Neurologist Pavel Brand. The main causes of pain in different parts of the abdomen

Oksana Galkevich: So, friends, as we said, our colleague Sergey Leskov is on vacation this week. But we, nevertheless, decided not to miss this time, not to leave it in vain, we invite different interesting people professionals from a variety of industries. We discuss with them those events that seem important and interesting to them, which they would like to discuss with you and with your participation. So, we present our interlocutor today. In the studio of the program "Reflection" Pavel Brand - chief physician, medical director networks medical centers Family Clinic. Hello, Pavel Yakovlevich.

Pavel Brand: Hello.

Peter Kuznetsov: Hello.

Oksana Galkevich: You know, since we began to talk in advance that at 19:30 we have such a half hour, I quietly put off some SMS messages on your medical topic in general. And I must say that a whole pool of questions related to the quality of training of doctors. Basically, roughly speaking, they formulated it like this: there are a lot of half-educated doctors.

I don't know, maybe it's too harsh. But what do you say? Is there a personnel problem in our Russian medicine here and now?

Pavel Brand:There is a personnel problem, if briefly and simply. There is a personnel problem. What has become a lot, before it was not enough - this is not entirely true. The percentage is about the same. The problem is that over the past 10-15 years, I think, the amount of information that a doctor needs to know in order to work as a doctor has changed somewhat. And this may be due to the fact that we have a certain backlog from world medicine. Due to the increase in the amount of information, it really seems that doctors know less than before.

To make it clearer, there is such a thing as doubling all medical information that occurs at some point in time. In 1950, it took about 50 years to double all the medical information that was known to mankind. By 1980 it was already 10 years old. By 2003 it was 5 years. By 2010 - 3 years. It is believed that in 2020 all medical information, known to mankind, will double every 78 days.

Oksana Galkevich: Accordingly, is it necessary to somehow respond to this challenge with a change in medical education?

Pavel Brand:Yes. This is the problem, that the amount of information is progressively increasing, and medical education is not changing very quickly. That is, it is trying to be in time, but so far it has not been very successful.

Oksana Galkevich: You said that our lagging behind world medicine is significant. What did you mean?

Pavel Brand:Yes. We are conceptually behind. Therefore, everything here is quite simple and complex at the same time. The problem of lagging behind is that we basically teach doctors in much the same way as 30 years ago. Nothing has changed globally. Now there are some attempts to change, the introduction of a system of continuous medical education. These are the last literally a year or two, and these are still pilot projects to a greater extent than any real situation that is changing right before our eyes. In fact, the lag lies in this as well. That is, education is changing, we do not have much time for it.

The main problem, among other things, is that we have not adopted the concept evidence-based medicine. I always talk about it. The fact that the whole world still switched to this concept. I can not say that she is downright brilliant. But no one has come up with anything better yet.

Oksana Galkevich: Explain to our audience, non-specialist people, non-professionals, what is the concept of evidence-based medicine.

Pavel Brand:The concept of evidence in medicine is very simple. It is really simple, understandable, there is nothing complicated in it. And it was formulated back in 1993, although in fact it all started a little earlier. In 1993, a fairly understandable definition was formulated, a fairly understandable formula that says that everything medical interventions treatment, prevention, rehabilitation, screening, should be based on the highest quality evidence available. For such the highest quality evidence, a pyramid of evidence was built and were accepted various levels evidence, the best of which are randomized clinical researches. These are studies carried out by specialists, doctors, scientists on certain rules. These rules are also quite simple. Globally speaking, from any study of any intervention medicinal product, rehab, screening, anything, should be very simple rules. These are the rules. All patients should be randomized into groups. Randomized - that is, they should be distributed to these groups without any preferences, that is, in a free order.

Randomization from word rnd , random distribution. All patients and physicians who treat these patients as part of the study should not know what kind of drug or what kind of method they are receiving. This is called the double blind method. That is, the patient does not know which drug he is receiving, drug or placebo, and the doctor does not know whether the patient is receiving drug or placebo. Only some controller, the so-called monitor, knows which drug the patient is receiving. Sometimes there are triple-blind studies, when even the monitor does not know, but only in the center that processes the results of the study.

Moreover, the study should be carried out in many different centers, preferably in different countries in order to avoid any conflicts of interest. These are basic principles conducting randomized clinical trials, which are taken as the basis of evidence. Naturally, there should be samples of patients that are as representative as possible. An essential, specific calculation formula that allows you to extrapolate or transfer data from a small group to the rest of the population. This is the basis of evidence-based medicine. Next come more simple studies- prospective, cohort. This is a range of studies. by the most low level Evidence according to different classifications is considered either the opinion of an expert, that is, a doctor. If the doctor says: "I've been doing this all my life and everything is fine with me," this is the weakest evidence.

Oksana Galkevich: Lower level.

Pavel Brand:Lower level. Even lower than this can only be studies on animals and cultures of bacteria. That is, when we hear that someone has proven on animals that there is a new cure for something, we must understand what it means that this has not actually been proven, because such things cannot be extrapolated directly to humans. This was done 50 years ago. Now this is no longer accepted.

Oksana Galkevich: Pavel Yakovlevich, but from what you just said about the concept of evidence-based medicine, as far as I understand, this requires a complete reconfiguration of domestic healthcare, its work.

Pavel Brand:Yes, it should have been done just then.

Oksana Galkevich: And another change, maybe in the minds of the professional community, as far as I understand, because this is a completely different approach.

Pavel Brand:This is a different approach, this is a different understanding. This is all somewhat more complicated than just relying on evidence. In essence, evidence-based medicine is a modification of what we have, because it includes three main pillars. This is really the latest, most serious evidence, this is the personal clinical experience of the doctor and this is the desire of the patient and his relatives. Because in the Soviet or in the old Russian medical school, things like evidence and the desire of the patient are usually not taken into account. Everything relies solely on the clinical experience of the doctor and on the scientific school to which this doctor belongs. Unfortunately, the scientific school is not a very good support, because each scientific school your vision of the problem. The most classic example, really textbook, is a stomach ulcer, when we had two schools in Russia, back in the Soviet Union, when one school said that the cause of a stomach ulcer is the effect of the vagus nerve, another school said that this is all helicobacter, that is, the bacterial theory of ulcers. Here they fought among themselves. Some patients were operated on, others were treated with antibiotics. Moreover, each stubbornly tried to prove that the other was wrong. As a result, it turned out that those who spoke about the Helicobacter pylori theory were still right. But, nevertheless, how many people were cooperating during this time, we can hardly imagine.

Although operations for ulcers that do not penetrate in any way do not manifest themselves, of course, are not required. It's already emergency situation. Therefore, it does require a change in the so-called paradigm, but, unfortunately, not only a change in the paradigm itself. This requires colossal economic costs, because, for example, 99% of drugs produced in Russia not under a foreign license, their own drugs, they are not clinical trials, unfortunately, according to the criteria that I outlined, they did not pass.

Oksana Galkevich: You are now saying some very disturbing things.

Pavel Brand:These are common knowledge. It's perfect open information. She is not disputed by anyone. There were animal trials, there were non-randomized trials.

Oksana Galkevich: Which, as you say, is not hard evidence.

Pavel Brand:There is no hard evidence. Therefore, we will have to take the entire pharmaceutical country and destroy it in one fell swoop for the sake of some kind of evidence-based medicine. Evidence-based medicine has its drawbacks. This is a high engagement of researchers by pharmaceutical companies. It also has its own nuances. There are problems with the fact that cardinal changes periodically occur depending on the sample sizes. That is, yesterday it was believed that this medicine is good, and tomorrow it is already considered that it is not very good.

The most striking example is aspirin, a drug acetylsalicylic acid, which the for a long time was considered correct, and the study was that it is good to use it for the prevention of cardiovascular events, that is, all people after 55-60 years old should drink aspirin so that they do not have a heart attack or stroke.

Oksana Galkevich: It seems that many people still think so now.

Pavel Brand:Yes. But not so long ago it was proved that this is wrong. Aspirin can only be drunk for secondary prevention, when an event has already happened, because it has certain disadvantages that do not allow it to be given to everyone.

Peter Kuznetsov:Marat from Kazan asks you via SMS: “Literally today I saw a therapist. The doctor says: “Ultrasound is only for October.” Is this a forced examination?”

Pavel Brand: Good question. I think there is nothing strange about this. We are just a little used to a very social system medicine for 70 years. Not even for 70, but for the last 50, probably years social medicine. This is such a problem all over the world: if nothing acute happens to a person, then research takes place rather delayed. Why? Because there are few really narrow specialists everywhere. There is probably no such number of doctors as in Russia anywhere in the world. Maybe only in China and India. But in civilized countries, there are quite a few doctors, and there, examinations in 3-4 months are the norm. And always the question is the stages of medical care. If this is an emergency, then health care should be provided within minutes or hours. If it is an urgent situation, then within hours and days. If it's a delayed situation, it's days and weeks. If planned, then months and years.

That is, there must be a clear understanding. Unfortunately, health officials do not communicate well with the population and cannot explain that there are things that really need to be examined and treated immediately, and there are things that are in no hurry. If a person needs to do a planned ultrasound, then it should not be done tomorrow or in a week.

Oksana Galkevich: And we like to demand that tomorrow.

Pavel Brand:Probably in this vein - if you want, you don't have medical indications but you want to do it tomorrow, here you go paid medicine gives such an opportunity. Please.

Peter Kuznetsov:There is a question about another form that has just appeared - this is telemedicine. A lot of questions. What do you think about it? What can be done about it?

Pavel Brand:Telemedicine is very interesting story. Telemedicine has, if I'm not mistaken, 24 forms.

Peter Kuznetsov:24 forms of telemedicine?

Pavel Brand:Yes. 24 variants of what can be called telemedicine. Because talking with a doctor on the phone is also telemedicine. A conversation between two doctors on the phone is again telemedicine. Review by a doctor of analyzes sent by whatsapp This is also telemedicine. If I don't confuse anything, 24 or 25 forms stand out. Therefore, to talk about what I think about telemedicine, it is necessary to disassemble each form.

Globally, I think it is effectively worth talking about the one form of telemedicine that is the worst in terms of its real application and the most interesting in terms of monetization. That's why everyone wants it. This is the medicine of the primary connection between the doctor and the patient, when the doctor and the patient are directly connected, without seeing each other in real life. Unfortunately, such telemedicine is not very good. It has certain nuances, you can formalize it, make certain standards, introduce certain restrictions, and then everything will be more or less, although also with its own nuances. Unfortunately, in the form of simply conducting "and now let's have doctors contact primary patients directly and try to make a diagnosis via Skype, phone or the Internet" - this is not very cool. Because there are huge risks of both missing the disease and prescribing wrong treatment, something not to see, not to ask, not to smell. Usually, bright opponents cite as an example the smell of diabetic acetone, which you will never smell by telephone or Internet communication.

On the other hand, telemedicine has a huge number of advantages. This is, for example, the connection of a doctor with a doctor, when a doctor in a remote region, not a specialized doctor general practice, can contact a highly specialized specialist from the federal center, who will already interpret the information that the doctor has collected. And he will be able to structure it in some way, suggest whether an operation is needed, whether some kind of additional examination and so on. Communication of the patient with the surgeon before the operation, when the patient is examined by a doctor and wants to clarify some nuances with the surgeon before flying to him across the country, again, to federal centers.

More than what telehealth advocates are talking about? The fact that every doctor every day, to one degree or another, is engaged in telemedicine. His acquaintances, acquaintances of acquaintances, friends, relatives call him, they ask him the question: "Listen, my back hurts - what should I do?" And here a dilemma arises. On the one hand, yes, it happens. Everyone understands what it is. But everyone really wants to monetize it. Because how is it? Money goes by. Usually no one pays for this. We came up with such a form with comrades, doctors, that we don’t want to monetize it directly, we monetize it, for example, in such a way that we launched such a small flash mob on Facebook, doctors help, that a person calls me for a consultation and says: “I want to know what should I treat or which doctor should I go to and which hospital. I tell him. - "Oh, how can I thank you?". I say: "Transfer money to some charitable foundation."

In my opinion, in this form, this monetization is understandable. As soon as it starts to be monetized through some kind of direct money from the patient to the doctor, then there are many additional temptations, besides what is already present. But there are doctors who really earn money from this and who can work like that. For example, many radiologists do work remotely. They look at the picture, give a description, get paid for it. Oncologists can check the prescribed treatment regimen in this way, give some preliminary conclusion, invite the patient for a consultation. There are options here. Therefore, it is impossible to say unequivocally that telemedicine is good or bad. She has her own nuances. It is necessary to state this very clearly, very carefully in legislation, so that there will be no questions later: who is responsible, who pays, who makes the appointments, what appointments, whether it is possible to make diagnoses or can only make a preliminary conclusion, is it necessary to send this patient to a doctor or just watch him on Skype or even talk to him on the phone. A lot of questions. They are very complex indeed.

Oksana Galkevich: Pavel Yakovlevich, you spoke about the concept of evidence-based medicine due to the fact that we are somewhat behind (I am softening the wording) from world healthcare, from world medicine. Tell me, but some movement to the side, perhaps the adoption of this concept, the reconfiguration of some new mechanisms. After all, the backlog must be somehow eliminated, it is necessary to catch up. And it is, or this understanding is not?

Pavel Brand:There is movement. We even have entire specialties that are, to one degree or another, very close to the world level, to the world evidence-based medicine, because they are quite narrow, and all of a sudden these specialties were headed by people who support the principles of evidence-based medicine, and it turned out that that everything is quite simple, it is enough to write correct recommendations, to approve them in the Ministry of Health, and in principle, if we do not enter evidence-based medicine, then at least we will participate in some of its moments: this is primarily cardiology. Indeed, especially in Moscow, we have a very pronounced movement towards evidence-based medicine. Although there are, of course, retrogrades. But there's nowhere to go. These are reproductive technologies. In Russia, they are generally very highly developed. This is endocrinology in many ways, which is really narrow enough to follow global trends. To some extent, urology is now starting to move, gynecology is starting to move slowly, that is, there are some progress. But therapy, neurology and pediatrics are still like before the moon.

Oksana Galkevich: And why did I let you down, returning to this topic again? Due to the fact that there are things that are very actively discussed even in your professional field, and even more so, we cannot understand whether this is pseudoscience or whether it should be taken seriously. Homeopathy, osteopathy.

Peter Kuznetsov:I recently encountered.

Oksana Galkevich: Petya has experience in communication.

Peter Kuznetsov: with an osteopath.

Pavel Brand:Not on the subway, I hope?

Peter Kuznetsov:The baby was probably a month old. They took me to an osteopath. In general, the reception lasted about 40 minutes. It consisted in probing some points. After that ... "doctor", perhaps, it is impossible to speak yet?

Pavel Brand:Why? This is the official medical specialty now recognized by the Ministry of Health.

Peter Kuznetsov: Ah, recognized, right?

Pavel Brand: Yes.

Peter Kuznetsov:The doctor says: "Well, that's it, I've stabilized something here. So much for you."

Pavel Brand:Yes, a very good story. I like it too.

Peter Kuznetsov:Sometimes you don't quite understand what you pay for.

Pavel Brand:In medicine, in general, you don’t always understand what you are paying for, even if it is real medicine. Look, pseudoscience is more of a formulation. It's just that neither homeopathy nor osteopathy can be explained by methods modern science- no chemistry, no biology, no physics, no mathematics, nothing. Therefore, it was somehow formulated precisely as pseudoscience. Although we have, of course, negative examples when genetics or cybernetics were recognized as pseudoscience. But here, just the same, this is a kind of milestone in designating what is on this stage we do not understand what it is, and most likely we will never understand this, because the depth of immersion in science is quite serious now, more serious than 80 years ago, when we discussed this story about genetics or about cybernetics. But, nevertheless, we do not see any evidence that there is at least some sense in homeopathy or osteopathy, except for the placebo effect, we do not see.

But we must not forget that in themselves homeopathy and osteopathy are not terrible. In general, people are prone to certain methods of influence that help them quickly and beautifully get rid of their own ailment, especially if this ailment is caused not by physiology, but by psychology. In this regard, homeopathy and osteopathy help many people very well. We know that a huge number of people are committed to homeopathy, to osteopathy. And they are good. God bless. We shouldn't waste medicine on these people. We do not treat them in any way for what they do not get sick with. On the one hand, it was so simple: a man came, he had nothing, told him to go. But he doesn't feel well. What's the problem? Psychological and psychiatric care is poorly developed in the country. Her actually... She's just getting started. Now only modern centers have appeared, again, with a certain level of evidence. There is a huge history of these pseudo-charlatan methods in the country. There is a disaster in the country with medicine, which does not give people real treatment. That is, the problem is at the level of a real doctor who cannot give normal pills, gives some so-called fuflomycins, which do not work, and do not help, and maybe harm something. And the homeopath gives balls, which seem to harm nothing exactly, but can only cause diabetes if you eat a lot of them.

Basically just sugar balls. And the person gets better. What's bad about it? There are several bad things about this. As long as we accept this history as equal to medicine, we are not advancing medicine. It is very difficult for us to move towards evidence when we recognize methods that 200 years ago showed not very good consistency. It just slows down the development of normal medicine. This is often just a scam because it cannot be verified.

Peter Kuznetsov:room for manipulation.

Pavel Brand:The scope for manipulation is enormous. There is no proof. A man came, gave a balloon and said… Everything is based on trust. This is such a variant of fraud on trust. It got easier, thank goodness. If it doesn't, then go to an ordinary doctor, he will help you.

Peter Kuznetsov: To the surgeon.

Pavel Brand:To the surgeon. And the third moment is when these doctors, they are now called that, nothing can be done, they actually delay the start normal treatment by applying their methods. And when they understand the boundaries very well (unfortunately, there are very few of them), where they understand that this is not fatal, that this is psychology. Let me give an example to make it clear, very simple. For example, back pain. What happens to everyone. What everyone knows, everyone has met. And why do osteopaths work most often?

There is one problem. Back pain is a proven fact, in 90% of cases it completely disappears on its own without any treatment within a month. Accordingly, we take any doctor, not a doctor, anyone and say: "OK, 15 sessions in 2 days - and after 15 sessions you will be all over." That is, with a 90% probability it will be exactly like this, because it will pass by itself - without any pills, without any physiotherapy, without homeopathy, without everything. It’s just that if you don’t touch a person at all, everything will go away with him. But since back pain is not only local pain, it is also psychological discomfort, it is uncomfortable for a person, it is difficult for him to get up, go to work, perform some of his usual functions, then naturally, when he comes to the doctor, who is 40 minutes holds his hands on him and says that he moves his sacred rhythm in one direction or another, then, probably, this somehow creates the effect of treatment for him, the placebo effect.

It must be said right away that the main objections of the supporters of homeopathy, osteopathy and other urinotherapies are that placebos do not work on children and animals. It has long been proven that this is not the case. Placebos work great on animals through their owners and on children through their parents. That is, there are studies that have shown this very well. Therefore, there is probably nothing bad in the placebo effect, again, no. The only thing I would really like is that those who use placebos, including doctors who are engaged in placebo therapy, prescribe all kinds of nootropics and vascular drugs, warn the patient that, you know, we are giving you a placebo, we are giving you we give a pacifier, but we give it to you, and it will still be easier for you. Because it has been proven that even if the patient knows about the placebo, the placebo still works.

Oksana Galkevich: Pavel Yakovlevich, I would like to turn to a certain information agenda. We are now more common topics discussed. For example, this week we raised the issue of reforming the work of our polyclinics, the polyclinic link. Here they are going to make them faster, higher, stronger, to reduce queues, not to delay people, to reduce this recording time, to increase the time of communication with the patient. What do you think should be done here? And if you got acquainted with these plans in some form, do you think how competently they are drawn up?

Pavel Brand:I'll tell you honestly. I did not get acquainted with these plans globally, since now I don’t particularly touch on public health. And I have enough work...

Oksana Galkevich: You just probably know anyway...

Pavel Brand:Yes. But roughly I imagine this project "Lean Polyclinic".

Oksana Galkevich: Yes, right. All right. Lean Clinic, yes.

Pavel Brand:outpatient centers. Look, any work aimed at strengthening the outpatient department is very good. We have a colossal surplus of beds in the country. Despite the fact that everyone is trying to tell us about the fact that our ...

Oksana Galkevich: Swear optimization. Like this, right?

Pavel Brand:Yes, to scold optimization and so on. The optimization problem is not to reduce the number of beds, but to reduce without providing an alternative. It is precisely the development of the outpatient department, a truly qualitative development, that would make it possible to reduce these inefficient beds and make everything good, everything right. But we start from the end. Therefore, in our country it is already such a scourge - to start everything from the end. It seems that everything was correctly thought out, everything was said correctly. But they started from the other side. They began to cut beds, the clinics did not change. The doctors were not trained. And in the end, we got what we got.

Oksana Galkevich: The first step is to cut costs.

Pavel Brand:Yes, to cut the castes, as it is now customary to say in the information agenda. The main problem is that you can build a very beautiful building, you can completely fill it with the most modern equipment. But someone has to work on it. This someone must be properly trained and well motivated. With this we have big problems. We have problems with both training and motivation. Education good doctor it costs expensive. Including the self-education of a doctor is expensive. And no one seeks to compensate him for his expenses on self-education. Thus, we get a stalemate in which we can kind of do a lot of good things, but at the same time we run into this very doctor who interferes with us.

Oksana Galkevich: With dull eyes.

Pavel Brand:Doctors burn out, they are often poorly trained, they burn out quickly, they have no financial opportunity for self-development, they are forced to work at two rates, and so on, in order to feed their families. It does not contribute to the improvement of medicine in such a context. Although the very focus on the outpatient link is absolutely correct. It would also be nice if there was some movement towards licensing doctors. But before that, we have yet, I'm afraid, as before the moon.

Oksana Galkevich: And how do you and your work affect everything that is happening around our country - sanctions pressure, our response, movement towards some kind of closeness, maybe isolation, self-isolation?

Pavel Brand:Retaliatory sanctions actions on naturopaths are most reflected. They love to heal with food.

Oksana Galkevich: Do you mean import substitution?

Pavel Brand:No. Who like to treat with foods, diets, high content of feijoa. But in a global sense, of course, there are problems related ... The biggest problems are related to the fact that the exchange rate of the dollar and the euro has changed. And these problems are long-standing, they are big. And if earlier it was possible to buy an ultrasound machine for 3 million rubles, now it costs, relatively speaking, 6 million rubles. And it really serious problem, because health care to raise prices in the same way (for example, in private health care), as the dollar exchange rate has changed, is simply physically impossible.

Oksana Galkevich: 2 times.

Pavel Brand:Therefore, it became more difficult to update equipment, it became more difficult to purchase high-quality equipment. There is, of course, a problem with this. However, new markets are opening up. Korean equipment is very high quality. The Chinese have learned to make quality equipment.

Oksana Galkevich: What about ours? Sorry.

Pavel Brand:Ours is more difficult. We have good ideas, but they are often poorly implemented. I mean, that's a big problem. Again, you know what the problem is? We have such a colossal history in our country when everyone wants to earn money quickly and at once. Therefore, now, for example, huge funds are being invested in the same telemedicine, forgetting that it would be nice for us to learn how to make normal ultrasound machines for a start. And only then to talk about telemedicine. Because, again, there will be telemedicine, but there will be no equipment to support this telemedicine. That is, we go back again, from the end. And, unfortunately, we also go in education. That is, we are changing postgraduate education without simply touching higher education. In my understanding (I always give such an example) this is an attempt to fasten the pedals to the horse. That is, it is impossible to transfer from a bicycle to a rocket, bypassing a car, a ship, and so on. You can't do that. And this leads to the fact that we really do not have our own normal cardiographs, tomographs, ultrasound machines, but we are ahead of the rest in the development of telemedicine. Great - immediately try to jump into XXIII century. But without crutches, I'm afraid it will not work.

Oksana Galkevich: Thank you very much. It was very interesting. Wide spectrum that we touched on today. Dear friends, Pavel Brand, chief physician and medical director of the family clinic chain of medical centers, was in the studio of the Reflection program today. We do not say goodbye, literally for three minutes we will interrupt and return to you. We will have a big topic ahead. Stay with us. We will talk about microfinance organizations, about loans, about who can and who cannot issue loans to the population. Stay with us.

Pavel Brand: Thank you.

Oksana Galkevich: Thank you.

On his Facebook page about the magical thinking of people, the desire to remain forever young without doing anything, and also about the development of a new direction in medicine on this basis - anti-aging.

Since the beginning of time, man has wanted to live as long as possible, while remaining young and healthy. Previously, they resorted to magical methods for this: they drank the blood of virgins, brewed the elixir of immortality, looked for a philosopher's stone or a sip of living water.

Over time, people came to understand that eternal life is impossible, but the desire to live as long as possible was preserved. Various magical rituals did not give a significant effect, so science replaced magic. With the help of medicine and ecology, a person has managed to more than double life expectancy. It would seem that what else is needed? But a person is always missing something! Now he wanted not only to live long, but to live long and at the same time remain young and full of strength.

Realizing the impossibility of immortality, they sought to preserve youth. This is how legends about rejuvenating apples, the fountain of eternal youth, the humpbacked horse and others appeared. interesting ways prolongation of youth.

The development of science seems to have put an end to the hope for a miracle cure for aging, but a person is not at all so simple as to give up without a fight, because if Medicine could prolong life, why not prolong youth?

Since people, regardless of the standard of living and education, are characterized by magical thinking (yes, homeopathy, osteopathy and other magical healing methods are popular precisely because of it), as well as incredible laziness (I don’t want to do anything, I want a pill for all diseases), they with worthy perseverance best use believed in the possibility of inventing a means of preserving youth with the help of the latest achievements of science and technology. The demand for such a medicine would be simply huge, but as you know, demand creates supply! This is how a whole branch of medicine appeared, which was called the fashionable English word anti-aging!

In the past 20 years, anti-aging medicine has been aggressively gaining its place in the market. The number of new “medicines” and devices for rejuvenation is incalculable, and more and more new ones appear. Vitamins and coenzymes, antioxidants and biologically active additives, hormone therapy and stem cells, placenta preparations and extracts from various parts large body cattle… This is far from full list what a person is ready to shove into himself, for the sake of youth and beauty. The main thing is not to do anything, but to sit somewhere on the beach, eating a hamburger with fries, drinking a glass of whiskey and smoking 15-20 cigarettes a day. No, but what? Scientists let them bother. They are always inventing something there, inventing something. So let them work for the benefit of our youth and beauty ...

The most interesting thing is that the belief in all these antioxidants and stem cells is the very magical thinking. It didn't go anywhere. It still makes seemingly smart and well-to-do people spend huge amounts of money on modern rejuvenating apples. Scientists have not been able to find a cure for old age. Over the past 50 years, there has not been any significant research With a positive result about slowing down aging. No, there are certainly some successes. But they concern, again, life expectancy, and not the prolongation of youth.

But the demand hasn't gone anywhere. Where there is demand, there is supply. Those who realized in time that people are ready to pay and pay a lot for anti-aging therapy, happily sell biologically active supplements, oak bark pomace and other pieces of placenta to gullible townsfolk, promising eternal youth and pristine beauty.

In fact, the secret of active longevity is quite simple. All you need to do is not drink, do not smoke, spend less time in the open sun (arguably, by the way), eat a balanced diet, have regular sex and exercise, monitor iron levels, blood pressure, blood sugar, cholesterol and contact a competent doctor to correct them, timely screening for curable cancers. Everything! No magic pills and miracle injections ...

It would seem that it is not at all difficult, and most importantly, not at all as expensive as anti-aging medicine ... But it requires effort and even, damn it, the rejection of some very pleasant joys of life. To follow this way of life or not, everyone decides for himself. But from magical thinking it’s time to get rid of it already ... The 21st century is in the yard ...

Pavel Brand:

Program "On nervous ground» and I, its presenter, Pavel Brand, neurologist, Ph.D. medical sciences, medical director of the network family clinics Family Clinic. With me is my co-host Marianna Mirzoyan, editor of the Namochi Mantou Instagram channel, medical journalist. Today our guest is a gastroenterologist, candidate of medical sciences, director and managing partner of the Rassvet clinic in Moscow, Alexei Paramonov.

Today we have an unusual, non-neurological topic: "Pain in the abdomen." It also has something in common with neuroscience. Rather, not even with neurology, but with elements of psychosomatics. The topic is huge. Alexey, I think that the very first problem that we will discuss is epigastric pain, gastritis.

What are the problems associated with this pain? Someone's stomach hurts so much that the person cannot bear the pain at all. He runs to the gastroenterologist, drinks packs of antacids, eats all sorts of Rennies and so on, nothing helps him. They do gastroscopy, find superficial gastritis with minimal changes. Another person with a huge ulcer lives and does not blow into his mustache, something aches. What is the problem, what is the reason? How to deal with it?

Alexey Paramonov:

For the patient, the problem, first of all, is that the correct diagnosis is rarely made anywhere, unfortunately. You said "superficial gastritis". This is what, indeed, we write in almost every first gastroscopy. In fact, there is no such thing in the nomenclature of diseases. This is an endoscopic phenomenon. But the paradox, indeed, is present, that the changes are minimal or they are absent at all during endoscopy, and it can hurt. At the same time, in some situations, for example, when diabetes, a large ulcer does not give any pain. This paradox is resolved in such a way that not everything that we usually call gastritis is gastritis.

In fact, gastritis is more of a histological concept. It can be reliably diagnosed only by taking a piece of the mucosa and looking under a microscope. At the same time, he may get sick, he may not get sick, these are completely parallel processes. The fact that, in percentage terms, the most common cause of epigastric pain is functional dyspepsia syndrome. Many of our patients in everyday life take this syndrome for gastritis. In fact, most of them have functional dyspepsia. This is a condition when the same processes are present as in gastritis. There, too, acid acts on the wall of the stomach, irritates it.

But, the main feature is not in this. main feature in individual settings of the gastric mucosa, its sensitivity nervous system. There are people who are hypersensitive to acid, they perceive it as pain. There are other people whose sensitivity is normal or reduced, they do not perceive even a rougher process as pain. These settings, in turn, are very closely tied to psychological phenomena. It has been proven that such disorders occur in people who have anxiety, who have depression. Sometimes these psychological phenomena do not lie on the surface, the patient may not be aware of them. His attending physician is a therapist, a gastroenterologist, too, may not be aware of them. They can sometimes be detected only by special tests by a specialist.

It is possible to reliably diagnose gastritis only by taking a piece of mucous and looking under a microscope.

Marianna Mirzoyan:

What tests are used for this and how to understand that your gastritis is not really gastritis?

Alexey Paramonov:

As for tests, there are many. There are such popular ones as the Beck Scale, the Hospital Anxiety and Depression Scale. But that's all auxiliary tools for a gastroenterologist, a reason to understand that a person has a psychological problem and refer him to a psychotherapist. We, as gastroenterologists, understand that there is such a problem, based on the duration of the disease, the persistence of this pain and the insufficient effect of standard drugs, inhibitors proton pump. Omeprazole, esomeprazole, Nexium, pariet - these drugs are well known to our patients. With a classic ulcer, with a classic gastritis, they relieve pain, if not from the first pill, then the next day for sure. And here we will hear a story - whether it helps or not. Or took three days - it helped, on the fourth day it stopped helping. In such cases, we are already beginning to look for functional dyspepsia.

Pavel Brand:

It turns out that, practically, our entire population, starting from a young age, is ill with something other than what is usually considered. We also believe that the main cause of gastritis is associated with malnutrition at school, with violations of the diet of office workers who eat dry food or do not eat regularly. Because of this, problems with the gastric mucosa develop, all kinds of ulcerations, erosions occur, which in themselves hurt. It turns out that this is not the case. That, in fact, we are premorbidly, somehow already prepared for our psychological condition influenced our pain. That is, it is psychosomatic. Even with minimal changes, normal nutrition we can have a pain syndrome that will bother us, disturb us, and so on.

Alexey Paramonov:

Undoubtedly. Gastritis really exists, there is such a disease. But it occurs several times less often than the diagnosis itself is made to patients. You have now brilliantly outlined the theory that you formulated back in late XIX century, and it dominated until the early 2000s, the 21st century. Until now, in the minds of some of our doctors, it remains to dominate.

In fact, nutrition does not play a significant role either in gastritis or in functional dyspepsia. All 15 tables according to Pevzner and their variations do not matter. real, most common cause gastritis, true gastritis, is Helicobacter pylori, a well-known microbe that causes chronic inflammation in the stomach. But this is not always parallel to the pain. The most common cause of pain is functional dyspepsia, where two main factors play a role. I'm oversimplifying, but the first factor is the acid in the stomach, the second factor is the psychological state that changes the settings for the perception of pain. Hence the impact. The patient often says to us: “It hurts when I'm nervous. I'm going on vacation, and everything went away in one day, I returned to work - on the same day I got sick. Here is the daily routine, sufficient sleep, good vacation, mood, hobby - this is a wonderful treatment. If this does not help, we block the second factor, acid, with the same proton pump inhibitor, which does not work as well as in gastritis, but still works. On the second floor there is already specialized medical care. It could be psychotherapy, it could be anti-anxiety drugs, it could be antidepressants.

Nutrition does not play a significant role in either gastritis or functional dyspepsia..

Pavel Brand:

We have not discussed gastritis caused, for example, by taking medicines. Yes, this is a separate category, gastritis caused by the intake. Most often in our life there are non-steroidal anti-inflammatory drugs, aspirin-associated gastritis, or NSAID-associated gastritis, this is, after all, a different pathology.

Alexey Paramonov:

Yes, now called NSAID gastropathy. Indeed, these drugs have a very active effect on the gastric mucosa, disrupt its protective mucus, remove the protective barrier, and it is freely damaged by acid. Therefore, there should be a policy to restrict non-steroidal pain medications. The patient should think before swallowing the pill. If he has been taking these pills long enough, or if he is in a risk group, he has had an ulcer at some time, or is an elderly person with comorbidities, an anesthetic drug should be taken in conjunction with a proton pump inhibitor, to prevent, first of all, gastric bleeding.

You said a lot about aspirin. Yes, we once fought for it to be prescribed for prevention. cardiovascular diseases, and now we are fighting to ensure that he is not prescribed so often. Cardiologists tell us that it must be prescribed in a limited number of cases - after a heart attack, after a stroke. Our patient has now begun to thin the blood from a hypothetical position at the age of 40, and apart from bleeding, an increase in mortality, nothing better happens from this.

Pavel Brand:

As I understand it, NSAIDs, after all, also do not stand still, and more modern options have appeared, like shiba, which reduce the effects of non-steroidal anti-inflammatory drugs on the stomach.

Alexey Paramonov:

Yes it is. They are improving, but here, too, there is a limit to perfection. When did one of the first selective drugs meloxicam, indeed, its frequency of damage is lower than that of the classic ortofen, diclofenac. But when we continued to develop further, it turned out that in order to achieve an equivalent analgesic effect, it is necessary to increase the dose, and when we increase the dose, the selectivity begins to be lost and the stomach is damaged only in the same way. Coxibs are more selective, but they have other problems. It's about thrombosis. Therefore, this problem cannot be called solved due to selective NSAIDs. The solution to the problem, rather, is in combination with a proton pump inhibitor.

Pavel Brand:

One way or another, everything should be according to the testimony and, if possible, undercover. For some reason, doctors still like to call cover by proton pump inhibitors, acidity regulators.

Let's move on to the next problem, in my opinion, no less frequent, and sometimes much more disturbing, disturbing patients - the problem of heartburn. Heartburn is not only a problem of the stomach, but also a problem of the esophagus, often even the throat. This point is not obvious to the majority of the population of our country, or our patients. What's more, the scariest part is that it's not obvious to most doctors. For example, a cough caused by gastroesophageal reflux is often the last thing a therapist in a clinic thinks about.

Heartburn is not always a reflux disease.

Alexey Paramonov:

Yes you are right. Reflux disease has many manifestations. In addition to the classic - heartburn, belching, this is what you called. It's a sore throat chronic tonsillitis, chronic pharyngitis. When it gets into the larynx and into the respiratory tract, it is both bronchitis and laryngitis. There are purely gastroenterological symptoms, but relatively rare, such as esophagospasm, when there is intense pain in the chest. Such a patient may be brought to the hospital with a suspected heart attack. There are many manifestations of reflux disease. Someone knows them better, someone worse.

The situation is much worse with the awareness of doctors and patients that heartburn is not always a reflux disease. In addition to the fact that heartburn is a reflux disease, it is also the same functional dyspepsia that we talked about. There is a wording, a terminological trap, maybe - it is also called functional heartburn. Here the mechanics are similar to what we talked about earlier - reflux occurs. In a healthy person, reflux also occurs, but healthy man he does not feel them, but a patient with functional heartburn has an overperception of pain and he feels refluxes, they torment him. Subjectively, this heartburn may be more severe than an equivalent reflux disease. In such patients, proton pump inhibitors also do not fully help, in contrast to the classic reflux disease, where they almost always remove heartburn; other symptoms may not be controlled, but heartburn is removed. Here, first of all, it is important differential diagnosis to help the patient. With functional heartburn, sooner or later we will apply the methods that were mentioned - psychotherapy, antidepressants, changing the daily routine, lifestyle. Enough rest, less nervous, to the point of changing jobs, if your boss is rude and a dangerous person. Change your boss, your health is more valuable.

In patients who have these symptoms for a long time, the question arises: is antireflux surgery necessary? This question is not idle. The fact is that in some situations we cannot cure reflux disease otherwise. We can eliminate many symptoms with proton pump inhibitors, but we cannot eliminate reflux itself. We make it less dangerous, less acidic. Then only anti-reflux surgery can help. Now these operations have become effective, safe, laparoscopically done in a short time. But they still require qualified specialist. Not everywhere it is done professionally. The fundamental trap is that the operation is sometimes performed on a patient with functional heartburn, which not only does not help him - it cannot help in principle, and they give additional problems. The patient begins to suffer from everything that was before the operation, plus, even bloating, distension of the stomach during aerophagia and other troubles are added here. Careful selection is important here. When a patient is taken for surgery, at a minimum, daily pH-metry should be done. It must be proven that it is reflux disease and not functional heartburn. Even with the evidence of pH metering, it would be nice to still understand this patient, because no one forbids a patient to have both reflux disease and a functional component. The task of the doctor is to understand what is more, and to predict the effect of the operation.

Pavel Brand:

Alexey, everything about heartburn is thorough and understandable. Thesis, as I understand it, we are talking about a laparoscopic fundoplication operation, which is called an antireflux operation.

The second symptom that usually worries our patients is belching. Here, the operation is not particularly helpful. The man ate, is at a social event, and then once - a burp. What to do?

Alexey Paramonov:

Belching can also be a manifestation of reflux disease. But, you correctly focused attention on this symptom. Very often, its cause is not in gastroenterology, it is aerophagia. Aerophagia is already a psychological phenomenon. This is a condition in which the patient, without realizing it, swallows a lot of air. We all swallow air, this is normal, we have a gas bubble in our stomach. Swallowing air occurs during eating, drinking and talking, especially emotional conversation. But for some it happens small quantities, and then a burp occurs or part of the air is generally realized in a different way. In people who are in a state of anxiety, or with others psychological problems, swallowing can be very massive and then there is a massive eructation. She torments the patient and becomes the cause of experiences, it is inconvenient for him to be in society. On the first trip of such patients to a gastroenterologist, it is necessary to understand whether there is a reflux disease. But most often, again, a psychotherapist is needed, and sometimes the way out here is treatment with an antidepressant.

Very often the cause of belching is aerophagia, swallowing air.

Pavel Brand:

We, it turns out, all major diseases, ladies and gentlemen, from the nerves. Therefore, we continue everything in the “Nervous Soil” program.

Alexey, let's not dwell on the stomach anymore, probably, everything is more or less clear with the stomach. The next item we have in turn is the gallbladder, if we go down. Let's probably discuss the gallbladder and the pancreas in one complex. Yes, these are two, practically opposite, located organs that are in a kind of symbiosis. I would like to understand why this is important. Firstly, there is the problem of gallbladder stones, which is acute - this is a surgical, often pathology. I think that in our country we have both overdiagnosis cholelithiasis, and underdiagnosis in terms of the need for surgery. Plus, operations and general treatment of the gallbladder, one way or another, affect the entire human life, because it greatly limits it in food for the future. It is classically believed that one should stop eating spicy, fried, hot, salty and, in general, everything. At the same time, the pancreas is extremely unpleasant in that it causes very bad states in the form of acute pancreatitis, the strongest dagger pains in the stomach, which practically cannot be stopped by anything. Bad, terrible, up to pankonekrozov, very sad. What do we know about it?

Gallstone disease is not always the basis for removal of the gallbladder.

Alexey Paramonov:

You've finished with a good question. We know little about this. Why does it happen acute pancreatitis we know little. As for the relationship of the gallbladder with the pancreas - yes, it is very close, and anatomically close. In most people, the pancreatic ducts and bile duct open side by side, or even merge into one duct before opening, and the problem goes back from there.

As for cholelithiasis, here is an important thesis - the treatment should not be worse than the disease itself. Many patients can carry stones in themselves and live happily ever after, stones will never manifest themselves. Statistics showed what to do cholecystectomy, remove gallbladder to everyone who had stones found, it turned out to be unjustified. Let this operation be accompanied by not very big risks, the operation is small and well-established. But the risks accompany any operation, they turned out to be higher than the risks of doing nothing. Yes, when cholelithiasis is detected, it happens that they scare patients that the stone can go into the duct - jaundice will occur, there may be suppuration of the gallbladder and other problems. But the likelihood of this in most cases is small, more likely get problems during the operation.

When is surgery really needed? In the presence of biliary pain. Biliary pain is pain in the center, or right hypochondrium, that occurs shortly after eating. The pain is cramping, undulating. If such an attack occurred at least once, this is an indication for surgery. Having happened once, it will repeat again and again and end with a complication. Another indication for surgery is a very large stone, 25 millimeters or more. This is also the surgeons decided to operate. In other cases, surgery is not always needed, you can refrain.

In pancreatitis, there is the concept of acute pancreatitis and chronic pancreatitis. Acute pancreatitis is the most serious disease that you mentioned, sometimes ending in death. It flows hard, these are many months of hospitalization. It's hard to predict. Diet probably plays a role. This is evidenced by our medical observations. But, at the same time, large studies have not shown a connection with diet. A clear association with smoking has been shown, oddly enough, and a clear association with high blood triglycerides. Triglycerides are common fats. Their number is determined, on the one hand, genetically, and on the other hand, depends on nutrition. If there is a lot of fat, then they will rise.

I can’t say how to prevent acute pancreatitis, hardly anyone can. At chronic pancreatitis from time to time there is pain and nausea, pain in the left hypochondrium, girdle pain. Such pain is not too dependent on food. There are periods of exacerbations - it happens that there is pain for two weeks, there is no pain for two months. There must be evidence that pancreatitis is present. Such evidence includes an increase in blood amylase, an increase in blood lipase, an increase in C-reactive protein, an inflammatory marker, inflammatory changes in clinical analysis blood - the growth of leukocytes, ESR. With ultrasound, computed tomography, reliable deviations should be detected - this is a thickening of the duct of the gastric gland, this is the formation of a cyst and its edema, the fluid around it.

Every first patient with superficial gastritis at ultrasound examination gets the conclusion: diffuse changes pancreas, pancreatitis cannot be ruled out. It has nothing to do with pancreatitis. These diffuse changes are in 99% of cases, on the one hand, a fantasy, and on the other hand, the patient came to the study and it is inconvenient to write that he is healthy. We see many patients who have been walking for years with complaints of abdominal pain, girdle pain, have the title of pancreatitis, have these very diffuse changes. At the same time, they have no evidence of the presence of inflammation in the pancreas. Such patients require study and understanding of what is wrong with them. The cause of the pain is completely different. This cause may also be dysfunction of the sphincter of Oddi, a muscle at the exit of the bile duct, which can spasm and give pain. Often this is the same psychosomatics that we talked about. Pain is associated with depression with anxiety and something else. Patients are treated for pancreatitis for years instead of a single course of antidepressants.

Pavel Brand:

Let's move on to a larger, more interesting and completely psychosomatic topic, in my opinion, in the form of irritable bowel syndrome. The problem that comes a large number of of people. I know about a hundred people with irritable bowel syndrome diffuse pain all over the stomach, constant urge to go to the toilet at the most unexpected time, in the most unexpected place, intensifying, indeed, with all kinds of emotional stress. Here the connection with emotions is well traced. But at the same time, there are people who are completely calm and suffer from the same problems. So there is something inside.

Alexey Paramonov:

In such people, it is necessary to understand whether they have irritable bowel syndrome, first of all. To do this, there is an algorithm that operates for the entire gastrointestinal tract: we first exclude the presence of organic diseases, then we assert that we are talking about irritable bowel syndrome. Depending on the group to which the patient belongs, the patient with a risk factor, young or old, whether he has weight loss or fever, a change in the tests, we come to the conclusion whether he needs a colonoscopy. Colonoscopy answers these questions in a significant proportion of cases. Colonoscopy with biopsy is almost always required. We have another problem, sometimes they even did a colonoscopy and they say: there was nothing to take a biopsy from, there is no ulcer, no tumor. You must always take. Because there is such a disease - microscopic colitis, which cannot be seen in any other way than by looking through a microscope. There will be a massive infiltration of lymphocytes, amyloidosis too. There are diseases that cannot be ruled out without a biopsy.

In terms of the incidence of the disease, in any case, above 80% will eventually turn out to be functional disorder. I can say that irritable bowel syndrome is functional dyspepsia one floor down. All the same laws, but no acid in the intestines. But the basic basis - anxiety, depression - plays a very significant role. Yes, there are studies that show that irritable bowel syndrome occurs after infections, for example. One way or another, in the long term, when it exists for months and years, without an emotional background, it will not work anyway.

Marianna Mirzoyan:

The question immediately arises, what can a gastroenterologist do in this case? First, is it possible to refer to psychotherapists, do people get through? The second point, can you prescribe anti-anxiety drugs and antidepressants yourself to help the patient?

Alexey Paramonov:

Yes, this is a fundamental point. Indeed, our Russian patient does not like psychotherapy, and "psychiatrist" sounds threatening to him. Although these people do not always treat those who are "chased by aliens." Ordinary city stresses sometimes also require the help of such a specialist. In our purely gastroenterological guidelines, the same Roman criteria, the consensus for gastroenterologists, they contain recommendations for prescribing antidepressants. There are antidepressants that have been proven effective for the same irritable bowel syndrome. We can appoint them ourselves. We don't prescribe them for the purpose of treating depression or other things - gastroenterologists don't have enough classification to do that. We prescribe to treat irritable bowel syndrome. We know it's highly likely to help. If the patient comes to a psychotherapist, it will be great.

Pavel Brand:

Excellent, Alexey! It remains a very important point to discuss, finishing, beautiful - taking antibiotics. The most important topic in my opinion. We all know, since childhood, mothers told us: an antibiotic, so we need nystatin or some kind of diflucan. Nystatin is really bad. We always have a theory that the antibiotic kills not only the bad flora in the intestine, but also the good one. When the good flora dies, mushrooms start to grow, they must be killed with an antifungal drug. Then there was a new trend: to populate with probiotics, eubiotics, which can improve the situation. Even taking 3-4 days of an antibiotic, you must definitely immediately take an antifungal drug and a probiotic, so that life immediately improves. Is it so?

Alexey Paramonov:

It's so very partial. It is simply dangerous to prescribe an antifungal drug for every occasion, they are quite toxic. Their benefits have not been proven. The main danger from taking antibiotics is antibiotic-associated diarrhea. In a severe case, this is pseudomembranous colitis, when Clostridium difficile (lostridium difficile) present in the intestines multiplies. Antibiotics create conditions for its reproduction. It can cause severe diarrhea bloody diarrhea, and in severe cases and generalized severe infection. These situations can be prevented. On the one hand, here is the well-known domestic concept of dysbacteriosis, however, it is completely wild, this is understandable. This concept has compromised probiotics as a drug class. It is completely wrong to refuse probiotics completely. There are several types of probiotics that have been proven and recognized to be effective, and are included in the leading consensus and guidelines, in particular, in the prevention of antibiotic-associated diarrhea. If we assign certain types pribiotics at the time of antibiotic treatment, the likelihood of complications is reduced.

It is dangerous to prescribe an antifungal drug for every occasion, they are quite toxic.

Pavel Brand:

Alexey, where can I get magic probiotics? In a store or pharmacy?

Alexey Paramonov:

The best of them are some strains of lactobacilli, the so-called LGG, the preparation of which is not registered in Russia. They are present on our market in the form of nutritional supplements, nutritional supplements even mixed with vitamins. Those that we sell in pharmacies as probiotics contain completely different strains. The only thing we have in pharmacies is Saccharomyces, Enterol. It is the same all over the world. As for the most effective lactobacilli, they have to be bought abroad for the time being.

Pavel Brand:

It's clear. Then, a clarifying point: how long do you need to take antibiotics to cause antibiotic-associated diarrhea, pseudomembranous colitis. Why am I asking. Relatively speaking, the treatment of purulent sinusitis, or three, five, seven, or ten days of an antibiotic, or is it a serious therapy with monthly courses of antibiotics.

Alexey Paramonov:

Naturally, if you take an antibiotic for a long time and still change antibiotics, the risk increases.

Pavel Brand:

"A lot" is how much? For some, "a lot" is three days. I know people who are like death for three days of antibiotics.

Alexey Paramonov:

The standard course, after all, is seven days for most types of antibiotics, plus or minus something. The fundamental point is that even one antibiotic tablet in a predisposed person can cause all these severe disorders. Therefore, in the first place - do not take an antibiotic without clear indications. SARS cannot be treated with antibiotics. The next point: the risk increases significantly in the elderly, in people after big operations is a joint replacement, similar major operations. The risk increases significantly. For such patients, if a course of an antibiotic is prescribed, and they are often prescribed, it is imperative to prescribe at least saccharomycetes, Enterol, which is available with us, in parallel. If there are minimal signs of diarrhea, a stool test for Clostridium toxin should be done. Moreover, this toxin in diarrhea must be determined four times in a row. A single analysis does nothing. Care is needed here on the part of physicians to avoid severe forms this disease.

Pavel Brand:

Today we tried to analyze the main points associated with abdominal pain. We did not have time to discuss a huge number of problems, we will have to meet with Alexei again. I would like to put a final emphasis on the very important point which we have just discussed. I met a lot of patients, especially after major operations, by the way, after joint replacement, who developed bloody diarrhea during antibiotic therapy. All these patients were treated by traumatologists, orthopedists as patients with an infection - with a virus, with something else, with symptoms infection. Almost isolated in separate boxed chambers. Also, elderly patients with long-term problems, which then developed into big problems with activation and so on, with dehydration. Doctors need to be educated, doctors need to know certain points that allow them to better manage patients, otherwise there will be no problems. Unfortunately, we have a lot of such problems. We will continue to educate people, we must do something useful.

Thanks a lot Alexey! I think we will meet again in our program, because this is a very interesting topic.