Treatment of gastroesophageal reflux disease (GERD) is an urgent problem of modern gastroenterology. According to numerous studies carried out from 2000 to 2011, the prevalence of GERD varies depending on the region of the world from 2.5% (in East Asia) to 33.1% (in the Middle East). Moreover, according to various authors, the rate of failure of GERD therapy can reach 40%. Today there is no general accepted definition of “refractoriness” in all professional communities. In the clinical guidelines for the diagnosis and treatment of GERD of the Russian Gastroenterological Association (RGA), refractoriness is understood as the persistence of typical symptoms of the disease and/or incomplete healing of the esophageal mucosa while taking a standard dose of proton pump inhibitors (PPIs) once a day for 8 weeks. It should be noted that it is legitimate to talk about the refractory form of GERD in the case when the diagnosis of GERD was verified according to current clinical recommendations, treatment was prescribed according to the identified phenotype of the disease, but the therapy administered to the patient is accompanied by a partial effect. The article presents the basic principles of treatment a patient with gastroesophageal reflux disease refractory to proton pump inhibitor therapy. An algorithm for identifying and eliminating possible causes of refractoriness is proposed, taking into account the phenotype of the disease and the presence of concomitant pathology.

Due to the lack of clear criteria in the diagnosis of gastroesophageal reflux disease (GERD) in children, it becomes appropriate to study the pathology, the factors of its formation and clinical course, including the association with manifestations of diseases of adjacent organs. The ethnic aspect is poorly studied. Aim: to evaluate the population characteristics of comorbidity of clinical manifestations of GERD with SD (dyspepsia syndrome) and IBS (irritable bowel syndrome) in schoolchildren of the Republic of Tyva with erosive and ulcerative defects of the gastroduodenal mucosa. Material and methods. The study was conducted in the Republic of Tyva: 1079 schoolchildren aged 7-17 years were clinically examined. GERD was defined in accordance with the pediatric consensus on pathology. IBS and SD were diagnosed based on Rome IV criteria. Subsequently, 129 children with gastrointestinal complaints underwent endoscopic examination of the upper gastrointestinal tract. The subjects were divided into two groups depending on the presence of GERD. Results. Erosive and ulcerative pathology of the gastroduodenal mucosa was more often detected in schoolchildren with GERD (p=0.032), mainly in the form of erosions (p=0.010) and significantly more often among Tuvans compared to Caucasians (p=0.004). The highest frequency of defects of the gastroduodenal mucosa was detected in schoolchildren with GERD, who also had manifestations of dyspepsia (in 27.8%). In children with GERD, the frequency of the destructive process was 2 times higher when associated with the clinical picture of IBS (p=0.185) and significantly higher than in children without GERD, but with IBS (p=0.036). In general, in children with an association of GERD and IBS, erosions were diagnosed more than 3 times more often than in other children. Conclusion. An association of GERD and erosive changes in the gastroduodenal mucosa is observed. The expediency of endoscopic examination of schoolchildren in the presence of an overlap of GERD with IBS for the purpose of diagnosing erosive pathology increases.

Gastroesophageal reflux disease (GERD) is characterized by impaired motility at the gastroesophageal junction and the development of inflammatory changes in the mucosa of the distal esophagus. The aim of this review is to discuss the mechanisms contributing to the development of GERD. A literature search was conducted using the eLibrary.Ru and PubMed databases, focusing on articles published after 2000. Following the application of selection criteria, a total of 80 articles were included in the final literature review. Current understanding suggests that reflux esophagitis begins with damage to the esophageal epithelium caused by the reflux of acid and pepsin, leading to increased epithelial permeability. This allows hydrochloric acid and pepsin to penetrate deeper into the epithelial layer, attacking intact cells. Research indicates that the mechanisms of epithelial damage in the esophagus induced by acidic and bile reflux differ. Acid reflux causes tissue damage through protein denaturation, degradation by proteases, activation of cyclooxygenase-2 (COX-2), c-myc, and mitogen-activated protein kinase pathways, while simultaneously limiting prostaglandin synthesis. In contrast, bile acids induce cytotoxic mechanisms, activating oncogenes and c-myc, which contribute to epigenetic carcinogenic processes. Alterations in the esophageal microbiome trigger the activation of both innate and adaptive immune systems, as well as the sensory nervous system. Immune competent cells express receptors for numerous mediators released by sensory and autonomic nerves, enabling the nervous system to directly regulate the functional activity of the immune system. Conversely, immune cells can produce neuroactive substances and modulate nervous system functions, including pacemaker cells, leading to the development of reflux and exposing the esophageal mucosa to hydrochloric acid and pepsin or bile acids, resulting in inflammation and creating a vicious cycle.

Iron deficiency conditions are caused by disorders of iron metabolism due to its deficiency in the body and are characterized by clinical and laboratory signs, the severity of which depends on the stage of iron deficiency. The development of iron deficiency anemia (IDA) in pregnant women is due to increased iron intake by the mother and fetus against the background of insufficient exogenous intake and / or assimilation and occurs at any stage of pregnancy. The presence of anemia in pregnant women adversely affects the course of pregnancy, childbirth, the postpartum period, the condition of the fetus and newborn. It should be noted that the effectiveness of the treatment of pregnant and maternity women with IDA depends on the daily dose of elemental iron and on the level of endogenous erythropoietin (EPO). With an adequate level of EPO, the effectiveness of treatment is 2.5 times higher. In addition, the use of EPO drugs in combination with ferrotherapy in pregnant women and maternity patients leads to a more pronounced clinical effect.