Passed away on June 12, 2018 Yakov Beniaminovich Brand- famous cardiac surgeon, head of the department of emergency coronary surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, TV presenter of the programs “Without a Prescription” and “Coma”.
As part of a team of cardiac surgeons in 1996, he performed coronary bypass surgery on the first president of Russia, Boris Yeltsin.
Yakov Brand knew how to talk with patients (he could discuss the upcoming operation with a patient for two hours), he could tell the truth to his boss in unprintable words, and in general he wanted to become an artist, but it didn’t work out, and he went to medical school.
In medicine - doubt, in life - do not give in
— What did you learn from your father as a doctor and a person?
“It seems to me that it would be correct to separate the doctor and the person here.” As a doctor, I remember well one phrase that my father once said: “A doctor must always think and doubt!” This principle still helps me a lot in medical practice. Unfortunately, our doctors usually don’t think or doubt.
Peremptory actions of doctors are the scourge of our country, which results in not very good consequences for patients.
As a person, what I respected most about my father was his integrity. It was absolutely impossible for him to compromise with his own conscience. If he thought something was wrong, he did not do it under any circumstances.
By the way, he suffered repeatedly for his integrity. For example, about fifteen years ago my father was offered to buy one medical device, having written down in the documents an amount twice as large as it was worth. The father refused in a harsh manner, after which he was sent away by one of the heads of the Department of Health. His father looked at him and asked: “Is this for work or friendship? If it's for work, then I'll go. If it was out of friendship, wouldn’t you go yourself?”
Of course, he could not prevent all the evil in the world, but he considered participation in gray-black schemes absolutely unacceptable for himself. It was a taboo for him in medicine.
Surgeon and teledoctor
Jacob Brand in one of the programs. Screenshot from youtube.com
— Dr. Brand hosted television programs for many years. How realistic is it to present such a complex thing as medicine in television format? It seems that treatment is an individual action.
— It all arose quite by accident. After Boris Nikolayevich Yeltsin’s operation in 1996, the film “Yeltsin’s Heart” was made, where my father, as one of the surgeons who operated, gave an interview. The TV people really liked him as a colorful person, and when the idea of a TV show that would be hosted by a doctor arose, he was invited, and for ten years he became a TV presenter.
This combined with the life of an operating surgeon: the program ran on a weekly basis, and once a month on Sunday, four programs were filmed at once for a month in advance. So, having spent one day off a month on filming, the rest of the days my father continued to operate on a regular schedule.
I don’t think that the television format “degrades” medicine. One of the main tasks of a doctor is education, when information is conveyed to the population, the wider the better.
Now we have educational doctors who write books and host television shows. People have a lot of topics, questions, and bewilderments. And it’s good if an authoritative specialist answers them.
The process of television work itself was very close to my father. After all, at one time he really wanted to become an actor. I think this desire, to some extent, pushed him to TV.
- Why didn’t Yakov Benyaminovich go to the theater?
- He went. I came to some theater university, went to the dean of the faculty and said from the doorway: “Hello!” with a characteristic Odessa accent. The dean immediately said: “Goodbye!”
After which he had no choice but to follow in his family footsteps into medicine.
Patients want treatment and comfort in a 50/50 ratio
— Russians have an archetype of a good doctor, an aibolit, who not only heals, but who is kind. Talks to you, consoles you, invigorates you, and so on. You wrote about your father that he knew how to talk with people and considered this skill absolutely necessary for a doctor.
— I don’t know how it was at the beginning of his medical career, but in last years Long conversations with patients were the norm for my father. Those seventeen years that he headed the department of emergency cardiac surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, he could communicate with patients and their relatives for several hours. He spoke about the prospects for treatment, about possible consequences one or another medical manipulations- this was completely normal for him. He then continued to communicate with many patients and became friends.
— But how to combine such communication with the current purely medical workload of a doctor?
“The fact is that my father was never an ordinary doctor, he never worked in a clinic - he did not conduct outpatient visits. This was communication regarding the specific operations of his patients.
Nowadays, Soviet medicine is often idealized - but in fact, Soviet years everything was the same as today - communication with the patient at an outpatient appointment was never a priority for doctors.
But serious specialists did not limit the time for such communication. If necessary, the father could communicate with patients for two or three hours. There was always someone sitting under his office who needed attention, and he found time to explain everything to the person, and simply discuss something with him.
- As it seems to you, from your current medical practice, do patients expect to be communicated with?
- All people are different. Someone needs to quickly, just get information. Someone needs to ask clarifying questions and talk to the doctor. But still, people want to get as much information as possible, so now I myself don’t hold meetings for less than one and a half to two hours.
As a rule, this time is occupied 50/50 - with information and reassurance, giving the patient some kind of comfort. My father performed quite serious operations, I can assume that his patients also needed reassurance.
The Myth of a Respected Profession
S.M. Fedotov, “Doctors” (1970s)
— You mentioned the idealization of Soviet medicine, when “doctors were more responsible and knew more.” Do you think this is nostalgia, an illusion? What then are its reasons?
— The fact is that trees are always big in childhood. High quality Soviet medicine is not just an illusion, it is a very harmful illusion. There really wasn't anything particularly good there. But when any system changes, there will always be people who say: “It was better before.”
Yes, there were probably more doctors then. But the doctors also received pennies. There were no normal medications. The country did not carry out high-tech operations that were already being done all over the world. Being behind iron curtain, we were forced to come up with some of our own theories, which had already been tested and rejected all over the world.
By and large, we are now dismantling the legacy of Soviet times - an isolated healthcare system.
But the trouble is that nothing has yet replaced Soviet medicine.
Another huge problem: people begin to think about their health only when they get sick. This approach is now changing around the world - doctors, patients, and governments are trying to think more about prevention. For now, we only think about how to live well and beautifully, and we will deal with the disease when it comes.
“Maybe that’s why we used to respect doctors so much: a person was “suddenly” overcome by illness and there was only one hope - for the doctor as a rescuer!
— Excessive respect for doctors in Soviet time– this, again, I’m afraid, is a beautiful fairy tale. I think the attitude towards the doctor was not a matter of respect - it was a matter of personal necessity.
When your pipe bursts, you also run to the plumber shouting: “We will do whatever you say!” Is this a sign of respect?
True respect is shown not when something has happened, and not when it is a matter of profession or specialty. Respect should be shown for the fact that a person studies all his life, and then works very hard.
About three years ago I visited Sweden. They measure the “trust rating of a doctor.” That is, how many patients, after listening to the doctor’s recommendations, will unquestioningly follow them and will not go to another specialist for a second opinion. The trust rating of Swedish doctors is 96%. For us it’s good if it’s 4%. That's it, respect.
Is the doctor responsible for the patient's health?
—What is the ethical credo of today’s doctors? The “Hippocratic Oath” was abolished a long time ago.
— At one time at the institute, I took a so-called course in bioethics and deontology. It was, in my opinion, the fifth year, the lectures were in evening time in the most mossy auditorium of the most mossy building. At most half of the students made it to those classes, and even those during the lectures, as a rule, slept or played cards. These were the lectures.
The Russian doctor has no concept of ethics, because he was not taught this in principle.
That is, everyone knows this word, but everyone is terribly far from fulfilling it. For example, a lot of people here have a poor idea of what it is medical secrecy. It is normal for us to inform the patient’s relative of his diagnosis, even the patient did not ask for this and did not give consent to it.
We will discuss the patient's condition with his relatives and colleagues. We have a huge problem with allowing relatives into intensive care, while throughout the world this is considered the norm, and it does not harm anyone, but only helps.
It’s completely normal for us to come to a doctor’s appointment with another doctor’s prescription to hear the phrase: “What idiot prescribed this to you?”
Yes, there was an oath between Soviet and Russian doctors. But by the way, when I was studying, even this oath was no longer mandatory, but voluntary. And I very much doubt that it has legal force.
In my opinion, it is much more promising to adhere to the classical principles in medicine - “do no harm”, “act in the interests of the patient”, and the same medical ethics. The doctor should give the patient the maximum full information, educate, try to do everything possible to cure him, even if the patient actively resists.
And only if the patient very actively and informedly resists (in full consciousness signs the appropriate documents refusing treatment), the doctor, respecting his free decision, should not treat him.
Most doctors in Russia act either in the interests medical system, either in their own interests or in the interests of private clinic which they represent.
At the same time, in the patient’s mind, the doctor is for some reason a unique being who has unique knowledge. In fact, doctors are also people, just like everyone else, with their own shortcomings and advantages.
Moreover, in our country, a doctor’s knowledge, as a rule, is twenty-five years out of date, and he is no longer an expert in his field. Of course, there are doctors who support high level medical literacy, work in the paradigm evidence-based medicine and act solely in the interests of the patient, but there are catastrophically few of them - according to my estimates, no more than 5%.
A special problem in Russia is that the group of doctors 40+, which is especially significant in terms of age all over the world and is at the peak of its career, is practically absent here.
We have people from forty to fifty, those who studied in the nineties either did not go into medicine or left the profession. In addition, the quality of treatment is greatly hampered by our programs and plans to create some kind of national medicine instead of integrating into the global system.
Patients need to become partners
— What should a patient do in such conditions?
- Look for your doctor, there are no other options.
You need to understand that 80 percent of exacerbations of chronic diseases go away on their own over time and do not require any medical intervention. In the same 20% of cases when intensive treatment is needed, the patient will have to largely take responsibility, delve into the specifics of his own illness, try to look for some nuances that the doctor may not know, may not be able to, or may not understand.
It's good when this happens at a therapist's appointment. Being unconscious on the operating table, a person can hardly advise the surgeon what to cut and what to sew. But you can read in advance about the methods that are used in treatment and study existing statistics.
At the same time, you need to understand: a patient cannot become a professional in his own disease; to do this, he needs to learn to filter information, and this is difficult to do even for doctors who have special education. But the patient will be able to become an accomplice in the treatment process. And this is no longer enough...
Jacob Brand. Photo: Alexey Nikolsky / RIA Novosti
Yakov Beniaminovich Brand(1955-2018) – Doctor of Medical Sciences, professor, since October 2001 he served as head of the department of emergency coronary surgery at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky.Hereditary doctor. Father Beniamin Volfovich is a surgeon, mother Anna Yakovlevna is a dermatovenerologist, sister Margarita is an infertologist and a specialist in female infertility.
He was involved in charity work and organized his own photo exhibitions in support of seriously ill children.
He was a member of the board of trustees of the Life Line Foundation, founder charitable foundation“Golden Hearts”, as well as chairman of the organizing committee of the “Golden Heart” award.
On November 5, 1996, as part of a team of cardiac surgeons, he performed coronary bypass surgery on the first President of Russia, Boris Yeltsin.
In 1999-2010, he was the author and host of the television program “Without a Prescription” on the NTV channel. In 2001-2003, he was the host of the program about drug addiction “Coma” on NTV, paired with musician Sergei Galanin.
Pavel Brand:
Program "On nervous soil"and I, its presenter, Pavel Brand, neurologist, candidate of medical sciences, medical director of the network family clinics"Family Clinic" With me is my co-host Marianna Mirzoyan, editor of the Namochi Mantu Instagram channel, medical journalist. Today our guest is a gastroenterologist, candidate of medical sciences, director and managing partner of the Rassvet clinic in Moscow, Alexey Paramonov.
Today we have an unusual, non-neurological topic: “Stomach pain.” It also has something in common with neurology. 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 problems are associated with this pain? Someone’s stomach hurts so much that the person cannot bear the pain at all. He runs to a gastroenterologist, drinks antacids in packs, eats all sorts of Rennies and so on, nothing helps him. They do a gastroscopy and find superficial gastritis with minimal changes. Another person with a huge ulcer lives and does not blow his mustache, something aches. What is the problem, what is the reason? How to deal with this?
Alexey Paramonov:
For the patient, the problem, first of all, is that the correct diagnosis is rarely made, 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 not at all during endoscopy, but it can hurt. At the same time, in some situations, for example, when diabetes mellitus, 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 mucous membrane 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. Our patients often mistake this syndrome for gastritis in everyday life. In fact, most of them have functional dyspepsia. This is a condition when the same processes are present as with gastritis. There, too, the acid affects the stomach wall and irritates it.
But this is not the main feature. 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 even perceive a more gross 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 and who have depression. Sometimes these psychological phenomena do not lie on the surface; the patient may not be aware of them. His attending physician, a general practitioner, or a gastroenterologist may also not be aware of them. They can sometimes only be identified special tests from a specialist.
Gastritis can only be reliably diagnosed by taking a piece of mucous membrane and looking under a microscope.
Marianna Mirzoyan:
What tests are used for this and how to understand that your gastritis is not actually gastritis?
Alexey Paramonov:
As for tests, there are many of them. There are such popular ones as the Beck Scale and the Hospital Anxiety and Depression Scale. But these are 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 a problem of this kind, based on the duration of the disease, the persistence of this pain and the insufficient effect of standard drugs, proton pump inhibitors. Omeprazole, esomeprazole, Nexium, Pariet - these drugs are well known to our patients. With a classic ulcer, with classic gastritis, they relieve pain, if not with the first tablet, then certainly the next day. And here we will hear a story - either it helps or not. Or I took it for three days - it helped, but on the fourth day it stopped helping. In such cases, we already begin to look for functional dyspepsia.
Pavel Brand:
It turns out that practically our entire population, starting from young, is not sick with what is usually considered. In our country, it is believed that the main cause of gastritis is associated with poor nutrition at school, with violations of the diet of office employees who eat dry food or do not eat regularly. Because of this, problems develop with the gastric mucosa, all kinds of ulcerations and erosions occur, which themselves hurt. It turns out that all this is not true. That, in fact, we are premorbidly, somehow already prepared for our psychological condition affected our painful sensations. That is, it is psychosomatics. Even with minimal changes, with normal nutrition we can have pain syndrome, which will pester us, bother us, and so on.
Alexey Paramonov:
Without a doubt. Gastritis really exists, there is such a disease. But it occurs several times less often than the diagnosis itself is given 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. It still remains dominant in the minds of some of our doctors.
In fact, nutrition does not play a significant role in either gastritis or functional dyspepsia. All 15 tables according to Pevzner and their variations have no meaning. Real, most common cause gastritis, true gastritis, is Helicobacter, a well-known microbe that causes chronic inflammation in the stomach. But this is not always parallel to pain. The most common cause of pain is functional dyspepsia, where two main factors play a role. I'm simplifying greatly, but the first factor is the acid in the stomach, the second factor is a psychological state that changes the settings for the perception of pain. Hence the impact. A patient often tells us: “I get pain when I’m nervous. I’m going on vacation, and everything went away in one day, I returned to work and got sick on the same day.” Here is the daily routine, adequate sleep, good vacation, mood, hobbies - 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 for gastritis, but still works. On the second floor there is already a specialized health care. This could be psychotherapy, it could be anti-anxiety medications, 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 intake. Most often in our life we encounter 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 very actively affect the gastric mucosa, disrupt its protective mucus, remove the protective barrier, and it is easily damaged by acid. Therefore, there should be a policy to limit non-steroidal pain medications. The patient should think before swallowing the tablet. If he's enough long term is taking these pills, or if he is at risk, has ever had an ulcer, or is old man With concomitant diseases, the painkiller should be taken together with a proton pump inhibitor, to prevent, first of all, gastric bleeding.
You said good things about aspirin. Yes, we once fought for it to be prescribed for prevention cardiovascular diseases, and now we are fighting to stop it being prescribed so often. Cardiologists tell us that it should be prescribed in a limited number of cases - after a heart attack, after a stroke. Our patient now began to thin his blood from a hypothetical position at the age of 40, and apart from bleeding and an increase in mortality, nothing better happens from this.
Pavel Brand:
As I understand it, NSAIDs, after all, do not stand still, and more modern options have appeared, like Sibs, which reduce the effect of non-steroidal anti-inflammatory drugs on the stomach.
Alexey Paramonov:
Yes it is. They are improving, but there is also a limit to perfection here. When one of the first such selective drugs, meloxicam, appeared, indeed, its incidence of damage was 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, we need to increase the dose, and when we increase the dose, selectivity begins to be lost and the stomach is damaged in exactly the same way. Coxibs are more selective, but they have other problems. There regarding thrombosis. Therefore, this problem cannot be said to be solved by selective NSAIDs. The solution to the problem is, rather, in combination with a proton pump inhibitor.
Pavel Brand:
One way or another, everything should be according to testimony and, if possible, then undercover. For some reason, doctors also like to call it a cover-up with proton pump inhibitors and acidity regulators.
Let's move on to the next problem, which, in my opinion, is no less common, and sometimes much more disturbing, disturbing to 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. Moreover, the worst thing is that this is 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 reflux disease.
Alexey Paramonov:
Yes you are right. Reflux disease has many manifestations. In addition to the classic ones - heartburn, belching, this is what you named. It's a sore throat, it's chronic tonsillitis, chronic pharyngitis. When it gets into the larynx and Airways- this is both bronchitis and laryngitis. There are purely gastroenterological symptoms, but relatively rare ones, such as esophagospasm, when intense chest pain occurs. Such a patient may be brought to the hospital with a suspected heart attack. Reflux disease has many manifestations. Some people know them better, some people know them 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 formulation, a terminological trap, perhaps - it is also called functional heartburn. The mechanics here are similar to what we talked about earlier - reflux occurs. In a healthy person, reflux also occurs, but healthy man he doesn’t feel them, but a patient with functional heartburn has a hyperperception of pain and he feels refluxes, they torment him. Subjectively, this heartburn may be more severe than with equivalent reflux disease. Proton pump inhibitors also do not help such patients completely, unlike classic reflux disease, where they almost always eliminate heartburn; other symptoms may not be controlled, but heartburn is eliminated. Here, first of all, it is important differential diagnosis to help the patient. With functional heartburn, sooner or later we will apply the techniques that were discussed - psychotherapy, antidepressants, changing the daily routine, lifestyle. Have enough rest, be less nervous, even to the point of changing jobs if your boss is rude and a dangerous person. Change your boss, your health is more important.
For patients whose symptoms last 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 antireflux surgery can help. Now these operations have become effective, safe, and can be done laparoscopically in a short time. But they still require a qualified specialist. Not everywhere it is done professionally. The fundamental pitfall is that the operation is sometimes performed on a patient with functional heartburn, which not only does not help him, but in principle cannot help him, and leads to additional problems. The patient begins to suffer from everything that was before the operation, plus 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 measurements should be done. It must be proven that it is reflux disease and not functional heartburn. Even with the proof of pH-metry, it would be nice to think about this patient further, because no one forbids the patient to have both reflux disease and a functional component. The doctor’s task is to understand what is more and predict the effect of the operation.
Pavel Brand:
Alexey, everything about heartburn is thorough and clear. Briefly, as I understand it, we are talking about laparoscopic fundoplication surgery, which is called anti-reflux surgery.
The second symptom that usually worries our patients is belching. Surgery won't help much here. A person has eaten, is at a social event, and then suddenly - belching. What to do?
Alexey Paramonov:
Belching can also be a manifestation of reflux disease. But, you correctly focused on this symptom. Very often its cause is not 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 talk. But for some people this happens in small quantities, and then belching occurs or some of the air is generally released in a different way. In people who are anxious or with others psychological problems, swallowing can be very massive and then a massive belching occurs. It torments the patient and causes anxiety; he feels uncomfortable being in society. On the first visit of such patients to a gastroenterologist, it is necessary to understand whether there is reflux disease. But most often, again, a psychotherapist is needed, and sometimes the solution here is treatment with an antidepressant.
Very often the cause of belching is aerophagia, swallowing air..
Pavel Brand:
It turns out that all our major illnesses, ladies and gentlemen, are caused by nerves. That’s why we continue everything in the “On Nervous Grounds” program.
Alexey, let’s not dwell further on the stomach; probably, everything is more or less clear with the stomach. The next item in our order is the gallbladder if we go down. Let's probably discuss the gallbladder and pancreas in one complex. Yes, these are two, practically opposite, located organs that are in some kind of symbiosis. I'd like to understand why this is important. Firstly, there is the problem of gallstones, which is acute - this is often a surgical pathology. I think that in our country there is both overdiagnosis cholelithiasis, and underdiagnosis in terms of the need for surgery. Plus, operations and treatment of the gallbladder in general, one way or another, affects the entire human life, because it really limits his food for the future. It is classically believed that you should stop eating spicy, fried, hot, salty and, in general, everything. At the same time, the pancreas is extremely unpleasant because it causes very bad conditions in the form of acute pancreatitis, severe stabbing pain in the abdomen, which practically cannot be relieved by anything. It’s bad, terrible, even to the point of pancononecrosis, which is absolutely sad. What do we know about this?
Gallstone disease is not always a reason to remove the gallbladder.
Alexey Paramonov:
You concluded with a good question. We know little about this. Why does it happen acute pancreatitis, we know little. As for the relationship between the gallbladder and the pancreas - yes, it is very close, and anatomically close. In most people, the pancreatic ducts and bile duct They open side by side, or even merge into one duct before opening, and the problem goes back from there.
As for cholelithiasis, an important thesis here is that treatment should not be worse than the disease itself. Many patients can carry stones within themselves and live happily ever after; the stones will never show themselves. Statistics have shown that to do a cholecystectomy, remove gallbladder for everyone who had stones found, it turned out not to be justified. Even if there are not very large risks associated with this operation, the operation is small and well-developed. 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 patients are scared that the stone may pass 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; there is a greater likelihood of problems during surgery.
When is surgery really necessary? 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 and wave-like in nature. If such an attack occurs at least once, this is an indication for surgery. Having happened once, it will happen again and again and end in complications. Another indication for surgery is a very large stone, 25 millimeters or more. It was also the surgeons who decided to operate. In other cases, surgery is not always necessary; you can abstain.
With 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. The course is difficult and requires many months of hospitalization. It's difficult to predict. Diet probably plays some role. Ours are talking about this medical observations. But, at the same time, large studies have not shown a connection with diet. There is a clear connection with smoking, oddly enough, and a clear connection with high triglycerides in the blood. Triglycerides are common fats. Their number is determined, on the one hand, genetically, and on the other hand, depends on nutrition. If you eat a lot of fat, 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. This kind of pain is not too dependent on food. Periods of exacerbations occur - sometimes there is pain for two weeks, but there is no pain for two months. There must be evidence that pancreatitis is occurring. Such evidence includes increased blood amylase, increased blood lipase, increased C-reactive protein, inflammatory marker, inflammatory changes in clinical analysis blood - growth of leukocytes, ESR. With ultrasound, computed tomography Reliable deviations should be detected - this is a thickening of the gastric gland duct, this is the formation of a cyst and its swelling, fluid around it.
Every first patient with superficial gastritis with ultrasound examination receives the conclusion: “ diffuse changes pancreas, pancreatitis cannot be ruled out." This has nothing to do with pancreatitis. In 99% of cases, these diffuse changes are, on the one hand, a fantasy, and on the other hand, the patient came for a study and it is inconvenient to write that he is healthy. We see many patients who have been walking around for years with complaints of abdominal pain, girdle pain, have the title of pancreatitis, and have these same 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 reason for the pain is completely different. This cause may also be dysfunction of the sphincter of Oddi, the muscle at the exit of the bile duct, which can spasm and cause pain. Often this is the same psychosomatics that we talked about. Pain is associated with depression, anxiety and something else. Patients are treated for pancreatitis for years, instead of a single course of antidepressant treatment.
Pavel Brand:
Let's move on to a broader, more interesting and completely psychosomatic topic, in my opinion, in the form of irritable bowel syndrome. A problem that affects a large number of people. I know about a hundred people with the problem of irritable bowel syndrome - diffuse pain throughout the abdomen, a constant urge to go to the toilet at the most unexpected time, in the most unexpected place, intensifying, indeed, with all sorts of emotional stress. Here the connection with emotions is clearly visible. But at the same time, there are people who are completely calm and suffer from the same problems. That means there's something inside.
Alexey Paramonov:
In such people, you need to understand whether they have irritable bowel syndrome, first of all. There is an algorithm for this that works for everything gastrointestinal tract: we rule out availability first organic diseases, then we claim that we are talking about irritable bowel syndrome. Depending on the group to which the patient belongs, a patient with a risk factor, young or elderly, whether he has lost weight or has an increase in temperature, a change in tests, we come to the conclusion whether he needs a colonoscopy. Colonoscopy answers these questions in a significant proportion of cases. A colonoscopy with biopsy is almost always required. We have another problem, sometimes they even did a colonoscopy and they said: there was nothing to take a biopsy from, there is no ulcer, no tumor. You should always take it. Because there is such a disease - microscopic colitis, which cannot be seen in any other way except by looking through a microscope. There will be massive infiltration of lymphocytes, amyloidosis too. There are diseases that cannot be excluded without a biopsy.
In terms of the incidence of the disease, in any case, it will ultimately be above 80% functional disorder. I can say that irritable bowel syndrome is functional dyspepsia on the floor below. All the same laws, but there is no acid in the intestines. But the basic basis - anxiety, depression - plays a very significant role. Yes, there are studies that show: 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 basis, it won’t work anyway.
Marianna Mirzoyan:
The question immediately arises, what can a gastroenterologist do in this case? Firstly, is it possible to refer people to psychotherapists, do people get there? 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 stress sometimes also requires the help of such a specialist. In our purely gastroenterological guidelines, the same Roman criteria, a 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 do not prescribe them for the purpose of treating depression or other things - gastroenterologists do not have enough classification to do this. We prescribe it to treat irritable bowel syndrome. We know this is highly likely to help. If a patient comes to a psychotherapist, it will be wonderful.
Pavel Brand:
Great, Alexey! There remains a very important point to discuss, the final, beautiful one - taking antibiotics. The most important topic, in my opinion. We all know, our mothers told us since childhood: an antibiotic, which means we need nystatin or some kind of Diflucan. Nystatin is a real disaster. We always have the theory that an antibiotic kills not only the bad flora in the intestines, but also the good one. When good flora dies, mushrooms begin to grow, they must be killed with an antifungal drug. Then there was a new trend: introducing probiotics and eubiotics, which could improve the situation. Even taking 3-4 days of antibiotics is necessary immediately antifungal drug and a probiotic to immediately improve your life. Is it so?
Alexey Paramonov:
This is so very partial. It is simply dangerous to prescribe an antifungal drug for every reason; they are quite toxic. Their benefits have not been proven. The main danger from taking antibiotics is antibiotic-associated diarrhea. In its severe form, it is pseudomembranous colitis, when the clostridium difficile present in the intestines multiplies. Antibiotics create conditions for its reproduction. It can cause quite severe diarrhea, bloody diarrhea, and in severe cases, a generalized severe infection. These situations can be prevented. On the one hand, here is the well-known domestic concept of dysbiosis, although it is completely wild, this is understandable. This concept has compromised probiotics as a class of drugs. It is completely wrong to give up probiotics completely. There are some types of probiotics, the effectiveness of which has been proven and recognized, and is included in leading consensuses and guides, in particular, in the prevention of antibiotic-associated diarrhea. If we prescribe certain types of pribiotics at the time of antibiotic treatment, the likelihood of complications is reduced.
It is dangerous to prescribe an antifungal drug for every reason; they are quite toxic.
Pavel Brand:
Alexey, where can I get magic probiotics? In a store or in a pharmacy?
Alexey Paramonov:
The optimal ones are some strains of lactobacilli, the so-called LGG, the drug of which is not registered in Russia. They are present on our market in the form of food additives, nutritional supplements also mixed with vitamins. Those that are sold in pharmacies as probiotics contain completely different strains. The only thing we have in pharmacies is Saccharomycetes, the drug Enterol. It is the same all over the world. As for the most effective lactobacilli, they have to be purchased abroad for now.
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, treatment of purulent sinusitis is either three, five, seven or ten days of antibiotics, or serious therapy with monthly courses of antibiotics.
Alexey Paramonov:
Naturally, if you take an antibiotic for a long time and also change antibiotics, the risk increases.
Pavel Brand:
“A lot” - how much? For some, “a lot” is three days. I know people for whom three days of antibiotics are already like death.
Alexey Paramonov:
The standard course, after all, is seven days for most types of antibiotics, give or take something. The fundamental point is that even one antibiotic tablet in a predisposed person can cause all these serious disorders. Therefore, first of all, do not take an antibiotic without clear indications. ARVI cannot be treated with antibiotics. The next point: the risk increases significantly in older people, in people after large operations- this is joint replacement, similar major operations. The risk increases significantly. For such patients, if a course of antibiotics is prescribed, and they are often prescribed, it is imperative to simultaneously prescribe at least Saccharomycetes, Enterol, which is available to us. If minimal signs of diarrhea occur, a stool test for clostridium toxin is needed. Moreover, this toxin during diarrhea must be determined four times in a row. A one-time analysis gives nothing. This requires caution on the part of doctors to avoid severe forms this disease.
Pavel Brand:
Today we tried to analyze the main points associated with abdominal pain. We didn't have time great amount To discuss problems, we will have to meet with Alexey again. I would like to place one last emphasis on the very important point, which we just discussed. I have 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 and orthopedists as patients with an acquired infection - with a virus, with something else, with symptoms of an infectious lesion. They were almost isolated in separate boxed wards. Also elderly patients with long-term problems that later 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 problems. Unfortunately, we have a lot of such problems. We will continue to educate people, we need to do something useful.
Thank you very much Alexey! I think we’ll meet again in our program, because this is a very interesting topic.
On his Facebook page about the magical thinking of people, the desire to remain forever young without doing anything, as well as the development on this basis of a new direction in medicine - 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 an elixir of immortality, looked for the philosopher's stone or a sip of living water.
Over time, people came to understand that immortal life impossible, but the desire to live as long as possible remained. Various magical rituals did not give a significant effect, so science replaced magic. With the help of medicine and ecology, man has managed to more than double his life expectancy. It would seem, what else is needed? But a person is always missing something! Now he wanted not just 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 people are 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 their 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 tenacity 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 enormous, and as you know, demand creates supply! This is how a whole direction of medicine appeared, which was called fashionable. English word anti-aging!
Over the past 20 years, anti-aging medicine has begun to aggressively gain 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 push 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? Let the scientists worry about it. They invent something all the time, come up with something. So let them work for the benefit of our youth and beauty...
The most interesting thing is that belief in all these antioxidants and stem cells is that same magical thinking. It hasn't gone anywhere. It still forces seemingly smart and quite wealthy people to spend a lot of money on modern rejuvenating apples. Scientists have never been able to find a cure for old age. Over the past 50 years, any significant research With positive result regarding slowing down aging. No, there are certainly some successes. But, again, they concern life expectancy, and not prolongation of youth.
But the demand hasn't gone away. And where there is demand, there is supply. Those who realized in time that people are willing to pay and pay a lot for anti-aging therapy happily sell dietary supplements, oak bark extracts and other pieces of placenta to gullible ordinary people, promising eternal youth and pristine beauty.
In fact, the secret of active longevity is quite simple. You just need to not drink, not smoke, spend less time in the open sun (debatable, by the way), eat a balanced diet, regularly have sex and exercise, monitor your iron levels, blood pressure, blood sugar, cholesterol and contact a competent doctor to correct them, undergo timely screening for curable oncological diseases. All! None 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, giving up some very pleasant joys of life. Whether to follow this lifestyle or not, everyone decides for themselves. But it’s time to get rid of magical thinking... The 21st century is just around the corner...
