Vol 50, No 6 (2022)

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Full Issue


Early diagnosis of chronic pancreatitis

Khatkov I.E., Tyulyaeva E.Y., Lesko K.A., Dubtsova E.A., Bordin D.S., Kiriukova M.A., Malykh M.V., Vinokurova L.V.


Chronic pancreatitis is one of the most challenging disorders from the perspective of its early diagnosis and effective treatment. Within the last decade, the diagnosis of “early chronic pancreatitis” has been firmly introduced into the practice of gastroenterology. The delineation of this form as an initial stage of chronic pancreatitis is based on the need in early and effective treatment that could cease the progression of the disease and reduce the possibility of its complications.

The diagnostic criteria of chronic pancreatitis have been described in details in the literature; however, specifics of the diagnosis in its early stage have been scarcely highlighted. Chronic pancreatitis is commonly diagnosed with a number of imaging techniques (they can show abnormalities in morphology of the pancreas), as well as laboratory tests (showing functional organ deficit). However, morphological and imaging techniques are insufficient for the diagnosis of the early chronic pancreatitis. A new integral strategy towards early diagnosis seems necessary, that would consider not only the morphology, but also potential etiology, risk factors of the disease and its complications in patients with suspected chronic pancreatitis.

The review of the literature presents the definition of the early pancreatitis and discusses the potential of imaging techniques and functional tests in its diagnosis. An adequate strategy for the diagnosis of the early pancreatitis is formulated, based on an individual patient characteristic with suspected early chronic pancreatitis, namely, risk factors, clinical manifestations, imaging results and serological biomarkers.

Almanac of Clinical Medicine. 2022;50(6):349-356
pages 349-356 views

Is an optimization of the use of proton pump inhibitors feasible in the real world medical practice?

Khomeriki N.M., Khomeriki S.G.


The review deals with the data on negative health impact of prolonged and inadequate use of proton pump inhibitors (PPI). Since their advent at the end of 1980s, their worldwide use has been continuously increasing. However, up to 70% of PPI use is not based on clear indications. Inadequate treatment with PPI not complying with clinical guidelines results in a higher risk of adverse events, especially in the elderly. Prolonged (more than 8 weeks) intake of PPI increases the risk of osteoporotic fractures, promotes Clostridioides difficile infection and gut microbiota abnormalities, community-acquired pneumonia, vitamin B12 deficiency, renal disease, dementia, risk of gastric cancer, etc. Most potential side effects of PPI are the results of hypochlorhydria and reflex hypergastrinemia. The main safety principle for PPI is adherence to short duration of treatment and minimally effective doses. Rational strategies for safe and effective PPI treatment are supported by the evidence-based deprescribing in gastroesophageal reflux disease and include dose tapering or therapy “as needed” after the treatment course for a specific indication has been finished, or stopping the treatment in patients with no adequate indications to PPI administration. Increased awareness of medical personnel and patients on the proper PPI use and their side effects would make it possible to optimize the use of these agents in the real world medical practice.

Almanac of Clinical Medicine. 2022;50(6):357-366
pages 357-366 views

Prospects for the treatment of gluten-associated diseases: on our daily bread, celiac disease, gluten proteins and more…

Bakulin I.G., Avalueva E.B., Semenova E.A., Оrеshkо L.S., Serkova M.Y., Sitkin S.I.


Food safety all over the world is largely dependent on production of grains that are cultivated in 60% of agricultural lands. Wheat is the main food for millions of people and one of the three most commonly cultivated grain cultures worldwide, along with corn and rice. Modern wheat is a product of gene engineering interventions aimed at increased productivity, yields, nutrient quota, and storage time, as well as immunogenic properties. However, the consumption of gluten, a proline and glutamine-rich wheat, rye and barley protein, triggers gluten-dependent disorders, such as celiac disease, wheat allergy, baker's asthma and wheat-dependent exercise-induced anaphylaxis. This group of disorders are curable provided the correct diagnosis has been made and strict lifelong gluten-free diet is implemented. Continuous patient's adherence to the gluten-free diet is associated with a number of medical and paramedical challenges, and the adherence level of the most compliant patients does not exceed 80%. The paper discuss other treatment strategies to improve the nutrition of people with gluten-sensitive disorders, in particular, the reduction grain gluten content, gluten sequestration in the gut before its digestion, prevention of gluten absorption and subsequent immune cell activation, and administration of tissue transglutaminase 2 inhibitors.

Almanac of Clinical Medicine. 2022;50(6):367-376
pages 367-376 views

Clostridioides difficile – a new name, the old problems with diagnosis and treatment

Zakharenko S.M.


Clostridium difficile was reclassified in 2016 under a new name of Clostridioides difficile. In 2021 to 2022, some changes were implemented into the main clinical guidelines on the diagnosis and treatment of infections caused by this pathogen. A two-step algorithm based on identification of C. difficile and then its toxins is still recommended for the diagnosis. The treatment regimens for the first episode and relapses of C. difficile-associated infection are based on metronidazole, vancomycin and fidaxomycin. Additional effectiveness of therapy has been associated with the use of microbiocenosis-oriented technologies aimed at restoration of the colon microbiota. In the Russian Federation, all widely applied diagnostic methods are available and all recommended antimicrobials, except fidaxomycin, as well as bezlotoxumab and fecal microbiota transplantation.

Almanac of Clinical Medicine. 2022;50(6):377-391
pages 377-391 views


The duration of gastrointestinal symptom persistence at various periods of coronavirus infection

Sadretdinova L.D., Gantseva K.K., Galina I.I., Tyurin A.V.


Aim: To analyze prevalence and type of symptomatic gastrointestinal involvement during symptomatic COVID-19 (up to 4–12 weeks after the disease) and post-COVID-19 syndrome (more than 12 weeks from the disease onset).

Materials and methods: We retrospectively analyzed the data from 785 in-patients with the diagnosis of COVID-19, who were treated in the infectious disease hospital from May to December 2020. At the first phase of the study we analyzed how frequently they were referred for out-patient care by a gastroenterology specialist after they were discharged from the hospital (all 785 patient medical files). At the 2nd study phase we performed phone calls to 247 patients, that were discharged from the infectious disease hospital, during which a specially designed questionnaire was filled with items on their comorbidities, general and specific complaints, as well as the standardized Gastrointestinal Symptom Rating Scale (GSRS).

Results: Within 2 years after their discharge from the infectious disease hospital, 88 patients asked for specialized gastroenterological care on an out-patient basis. The most common diagnoses were pancreatic diseases (33%), gastric disorders (31%), intestinal disorders (25%), liver and biliary disorders (11%). At referral, the most common complaints were dyspeptic: nausea, bitter taste in the mouth, heartburn, bloating (25%), abdominal pains of various location (17%) and stool abnormalities, such as diarrhea and constipation (11%).

Among patients who participated in the phone survey (N = 247), symptomatic COVID-19 was observed in 90 (11.46%) cases, with predominant complaints being loss of taste, loss of smell, and fever. Post-COVID-19 syndrome was identified in 157 (20%) cases, with their main complaints being weakness, shortness of breath and joint pain. Stool abnormalities and abdominal pain occurred during symptomatic COVID-19 and in the post-COVID-19 period with the same frequency (9% and 10%, respectively). According to the GSRS results, the post-COVID-19 dyspeptic syndrome was characterized by prevailing complaints of heartburn (24%), upper abdominal pain and discomfort (20%), and bloating (15%).

Conclusion: In the patients with a history of COVID-19, along with respiratory syndromes, gastrointestinal symptoms are seen, with their types being variable at various period of the coronavirus infection. In the early COVID-19, these are stool abnormalities and abdominal pain, and during the post-COVID-19 syndrome, nausea, bitter taste in the mouth, heartburn and bloating are more common.

Almanac of Clinical Medicine. 2022;50(6):392-399
pages 392-399 views

Differential diagnosis of inflammatory bowel diseases by endoscopic ultrasound

Budzinskaya A.A., Belousova E.A., Orlova L.P., Vakurova E.S.


Rationale: At present, there is no established standard for the differential diagnosis of Crohn's disease (CD) and ulcerative colitis (UC). Five to 15% of the patients have clinical, endoscopic, morphological, and radiological signs both of UC and CD and are therefore diagnosed with indeterminate colitis. However, the timely and correct diagnosis is essential for the choice of treatment strategy.

Aim: To evaluate the potential of endoscopic ultrasound examination (EUS) for the differential diagnosis of UC and CD and to identify the most pathognomonic criteria for each of the disorders.

Materials and methods: This was a prospective single center controlled study including 50 in-patients who were treated in the Department of Gastroenterology for inflammatory bowel disease (IBD) exacerbation. The inclusion criteria were an established diagnosis of IBD, absence of strictures, colon tumors, and infectious diseases. The control group consisted of 15 patients without IBD. In all patients, colon EUS with a radial ultrasound sensor and measurement of the intestinal wall thickness, assessment of the degree of intestinal wall vascularization by color Doppler mapping and measurement of the wall density by compression elastography were performed.

Results: From 50 patients of the study group, 28 (16 men and 12 women aged 18 to 49 years) had CD of the colon and 22 (8 men and 14 women aged 22 to 60 years) had total UC. In CD, the colon wall thickness was 2-fold higher than in the control group (5.66 ± 0.36 vs 2.62 ± 0.11; р < 0.001) and 1.5-fold higher than in the UC patients (5.66 ± 0.36 vs 3.96 ± 0.13; p = 0.002). In UC, the intestinal wall was thickened mainly due to its mucosal and submucosal layers (in 82% of the cases, р < 0.001 compared to that in the CD patients; diagnostic sensitivity 82%, specificity 93%). In CD, transmural thickening of the intestinal wall was more common (in 68% of the cases, p < 0.001 compared to that in UC; sensitivity 68%, specificity 91%), as differentiation of the intestinal wall layers was absent (in 68% of the cases, p < 0.001 compared to UC, sensitivity 68%, specificity 100%). The intestinal wall in most cases of UC was less well vascularized that in the control group (54.6% of the cases, p < 0.001), whereas in CD, on the contrary, the vascularization was increased (71.4% of the cases, р < 0.001); the sensitivity and specificity of this parameter being 54.6 and 82%, for UC vs 71.4 and 77.3% for CD, respectively). Compression elastometry showed that in CD, type 2 staining (E. Ueno classification) was more frequent (45%) compared to UC (22%) and the control group (6%; p = 0.002), which indicates a more dense structure of the intestinal wall in CD patients.

Conclusion: The differences in the intestinal wall structure (its thickness, density and degree of vascularization) identified by EUS UC and CD can be the differential diagnostic criteria between these diseases.

Almanac of Clinical Medicine. 2022;50(6):400-407
pages 400-407 views


Challenging diagnosis of amebiasis in a non-endemic region: a clinical case

Akhmedova E.F., Galyavin A.V., Zotov A.V.


In Russia, amebiasis is sporadically registered mainly in the southern regions. An endemic area is the Republic of Dagestan. We describe a clinical case, which illustrates challenges in the diagnosis of amebial colitis related to low awareness of physicians of parasitic diseases in non-endemic regions. A 38-year old female patient living in Moscow was initially misdiagnosed with Crohn's disease. Erosive and ulcerative colonic lesions found at colonoscopy were interpreted by a gastroenterologist as symptoms of an inflammatory bowel disease. No differential diagnosis with infections and parasitic diseases was performed. Long (2 years) persistence of symptoms despite treatment with 5-aminosalicylic agents for suspected Crohn's disease, absence of any significant laboratory abnormalities and no history of travelling to Asian countries were the reason for subsequent additional diagnostic work-up. After the patient was finally diagnosed with intestinal amebiasis, she was treated with metronidazole with some positive effect of decreased abdominal bloating and bowel growling. At the control colonoscopy, there was a positive trend seen in colonic mucosa, with healing of ulcers without any scarring. No protozoan cysts were any more found in her feces. According to the recommendations, the patient is regularly seen by a specialist in infectious diseases and a gastroenterologist. Expansion of amebiasis outside endemic regions points to the necessity to perform a wider diagnostic work-up in cases of mucosal lesions found at colonoscopy.

Almanac of Clinical Medicine. 2022;50(6):408-413
pages 408-413 views

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