there is no specific therapy for cirrhotic cardiomyopathy. Recommended treatment should be aimed at support of myocardial function and prevention of decompensation.

Big bezoars are rare foreign bodies of the stomach. In the literature, the problem of bezoars has been described mainly as isolated clinical cases. In this publication we present a case of endoscopic removal of a big bezoar, along with the diagnostics and treatment of concomitant erosive and ulcerative lesions, as well as detection of a gastric malignancy (tubular adenoma with severely dysplastic foci). The active endoscopic approach allowed for a timely preparation of the patient for a reconstructive surgery on the low extremity vasculature. The paper may be of interest for   internists,   gastroenterologists,   surgeons, providing them with a motivation to perform a regular follow up of upper gastrointestinal tract in patients after surgical interventions on the stomach and duodenum. This clinical observation is a good example for endoscopists of a successful diagnostics and treatment of a rare comorbid disorder.