[A case of severe hyperparathyroidism in clinical practice. Case report].

Disorders of the mineral balance often determine the symptoms, the severity of the course and the prognosis of many diseases. Primary hyperparathyroidism (PHPT) is a common endocrine disease caused by increased secretion of parathyroid hormone as a result of primary damage to the parathyroid glands. Diagnosis of PHPT is often difficult. Clinical signs of PHPT appear months or years after the onset of the disease, however, the presence of hypercalcemia serves as an early indication of the disease of the thyroid gland. Often, patients are observed for a long time by related specialists (rheumatologists, traumatologists-orthopedists, oncologists), which gives rise to a lot of problems consisting in the lack of adequate treatment and its result, the progression of the disease, disability, and a decrease in the quality of life. Often, patients are observed for a long time by related specialists (rheumatologists, orthopedic traumatologists, oncologists) under the "masks" of various pathologies (osteoporosis, recurrent urolithiasis, etc.), which gives rise to a lot of problems, consisting in an erroneous diagnosis, lack of adequate treatment and its result, progression of the disease, disability, and a decrease in the quality of life. Late diagnosis of PHPT leads to the development of severe complications (osteoporetic fractures, renal failure) and an increased risk of premature death. A clinical case of late diagnosis of PHPT at the stage of pronounced bone complications of the disease, which proceeded under the guise of osteoarthritis, is considered. According to the results of laboratory and instrumental studies, the following were revealed: hypercalcemia, a significant increase in the concentration of PTH, adenoma of the left lower parathyroid gland, hyperparathyroid osteodystrophy, and a decrease in bone mineral density. Surgical treatment was performed - selective parathyroidectomy with the development of hypocalcemia in the early postoperative period, which was stopped by taking calcium supplements and active vitamin D metabolites and is designed to help practitioners of various specialties to understand the issues of diagnosis of PHPT and effective care for patients.

[Clinical case of IgG4-related disease in a patient with Burkitt lymphoma].

The article provides a case of primary diagnosis of IgG4-related disease in a patient with Burkitt lymphoma.

Is it necessary to use capsular endoscopy to diagnose celiac disease?

AIM: To clarify the indications for capsular endoscopy (CE) in patients with celiac disease. MATERIALS AND METHODS: The study included 10 patients with celiac disease (6 women, 4 men) aged 22 to 69 years. The median age was 42.4±17.5 years. The diagnosis of celiac disease established on the basis of histological examination of the mucous membrane (MM) of the duodenum and detection of antibodies to diaminononane peptide gliadin and to tissue transglutaminase. In three patients celiac disease was diagnosed for the first time, in others - in terms of 3 months to 2 years. CE was performed using a Given Imaging systems (Yokneam, Israel), Olympus (Japan), the obtained data were analyzed using Rapidr® Reade (version 7.0). The results of the endoscopy were compared with the data of 78 patients examined by us, in which the indicators conformed to the normal CE criteria. RESULTS: All patients with celiac disease showed characteristic endoscopic markers of atrophy from the small intestine: scallop, nodularity, decrease in height and number of folds. Paid attention to the mosaic of defeat in the form of "atrophy fields" against a background of slightly modified MM. Erosive-ulcerative lesions of the small intestine were found in 4 patients. CONCLUSION: Indications for the appointment of CE in patients with celiac disease is the lack of response to treatment, which is based on strict adherence to gluten-free diet, the assumption of erosive and ulcerative lesions MM of the small intestine and refractory form of the disease. CE makes it possible to establish the extent of atrophy from the small intestine, which allows you to use it to evaluate the effectiveness of treatment.

[Video capsule endoscopy is one more step towards improving the diagnosis of small intestinal diseases]. / Videokapsul'naia éndoskopiia - eshche odin shag na puti sovershenstvovaniia diagnostiki boleznei tonkoi kishki.

AIM: To estimate the value of video capsule endoscopy (VCE) in the diagnosis of small intestine (SI) diseases.. SUBJECTS AND METHODS: A total of 134 patients, including 72 (53.7%) women and 62 (46.3%) men whose mean age was 41.48±9.33 years. Group 1 included 73 patients who were examined using an algorithm for the diagnosis of SI diseases, 61 patients underwent VCE by the referrals handed in other healthcare facilities. RESULTS: In the patients of Group 1, pathological SI changes were revealed by VCE by almost 4 times more frequently than in those of Group 2. VCE provides a possibility of establishing the sources of bleeding, Crohn's disease, and other inflammatory diseases, which are inaccessible to other diagnostic methods. SI arteriovenous malformations, polyps, and diverticula, parasitic infections, and nonsteroidal anti-inflammatory drug-associated enteropathy may be causes of obscure SI bleeding and anemia. In celiac disease, VCE may estimate the extent of SI mucosal atrophy and reveal its disintegration as erosions and ulcers, which are inherent in its refractory form. CONCLUSION: VCE is a highly informative method for examining the SI, but, in view of the specific features of its performance and the high cost of hardware, VCE is recommended to be performed in accordance with the proposed diagnostic algorithm.

[Diffuse esophageal spasm: difficulties of diagnosis and treatment].

The article describes the diffuse esophageal spasm which is not amenable to conservative treatment.

[Anemia as the only symptom of esophageal hiatal hernia of the diaphragm].

The clinical case of chronic post-hemorrhagic iron deficiency anemia in patients with large hiatal hernia is represented in this article.

[Pharmacokinetic and pharmacodynamic characteristics of antihypertensive drugs in the treatment of hypertensive patients with chronic diseases of the liver].

AIM: To determine optimal treatment of arterial hypertension (AH) in patients with hepatic cirrhosis (HC) basing on pharmacokinetic and pharmacodynamic characteristics of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenoblockers (BAB). MATERIAL AND METHODS: A total of 360 patients with AH of the second degree, steatosis and alcoholic HC of class A according to Child-Pue participated in the study. The control group consisted of 120 patients with peptic ulcer in remission and normal function of the liver. The patients' treatment with enalapril (pharmacologically inactive prodrug), lisinopril (biologically active substance), atenolol (hydrophilic drug) and metoprolol (lipophylic drug) was analysed. RESULTS: Lisinopril showed a better hypotensive effect than enalapril in AH patients with HC. BAB decreased blood pressure in all hypertensive patients. Atenolol and metoprolol effectively reduced blood pressure in 88.89% patients with AH and HC. Bradycardia episodes in atenolol treatment were observed in 14.4% patients while in metoprolol treatment--in 22.2% patients, this evidencing for pronounced shifts in pharmacokinetic parameters of metoprolol exposed to hepatic metabolism. CONCLUSION: Biological activity is an essential criterion of choice of ACE inhibitor in patients with hepatic pathology. Enalapril, for example, as a pharmacological inactive prodrug, is metabolized in the liver to acquire activity, whereas lisinopril has a direct biological activity and has, therefore, a stronger hypotensive action in AH patients with HC. BAB should be selected by the ability to effectively control blood pressure and heart rate without inducing bradycardia the appearance of which necessitates correction of dose regimen with reduction of day dose.

[Liver and drug metabolism].

Liver metabolism aims to change the biological activity of drugs to make them water-soluble to be excreted with bile and urine. The degree of metabolism depends on fermentative capacity for each drag (P450 fermentative system is localized in microsomal fraction of hepatocyte). Metabolism ability also changes under the influence of other substances. Liver diseases lead up to decrease of drug clirens and to increase the semi-excretion time because of reduction of liver metabolism. Therefore the drags usually undergoing intensive liver metabolism necessitate a high risk of overdose when liver diseases present. On the other hand no risk of overdose exist when drags with low liver metabolism are used.

[Cardiovascular pathology associated with digestive system diseases].

With age, a person has "accumulation" of diseases. In patients of older age groups occurs simultaneously for at least 3-4 diseases. Assigning patients with ischemic heart disease (IHD), the physician takes into account the presence of concomitant diseases, especially diseases of the gastrointestinal tract, since the defeat of the stomach, liver, intestine may influence not only on the clinical course of heart disease, but also to change the pharmacokinetics of cardiac drugs. All groups of drugs used in treating coronary artery disease, have different effects on the digestive organs. This can be a positive influence. For example, the use of beta-blockers and nitrates for prevention of bleeding from esophageal varices at cirrhosis of the liver, calcium antagonists in achalasia cardia. It is well known, and the negative effect of cardiac drugs: erosive and ulcerative lesions of the stomach with aspirin use, increasing manifestations of GERD in patients receiving calcium antagonists (dihydropyridines group). In this regard, we need for rational pharmacotherapy.

[Diagnostic criterion for anorexia nervosa].

Article presents a case of anorexia in 29 years old patient. Described the clinical symptoms of anorexia, the manifestations of the disease in patient; the premorbid characteristics of personality, the formation of which influences on relationships with parents.

[Pharmacokinetic and pharmacodynamic features of hypertensive drugs in treatment of patients with arterial hypertension associated with liver disease].

RESEARCH OBJECTIVE: Being based on pharmacokinetic and pharmacodynamic property of inhibitor ACE and -adrenoblokers to optimise treatment of patients arterial hypertension (AH), a liver proceeding against chronic diseases. MATERIALS AND RESEARCH METHODS: In research it is included 360 patients with AH 2 degree in a combination with steatosis and the cirrhosis of liver of an alcoholic etiology of a class A by Chald-Pugh. In control group patients with stomach ulcer are included in stages of remission with normal function of a liver. For the purpose of diagnostics AH and an efficiency estimation hypotensive preparations the patient it is spent systolic arterial pressure. For a pharmacokinetics estimation definition of concentration of preparations in whey of blood sick of a method of a highly effective liquid chromatography was spent. RESULTS: At patients AH with the normal and broken function of a liver after reception lizinoprili and atonololi it is noted distinctions in pharmacokinetic parametres. The broken function of a liver at patients AH against the cirrhosis lover is at the bottom of changes pharmacokinetic parametres metoprololi and enalaprili.

[Angiodysplasia and hemorrhages of the gastrointestinal tract as a particular manifestation of the connective tissue dysplasia].

The clinical case of hemorrhagic syndrome associated with alterations of gastrointestinal tract small vessels in the patient with connective tissue dysplasia, magnesium deficiency and with pathological addiction to alcohol is represented in this article.

[Hypereosinophilic syndrome with the esophagus, stomach and small intestine pathology].

In this article the differential diagnostic line of blood hypereosinophilia is analyzed and the complicated clinical case of severe eosinophilic esophagogastroenteritis with recurrent oedema associated with protein loss is represented.

[Combination therapy of arterial hypertension combined with liver pathology. The place of angiotensin converting enzyme inhibitors].

It is necessary to take into account presence of concomitant pathology while prescribing hypotensive therapy to patients with arterial hypertension (AH). Hydrophilic angiotensin converting enzyme inhibitors (ACEI) (lisinopril) which are not metabolized in the liver are theoretically safest in liver cirrhosis. We have examined and treated 180 patients with AH and assessed efficacy and tolerability of ACEI lisinopril and enalapril with consideration of their pharmacokinetic peculiarities in patients with various severity of involvement of the liver (steatosis or cirrhosis). Advantage of hypotensive effect of lisinopril (which required no biotransformation in the liver) over enalapril based on its pharmacokinetic properties has been demonstrated.

[Anorexia like severe extraintestinal diseases manifestations].

Patients with intra- and extrabowel diseases often have severe malnutrition as result of anorexia neuropsychica. The first investigators of this problem were W. Gull, Lasegue et al. There are clinical symptoms and phases, different diagnostic and treatment of such type of anorexia discribe in the article.

[Primary hyperparathyroidism associated with chronic pancreatitis, cholecysto- and nephrolithiasis].

The case of primary hyperparathyroidism in a combination to a chronic pancreatitis, bilious--and urolithic disease is exposed in this article. Difficulties of diagnostics and differential diagnostics of hyperparathyroidism are described there. You can find literatures, concerning this problem. Also here were made some recommendations to practising doctors.

[Pharmacokinetics of enalapril and metoprolol in hypertensive patients with hepatic pathology].

AIM: To examine characteristics of pharmacokinetics and pharmacodynamics of enalapril and metoprolol in hypertensive patients with gastrointestinal diseases to make relevant corrections in the treatment. MATERIAL AND METHODS: The study included 36 hypertensive patients with steatosis, hepatic cirrhosis and ulcer. All the patients received metoprolol or enalapril. Concentrations of metoprolol and enalaprilate (active enalapril metabolite) were determined with high performace liquid chromatography. The findings gave grounds for calculation of mean drug retention time (MRT) and area under curve "concentration-time" (AUC). Efficacy of the drugs was estimated by the data of 24-h blood pressure monitoring. RESULTS: Hypertensive patients with hepatic diseases given enalapril exhibited lowering of maximal concentration (C(max)) of enalaprilate and prolongation of time of its reaching (T(max)) compared to ulcer patients. MRT and AUC were increased in hepatic cirrhosis patients treated with enalapril and metoprolol. Metoprolol C(max) in this group of patients was higher than in the controls. Blood pressure monitoring showed that enalapril therapy was more effective in ulcer patients vs patients with liver diseases. Metoprolol treatment of hypertensive patients with hepatic cirrhosis resulted in development of bradycardia. CONCLUSION: In hypertensive patients with liver diseases on enalapril therapy its metabolite production may appear insufficient for therapeutic effect and higher dose may be needed. Metoprolol in the treatment of hypertensive patients with hepatic cirrhosis should be used with caution because of disturbance of its metabolism and possible cumulative effects.

[Particular features of the concurrent course of arterial hypertension and ulcer in elderly patients]. / Osobennosti sochetannogo techeniia arterial'noi gipertonii i iazvenoi bolezni u pozhilykh bol'nych

The article presents a clinical course analysis in elderly patients suffering concurrently from arterial hypertension and ulcer as well as a study of the state of the mucous coat of the stomach and duodenum at the endoscopy and morphological assessment. It gives data of the daily monitoring of arterial pressure, central hemodynamics and indices of the lipid blood composition and hemorheology. There was a comparative analysis, which established the direct dependence of the ulcerous defect area on the atherogeneity index. Data of the morphological assessment seem to be most interesting as this study revealed abnormalities in microcirculation in the mucous coat of the stomach. It should be noted that disorders in the blood supply of the mucous coat of the stomach play a considerable role in the formation of ulcers in elderly patients with long-term arterial hypertension, and semination with Helicobacter pylori is very rare.