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Aim: to analyse the principles of diagnosis and treatment of intrahepatic cholestasis in chronic liver diseases, to present data on the effectiveness of ademetionine in the treatment of chronic liver diseases with intrahepatic cholestasis and the materials of the Expert Meeting held in 2023. Key points. During the Expert Meeting, the problems of diagnostics and treatment of intrahepatic cholestasis in various chronic liver diseases were discussed, the effectiveness of ademetionine was clarified, and optimal regimens for its administration were determined. The relevance of the existing algorithm for diagnosing cholestasis in real clinical practice was assessed. The effectiveness of ademetionine in the treatment of various liver diseases occurring with intrahepatic cholestasis (cholestatic forms of drug-induced liver damage, alcoholic liver disease, non-alcoholic liver disease, primary biliary cholangitis) was demonstrated, manifested by a decrease in clinical and laboratory signs of cholestasis. The anticholestatic mechanisms of ademetionine action were clarified, which consist in normalizing the fluidity of hepatocyte membranes, regulating the activity of Nrf2, a key transcription factor, suppressing lipid peroxidation and the resulting damage to hepatocytes and cholangiocytes. Optimal regimens for prescribing ademetionine for various clinical situations were considered. Conclusions. Ademetionine is an effective drug that, due to its pleiotropic action and favourable safety profile, can be used in various chronic liver diseases accompanied by cholestasis, including as a part of the complex therapy.

Aim: to optimize outcomes of the treatment and prevention of gastrointestinal diseases in adults and children. Key points. The Methodological Guidelines contain sections on the terminology, classification, mechanisms of action, requirements for sale in the Russian Federation, requirements for proving the efficacy and safety of probiotics, prebiotics, synbiotics and metabiotics, as well as functional foods enriched with them. An overview of relevant data allowing to include these drugs and products in the treatment an d prevention of gastrointestinal diseases in adults and children is presented. Conclusion. The clinical efficacy of probiotics, prebiotics, synbiotics and metabiotics depends on the specificity and quantity of their components, the dosage form, the regimen and duration of treatment. Products and functional foods with proven efficacy and safety are recommended for the treatment and prevention of gastrointestinal diseases in adults and children.

Aim: to provide the basic points of the Expert Panel of the Russian Gastroenterological Association with discussion of measures to improve diagnostics, treatment and management of chronic gastritis patients.Key points. In the Russian Federation in 2021 more than 30 million patients diagnosed with “Gastritis and duodenitis” were recorded (K29 in accordance with International Classification of Diseases-10). H. pylori incidence rate in the Russian population has reduced and presently is about 40 %. In chronic gastritis pattern H. pylori-associated gastritis has still dominated though gastritis percent after successful H. pylori eradication, reactive gastropathy (including reflux gastritis) and autoimmune gastritis, has increased. Endoscopic and histologic examinations serve as key diagnostic techniques that provide a means for assessing the ethiology of gastritis, topography and degree of atrophic changes, gastritis staging as per OLGA/OLGIM system that properly correlates with the risk of stomach cancer and determines endoscopic examination strategy. H. pylori eradication therapy of gastritis serves as an etiotropic treatment and makes it possible to prevent progression of atrophy and stomach cancer. Conventional triple therapy combined with bismuth tripotassium dicitrate allows for achieving optimal cure rates of H. pylori eradication. Addition of rebamipide to regimens of H. pylori eradication improves their efficiency. Rebamipide arrests symptoms of dyspepsia in the case of chronic gastritis and functional dyspepsia. The administration of rebamipide for chronic gastritis makes it possible to influence the syndrome of increased epithelial permeability and inflammation, which makes it advisable to study it as a means of preventing stomach cancer and the progression of atrophy in various types of chronic gastritis.Conclusion. Members of the Expert Panel has approved the algorithm of diagnosis and treatment of H. pylori-associated gastritis, gastritis after H. pylori eradication and H. pylori-negative gastritis at the diagnostic stage in the case of initial presentation and long-term follow-up when needed.

Aim: to discuss current views on the clinical significance, diagnostic opportunities, and therapeutic approaches in the treatment of small intestinal bacterial overgrowth (SIBO) as an important component in the gut microbiota function assessment, to assess the awareness of physicians and the opportunities in the diagnosis and treatment of this disease in patients in the Federal districts of the Russian Federation, as well as to present the proceedings of the Expert Council held on December 16, 2023 in Moscow.Key points. SIBO is a common syndrome often associated with irritable bowel syndrome, liver cirrhosis, asthma, and congestive heart failure, being also a predictor of early death in the elderly. Today, in many regions of the Russian Federation, there are limitations for instrumental diagnosis of this disease — lack of awareness among doctors, unavailability of gas analyzers for diagnosing SIBO, lack of information about the need to diagnose SIBO in the standards of compulsory health insurance. Rifaximin is the first-line treatment due to the highest therapeutic efficacy. One of the ways to increase the efficacy of SIBO treatment is to include strain-specific probiotics in the treatment regimen. Saccharomyces boulardii CNCM I-745 is thought to be the most studied, promising probiotic. The review also presents statistical data on the issues in the diagnosis and treatment of SIBO in the regions of the Russian Federation.Conclusion. Optimization of approaches to the diagnosis and treatment of SIBO, the development of domestic gas analyzers, increasing the awareness of physicians in all regions of the Russian Federation, as well as the development and optimization of clinical recommendations appear to be necessary measures to increase the effectiveness of medical care, the duration and quality of life of the Russian population. These goals can be achieved within the framework of Federal programs under the supervision of specialized reference centers of the Ministry of Health of the Russian Federation.

Aim: to study the effectiveness and safety of using the drug Kolofort® in outpatients with irritable bowel syndrome (IBS) after a new coronavirus infection.Materials and methods. An observational non-interventional program was conducted in patients with exacerbation of IBS symptoms after a new coronavirus infection. One hundred forty-one patients took part in the study. The final efficacy analysis included data from 127 study participants. All patients complained of increased/appearing gastrointestinal symptoms that appeared within 1–6 months after the infection (all patients had a history of COVID-19 infection). To assess the presence and severity of symptoms of the disease, the “7 × 7” questionnaire was used before the start of treatment and three months after the start of treatment.Results. At the stage of inclusion in the program, the average total score on the “7 × 7” questionnaire was 17.36, which corresponded to a moderately severe disorder. During the treatment period, the average total score decreased to 6.14, which corresponded to borderline disorder. In addition, significant improvement was observed for each symptom separately. After three months of therapy, doctors rated the overall impression of the treatment on a 5-point Likert scale from “very effective” to “ineffective”. The average score was 4.24. In addition, no serious adverse events were identified while taking the drug.Conclusion. In real clinical practice, the drug Kolofort® demonstrated high clinical efficacy in the treatment of patients with IBS after COVID-19 infection.

Aim: to present the results of an expert discussion of modern aspects of the clinical manifestations, pathogenesis and treatment of alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD).Key points. ALD and NAFLD are characterized by high prevalence and have a significant impact on public health. For the diagnosis of liver pathology, it is important to determine the stage of fibrosis and the severity of the exacerbation of the disease. In the treatment of ALD, it is recommended to achieve abstinence, proper nutrition, the appointment of B vitamins, drugs with cytoprotective activity. In severe hepatitis, corticosteroids may be prescribed. In the treatment of NAFLD, diet and lifestyle modification, weight loss, the use of insulin sensitizers, vitamin E, statins (in the presence of hyperlipidemia) and drugs with metabolic activity are effective.Currently, a point of view is being actively expressed about the synergism of the action of alcohol and the metabolic syndrome on the development of fibrosis, cirrhosis, and hepatocellular carcinoma. The current international consensus recommends a change in the nomenclature of NAFLD and ALD and proposes the terms “metabolically associated steatotic liver disease” and “metabolically associated alcoholic liver disease”.Conclusion. The closeness of the clinical manifestations and pathogenesis of NAFLD and ALD justifies attention to drugs with metabolic activity, which are recommended by the Russian Gastroenterological Association and Russian Scientific Liver Society for the treatment of these diseases. The experts support the suggestion to quantify alcohol consumption in patients with NAFLD in order to change the management of patients, if necessary.

Aim: to present data on the prevalence of various phenotypes of non-alcoholic fatty liver disease (NAFLD), the features of its diagnosis and treatment in various regions of the Russian Federation following a meeting of chief gastroenterologists.Key points. Non-alcoholic fatty liver disease (NAFLD) holds the leading position among non-infectious liver diseases in the Russian Federation, its prevalence is 37.3 % and does not tend to decrease.To get information on various aspects of NAFLD diagnosis and treatment, opinion of 18 chief external regional gastroenterologists and leading specialists in the field of liver diseases was studied by analyzing the responses to questions specially formulated for them. Information on the situation in the Ural, Privolzhsky, Southern, Central and North-western Federal Districts was obtained. Regional statistics on the prevalence of NAFLD and its certain phenotypes (steatosis, steatohepatitis, cirrhosis), diagnostic instruments and treatment approaches which are used in clinical practice, as well as on the most common associated conditions was presented.Conclusions. The collected information allows to improve both administrative and treatment and diagnostic-related activities in managing patients suffering from this disease.

Aim: to analyze current approaches to H. pylori eradication therapy in adults and present the materials of Experts Council held on December 9, 2022 in Moscow.General statements. H. pylori infection is the main etiological factor of gastritis, peptic ulcer, and gastric cancer. Eradication of H. pylori is recognized as a necessary measure to reduce the incidence of these diseases. The approaches to selecting an eradication regimen should be optimized to take into account epidemiological trends and achieve better treatment outcomes. The updated Maastricht VI Consensus Report presents the means to overcome the difficulties in selecting an approach to the treatment of H. pylori infection. However, eradication therapy remains challenging due to adverse events (primarily antibiotic-associated diarrhea), poor treatment tolerance and patient compliance. Eradication therapy can be optimized by supplementing treatment regimens with strain-specific probiotics that reduce adverse events, improve patient compliance and eradication rates, such as Saccharomyces boulardii CNCM I-745 strain with established efficacy.Conclusion. The inclusion of certain probiotics in eradication regimens improves treatment tolerance, reduces the risk of adverse events, improves patient compliance and eradication rates.

Aim: bring to the attention of practitioners indications for anti-Helicobacter therapy, methods and procedure for diagnostics and eradication therapy of Н. pylori infection.Key points. Chronic gastritis caused by Н. pylori infection, including asymptomatic persons, may be considered as an indication for eradication therapy of Н. pylori as etiological therapy and opportunistic screening for gastric cancer prevention. Indications, for obligatory anti-Helicobacter therapy include peptic ulcer, gastric MALT lymphoma, early gastric cancer (EGC) with endoscopic resection. H. pylori primary diagnostics methods include 13C-urea breath test, H. pylori stool antigen lab test, rapid urease test and serological method. The serological method cannot be used after anti-Helicobacter therapy.In Russia H. pylori strains' resistance to clarithromycin does not exceed 15 % in most regional studies. The first line therapy for Н. pylori infection eradication is the standard triple therapy including a proton pump inhibitor (PPI), clarithromycin and amoxicillin, enhanced with bismuthate tripotassium dicitrate. A classic four-component therapy based on bismuthate tripotassium dicitrate or quadrotherapy without bismuth drug products which includes PPI, amoxicillin, clarithromycin and metronidazole, may be used as alternative to the first line eradication therapy. The standard triple therapy may be prescribed for 14 days only in those regions, where it has been proven to be effective. Quadrotherapy with bismuthate tripotassium dicitrate is also used as main second line therapy in case of standard triple therapy, bismuth enhanced standard triple therapy or combined therapy failure. Another second line therapy includes PPI, levofloxacin and amoxicillin, to which a bismuth-containing drug product may be added. The third line therapy is selected individually based on previously used treatment settings.Conclusion. In each case of H. pylori infection the decision for eradication therapy should be made, which is especially relevant as eradication of H. pylori has been recognized as an effective measure for the prevention of gastric cancer.

Aim. To optimize the choice of treatment strategies by physicians and gastroenterologists to improve treatment and prevention of small intestinal bacterial overgrowth (SIBO) in adults.Key points. SIBO is a condition characterized by an increased amount and/or abnormal composition of the microbiota in the small intestine. Clinically, the syndrome is manifested by nonspecific gastroenterological complaints and the development of malabsorption syndrome. Most often, SIBO is associated with various chronic non- infectious diseases (both diseases of the gastrointestinal tract, and the cardiovascular system and the neuromuscular apparatus) and can affect the severity of their symptoms. Specific methods for diagnosing SIBO are the culture method and breath tests. The main approaches to the treatment of SIBO include the elimination of the underlying cause of its occurrence, the use of antibacterial drugs and adherence to dietary recommendations (elemental diet).Conclusion. Small intestinal bacterial overgrowth is common in patients with various diseases, but has non-specific manifestations, so proper diagnosis of this condition is required. SIBO therapy involves prescription of antibacterial agents, the most studied of which is the non-absorbable antibiotic rifaximin-α.

The aim of the study was to evaluate the efficacy and safety of Kolofort® (a complex medicine containing technologically processed forms of antibodies to S-100 protein, tumor necrosis factor-α and histamine) in the management of functional dyspepsia (FD) in outpatient clinical practice.Methods: Outpatients (N = 309) at the age of 18–45 in whom FD was diagnosed according to the Rome IV criteria were enrolled in a multicenter, double-blind, placebo-controlled, randomized clinical trial. Patients were randomized in two groups receiving Kolofort® or placebo 2 tablets tid for 8 weeks. The primary endpoint of the study was a change in the FD symptoms severity score according to the Gastrointestinal symptom score (GIS) at week 8. ITT and [PP] analysis were performed.Results: at week 8 the reduction in GIS sum score was observed in Kolofort® group and placebo group (by 7.2 ± 3.3 [7.2 ± 3.4] and 6.3 ± 4.6 [6.2 ± 4.5], respectively, p = 0.041 [0.039]). The proportion of cases with GIS score reduction by ≥4 was 88,1 % [88.6 %] and 79.1 % [79.6 %] in Kolofort® group and placebo group, respectively (p = 0.046 [p = 0.051]). None of the patients in Kolofort® group had progression of FD symptoms or required additional therapy. There were 29 adverse events (AEs) recorded in 25 patients including 16 cases in 13 (8.6 %) patients in Kolofort® group and 13 AEs in 12 (7.6 %) patients in placebo group.Conclusion: the clinical trial demonstrates the positive effect of Kolofort® in FD with a favorable safety profile.

Aim. To review the main indications for probiotics prescription in patients with irritable bowel syndrome and to present the materials of an Expert Council, which was held on 18 March 2022 in Moscow.Key points. Gut microbiota disturbance is an integral part of irritable bowel syndrome (IBS) pathogenesis. Changes of colonic microbiota composition are associated with its functional potential modification, which leads to an increasing of the pro-inflammatory immune response, as well as to an exacerbation of the disease symptoms and quality of life decreasing in patients with IBS. The novel coronavirus infection (COVID-19) is an independent risk factor for both exacerbation and onset of IBS, which predispose to increase IBS incidence. Correction of gut microbiota composition with probiotics seems to be a promising therapeutic target for IBS treatment optimizing. The optimal probiotic should be effective, safe, strain-specific, and its dose and duration of administration should be confirmed by the results of clinical studies. Some of the probiotics with proven efficacy in IBS are Alflorex® and Enterol®.Conclusion. Prescription of certain probiotics in IBS is advisable to normalize the frequency and consistency of stools, relieve abdominal pain and bloating, as well as improve patients’ quality of life.

Aim: to present modern methods of diagnosis and treatment of chronic pancreatitis for gastroenterologists, general practitioners and physicians.Chronic pancreatitis (CP) is a long-term inflammatory disease of the pancreas, manifested by irreversible morphological changes in the parenchyma and pancreatic ducts, which cause pain and/or persistent impairment of function. Current concept on the etiology of CP is reflected by the TIGAR-O classification. The criteria for establishing the diagnosis of CP include typical attacks of abdominal pain and/or clinical and laboratory signs of exocrine, endocrine insufficiency with the mandatory detection of characteristic morphological changes (calcifications in the parenchyma and pancreatic ductal stones, dilatation of the main pancreatic duct and its branches). CT, MRCP, and pancreatobiliary endosonography are recommended as the methods of choice to verify the diagnosis of CP. Conservative treatment of patients with CP is provided for symptom relief and prevention of complications. Individual cases with severe non-interactable abdominal pain, as well as a complicated course of the disease (development of ductal hypertension due to main pancreatic duct stones or strictures, obstructive jaundice caused by compression of the common bile duct, symptomatic postnecrotic cysts, portal hypertension due to compression of the portal vein or thrombosis of the splenic vein, persistent duodenal obstruction, pseudoaneurysm of the celiac trunk basin and the superior mesenteric artery) serve as an indication for endoscopic or surgical treatment. The Guidelines set out modern approaches to the diagnosis, conservative, endoscopic and surgical treatment of CP, and the prevention of its complications.Conclusion. The implementation of clinical guidelines can contribute to the timely diagnosis and improve the quality of medical care for patients with chronic pancreatitis.

Aim. Current clinical recommendations accentuate current methods for the diagnosis and treatment of irritable bowel syndrome (IBS).Key points. IBS is a functional bowel disorder manifested with recurrent, at least weekly, abdominal pain with the following attributes (any two leastwise): link to defecation, its frequency or stool shape. The symptoms are expected to persist for at minimum three months in a total six-month follow-up. Similar to other functional gastrointestinal (GI) disorders, IBS can be diagnosed basing on the patient symptoms compliance with Rome IV criteria, provided the absence of potentially symptom-causative organic GI diseases. Due to challenging differential diagnosis, IBS can be appropriately established per exclusionem, with pre-examination as follows: general and biochemical blood tests; tissue transglutaminase IgA/IgG antibody tests; thyroid hormones test; faecal occult blood test; hydrogen glucose/ lactulose breath test for bacterial overgrowth; stool test for enteric bacterial pathogens and Clostridium difficile A/B toxins; stool calprotectin test; abdominal ultrasound; OGDS, with biopsy as appropriate; colonoscopy with biopsy. The IBS sequence is typically wavelike, with alternating remissions and exacerbations often triggered by psychoemotional stress. Treatment of IBS patients includes dietary and lifestyle adjustments, various-class drug agents prescription and psychotherapeutic measures.Conclusion. Adherence to clinical recommendations can facilitate timely diagnosis and improve medical aid quality in patients with different clinical IBS variants.

Aim. An analysis of digestive disease mortality dynamics in different subjects of the Russian Federation in course of the new coronavirus infection pandemic.Key points. In most subjects of the Russian Federation, the first half of 2021 enduring the COVID-19 pandemic has witnessed a higher overall mortality from digestive diseases and from peptic ulcer, liver and pancreatic illnesses compared to the same period in 2020. This situation may have roots in both the adverse impact of coronavirus infection on pre-existing digestive diseases and shortages in providing specialty medical aid to gastroenterological patients during the pandemic. Improved outpatient care and remote counselling, as well as successful educational measures, may reduce gastroenterological disease-associated mortality.Conclusion. Most regions of Russia have registered a growing mortality from digestive diseases at the new coronavirus infection pandemic due to the SARS-CoV-2 adverse impact on illness progression, as well as imposed difficulties in providing specialty medical aid.

Aim. The clinical guidelines are intended to supplement specialty decision-making for improved aid quality in patients with gastritis and duodenitis though acknowledging the latest clinical evidence and principles of evidencebased medicine.Key points. Gastritis is an inflammatory disease of stomach mucosa, with a separate definition of acute and chronic gastritis. Chronic gastritis is a cohort of chronic diseases uniting a typical morphology of persistent inflammatory infiltration, impaired cellular renewal with emergent intestinal metaplasia, atrophy and epithelial dysplasia of gastric mucosa. Oesophagogastroduodenoscopy (OGDS) or high-resolution OGDS with magnified or non-magnified virtual chromoendoscopy, including targeted biopsy for atrophy and intestinal metaplasia grading and neoplasia detection, are recommended to verify gastritis and duodenitis, precancer states and/or gastric mucosal changes. All chronic gastritis patients positive for H. рylori should undergo eradication therapy as aetiological and subsidiary for gastric cancer prevention. Chronic gastritis patients with symptoms of dyspepsia (epigastric pain, burning and congestion, early satiety), also combined with functional dyspepsia, are recommended proton pump inhibitors, prokinetics, rebamipide and bismuth tripotassium dicitrate in symptomatic treatment. With focal restricted intestinal metaplasia, follow-up is not required in most cases, mainly when advanced atrophic gastritis is ruled out in high-quality endoscopy with biopsy. However, a familial history of gastric cancer, incomplete intestinal metaplasia and persistent H. pylori infection render endoscopy monitoring with chromoendoscopy and targeted biopsy desirable once in three years. Patients with advanced atrophic gastritis should have high-quality endoscopy every 3 years, and once in 1–2 years if complicated with a familial history of gastric cancer.Conclusion. The recommendations condense current knowledge on the aetiology and pathogenesis of gastritis and duodenitis, as well as laboratory and instrumental diagnostic techniques, main approaches to aetiological H. pylori eradication and treatment of dyspeptic states.

Aim. Presentation of the Forum “Deprescribing and optimal selection of proton pump inhibitors” held in Moscow on 29 September 2020 during the 26th United Russian Gastroenterology Week.Key points. The Forum was aimed at discussing issues associated with improving the proton pump inhibitor (PPIs) therapy in treatment and prevention of acid-related diseases and upper gastrointestinal tract (GIT) disorders induced by non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet medications. Deprescribing is considered to be an effective strategy of a motivated reduction of the PPI dosage, duration of therapy and the patient’s transfer from a regular to on-demand intake regimen. The choice of PPI may condition an optimal therapy for acid-related diseases.Conclusion. PPIs prevail in therapies for acid-related diseases and NSAID-induced upper GIT lesions. PPI deprescribing should be a strategy of choice if medically indicated. A non-enzymatic metabolism, high acid suppression, stable antisecretory effect from day 1 of therapy and cytoprotective action justify the application of rabeprazole (Pariet®) for optimising therapies for acid-related diseases and implementing the deprescribing strategy.

Aim of publication. To present the modern concept on the causes and pathogenesis of pancreatic exocrine insufficiency (PEI) as well as the new diagnostic and therapeutic approaches at this syndrome to general practitioners. Summary. PEI in the state it which secretion of pancreatic enzymes into duodenum is insufficient for normal digestion of nutrients. This syndrome may develop primarily, due to various pancreatic diseases (chronic pancreatitis, pancreatic cancer, cystic fibrosis etc.), and secondarily, at impaired stimulation of pancreatic secretion or impairment of conditions, necessary for the normal action of pancreatic enzymes. Basic clinical manifestations of PEI include maldigestion and malabsorption that lead to development of nutritional failure. No standardized methods of pancreatic exocrine function assessment are developed at the present time, therefore standard diagnostic criteria of PEI are lacking. In routine clinical practice PEI is diagnosed mainly on the basis of decreased pancreatic enzymes activity in stool in patients with verified pancreatic disease but can result in decreased exocrine function. Basic method of PEI treatment is pancreatic enzyme replacement therapy (PERT). Within 50 years which passed after initial implementation of PERT in clinical practice it was significantly modified, numerous pharmaceutical forms of pancreatin were developed. Anyhow for the purpose of replacement therapy capsules with enteric-coated pancreatin microparticles should be applied. Initial recommended dose of PERT for adult patient is 25’000 lipolytical units per meal that should be subsequently increased up to normalization of patients nutritional status according to both clinical and laboratory scores. Digestive enzymes should be taken at the beginning of the meal, in the case of incomplete response it can be recommended to use antisecretory agents. Patient should be consulted by nutritionist, no significant limitation of fat intake is recommended. Daily ration should be divided into six or more meals. Patients should be motivated to stop both alcohol intake and smoking as they can cause progression of PEI alone and/or persistence of symptoms, like pancreatic pain.

The aim of publication. To present the modern concept of etiology and pathogenesis of exocrine pancreatic insufficiency to general practitioners as well as with the established approach to diagnostics and treatment of this syndrome. Summary. Exocrine pancreatic insufficiency (EPI) develops if activity of the enzymes in duodenal lumen in response to meal stimulation is insufficient to maintain normal nutrient digestion. This state can develop primarily, due to various pancreatic diseases (chronic pancreatitis, pancreatic cancer, cystic fibrosis), and secondarily, due to impaired stimulation of pancreatic secretion or non-physiological conditions for activity of digestive enzymes. Basic manifestations of EPN the syndromes of maldigestion and malabsorption leading to development of nutritional failure. At the present time there is no standardized diagnostic method for estimation of pancreatic exocrine function, therefore there are no standard diagnostic criteria for EPN. In clinical practice EPN is diagnosed according to decreased fecal elastase activity in patients with verified pancreatic disease, which can cause decrease of pancreatic exocrine function. The basic EPN treatment method is pancreatic enzyme replacement therapy (PERT). For last 50 years there was an significant progress in development of PERT, numerous pancreatin-containing preparations were developed. Treatment of PERT require prescription of capsules, containing pancreatin microparticles protected by enteric coating. The highest evidential base at EPN is accumulated for pancreatin mini-microspheres. The starting dose of pancreatic enzymes for adults is 25 000 units of lipase per meal, which should be subsequently increased up to achievement of complete response confirmed by both clinical and laboratory scores. Digestive enzymes should be taken at the beginning of food intake, to increase treatment efficacy PERT should be accompanied by prescription of proton pump inhibitors. Patient’s diet quantity and content should be adjusted with participation of nutritionist. Patient should intake at least normal daily amount of fat and divide daily ration to at least six meals. Patients should be motivated to restrain from alcohol consumption and smoking as they can lead to further progression of pancreatic exocrine insufficiency and symptoms of pancreatitis.

Aim of review. To present data of clinical trials, systematic reviews and metaanalyses which allow to optimize eradication therapy of Helicobacter pylori (H. pylori) infection. Summary. Standard triple therapy including proton pump inhibitor (PPI), clarithromycin and amoxicillin is the first­line treatment for H. pylori eradication. At prescription of standard triple therapy various measures increasing its efficacy should be utilized. Classical fourcomponent bismuth tripotassium dicitrate­based treatment or quadrotherapy without bismuth including PPI, amoxicillin, clarithromycin and metronidazole may be alternative options for the first line eradication therapy. Quadrotherapy with bismuth tripotassium dicitrate is applied as the basic mode of second line therapy at failure of standard triple therapy. Alternative mode of the second line therapy includes PPI, levofloxacin and amoxicillin. Levofloxacin­based triple therapy can be prescribed only by specialist in gastroenterology at strict indications. Third line therapy is personalized according to the choice of the previous treatment modes. The choice of H. pylori eradication therapy in the Russian Federation is based on empirical approach. The rate of clarithromycin resistance of H. pylori strains in Russia does not exceed 15% in the majority of regional studies. There are data indicating absence of significant metronidazole resistance of H. pylori and low level of double clarithromycin and metronidazole resistance. Efficacy of H. pylori eradication therapy may be enhanced by increasing treatment duration to 14 days. Prescription of new generation PPI or increase of PPI dose are targeted to provide the maximum acid suppression, highly important for successful H. pylori infection eradication. Additional prescription of bismuth tripotassium dicitrate, probiotics or rebamipid increases efficacy of antihelicobacter therapy. Significant decrease of adverse events rate at H. pylori eradication treatment is reached at combined prescription of probiotics. Rebamipid may potentiate reparative processes in the stomach mucosa. Conclusion: Methods of H. pylori eradication optimization can be applied for enhancement of both standard triple therapy and other concomitant treatment modes, and the combination of these methods provides best result for the given patient.

Aim of publication. To present indications for antihelicobacter therapy, methods and sequence of diagnostics and eradication treatment of Helicobacter pylori (H. pylori) infection to general practitioners. Key points. Chronic gastritis caused by H. pylori infection, including that in «asymptomatic» patients can be considered to be an indication for H. pylori eradication therapy both as etiological treatment and opportunistic screening diagnostics for gastric cancer prevention. Indications for obligatory antihelicobacter therapy include stomach and a duodenum peptic ulcer (PU), stomach MALT-lymphoma, early gastric cancer with endoscopic resection. Breath test with 13С-labeled urea, laboratory test for assessment of anti-H. pylori antibodies in feces, rapid urease test and serological method can be recommended for primary diagnostics of infection. Serological test is not applicable after antihelicobacter therapy. According to the bulk of regional studies clarithromycin resistance level of H. pylori strains in Russia does not exceed 15%. Obtained data indicate the absence of high metronidazole-resistance of H. pylori as well as double resistance to clarithromycin and metronidazole. Standard triple therapy including proton pump inhibitor (PPI), clarithromycin and amoxicillin is recommended as first-line treatment for H. pylori eradication. Standard triple therapy should be carried out, applying various means that increase its efficacy. Alternatively to standard triple therapy, first-line eradication treatment may include four-component bismuth tripotassium dicitratebased therapy or non-bismuth quadrotherapy which includes PPI, amoxicillin, clarithromycin and metronidazole. Quadrotherapy with bismuth tripotassium dicitrate can also be applied as a basic mode of the second line treatment at inefficiency of standard triple therapy. Alternative mode of second line eradication treatment includes PPI, levofloxacin and amoxicillin. Levofloxacinbased triple therapy prescription in the presence of strict indications should be limited to gastroenterologists. The third-line eradication treatment is adjusted individually according to the history of previous treatment modes. Eradication efficacy may be increased by prolongation of treatment up to 14 days, applicaiton of modern PPIs or increase of PPI doze, addition of bismuth tripotassium dicitrate or probiotic. Conclusion. In each case of H. pylori detection it is reasonable to consider eradication therapy that is especially actual as H. pylori infection eradication is recognized as effective method of stomach cancer prevention. H. pylori eradication optimization methods can be applied both to standard and alternative modes while combination of these approaches allows to achieve the best result in a given patient.

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.

Aim of review. To present management approach for acid-related diseases in patients with Helicobacter pylori (H. pylori) infection, under long-term proton pump inhibitor therapy. Summary. There is no relation of gastroesophageal reflux disease (GERD) symptom severity, the pattern of relapses and treatment efficacy to the presence or absence of H. pylori infection; successful H. pylori eradication does not cause relapse of pre-existing GERD and does not induce its development. At the same time it is impossible to neglect the data on potential induction or aggravation of GERD after H. pylori eradication in separate population groups, including those in Asia. The presence of GERD could not prevent infection eradication in the presence of other indications (e.g., peptic ulcer, chronic gastritis). Monotherapy by proton pump inhibitors (PPI) in H. pylori-positive patients with GERD may lead to progression of gastric corpus atrophy that can be regarded as risk factor for stomach cancer development. H. pylori infection eradication promotes reduction of gastritis-like changes severity irrespective of maintaining of acid-suppressive treatment. The choice of specific PPI for treatment of patients with GERD and other acid-related diseases, carrying out H. pylori eradication therapy or substitution of one PPI agent to another are individualized and depend on the indications registered in the drugs administration instructions, features of its pharmacokinetics and pharmacodynamics, possible drug-to-drug interactions. Conclusion. Testing for H. pylori infection and carrying out the subsequent eradication therapy could allow to prevent progression of corpus mucosa atrophy in patients with acid-related disorders, first of all those with GERD, who received long-term PPI treatment. Estimation of duration of PPI treatment at acid-related disorders, and terms of H. pylori eradication therapy should be evaluated according to clinical guidelines and treatment protocols of these diseases taking into account age of the patient, clinical features, course of disease, presence of complications.

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.