Сочетание неалкогольной жировой болезни печени и желчнокаменной болезни: патофизиологические и клинические взаимосвязи, особенности терапии

Топчий Т.Б., Ардатская М.Д., Масловский Л.В., Минушкин О.Н. Сочетание неалкогольной жировой болезни печени и желчнокаменной болезни: патофизиологические и клинические взаимосвязи, особенности терапии. Consilium Medicum. 2025;27(12):754–761. DOI: 10.26442/20751753.2025.12.203514

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Topchii TB, Ardatskaya MD, Maslovskii LV, Minushkin ON. Combination of non-alcoholic fatty liver disease and cholelithiasis: Pathophysiological and clinical relationships and specific features of therapy. A review. Consilium Medicum. 2025;27(12):754–761. DOI: 10.26442/20751753.2025.12.203514

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Аннотация

Неалкогольная жировая болезнь печени (НАЖБП) и желчнокаменная болезнь (ЖКБ) являются широко распространенными заболеваниями во всем мире. Сочетание НАЖБП и ЖКБ – частая клиническая ситуация. ЖКБ и НАЖБП имеют общие факторы риска и тесно ассоциированы с такими сопутствующими заболеваниями, как ожирение, дислипидемия, нарушение углеводного обмена. Многочисленные исследования в разных популяциях показали, что НАЖБП является независимым фактором риска ЖКБ, а ЖКБ представляет собой независимый фактор риска НАЖБП. В настоящее время в качестве ключевого фактора, обеспечивающего связь между НАЖБП и развитием холестеринового холелитиаза, рассматривается инсулинорезистентность. Кроме этого, большую роль играет изменение экспрессии транскрипционных факторов: печеночного Х-рецептора, фарнезоидного Х-рецептора и мембранных рецепторов желчных кислот. В итоге это приводит к повышенному липогенезу в печени, перенасыщению желчи холестерином, способствуя образованию как желчных камней, так и жировой дистрофии печени. Не менее важную роль в патогенезе обоих заболеваний играет нарушение функции желчного пузыря, являющейся важным звеном связи печени и кишечника в печеночно-пузырно-кишечной оси и поддерживающей метаболический гомеостаз холестерина, триглицеридов и желчных кислот. Это подтверждается данными, согласно которым холецистэктомия увеличивает риск НАЖБП, способствует усилению инсулинорезистентности и накопления жира в печени. Выбор лекарственной терапии у пациентов с сочетанием НАЖБП и ЖКБ основывается на знаниях общих патофизиологических процессов, характерных для обоих заболеваний. Лекарственные препараты должны соответствовать принципам многоцелевой монотерапии, воздействуя на максимальное число терапевтических мишеней, а сочетание их фармакологических эффектов – потенцировать действие друг друга. Лечение пациентов с сочетанием НАЖБП и ЖКБ основывается в первую очередь на снижении массы тела с помощью физических нагрузок и средиземноморского типа питания, усиленного лекарственными препаратами псиллиума и масляной кислотой, являющейся ключевым медиатором позитивных эффектов средиземноморской диеты. Препаратом выбора у пациентов с сочетанием НАЖБП и ЖКБ является урсодезоксихолевая кислота, позволяющая патогенетически воздействовать на оба заболевания.

Ключевые слова: неалкогольная жировая болезнь печени, желчнокаменная болезнь, урсодезоксихолевая кислота, псиллиум, масляная кислота

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Non-alcoholic fatty liver disease (NAFLD) and cholelithiasis (CL) are widespread diseases worldwide. The combination of NAFLD and CL is a common clinical situation. CL and NAFLD have common risk factors and are closely associated with such concomitant diseases as obesity, dyslipidemia, and carbohydrate metabolism disorders. Numerous studies in different populations have shown that NAFLD is an independent risk factor for CL, and CL is an independent risk factor for NAFLD. Insulin resistance is now being considered as a key link between NAFLD and the development of cholesterol cholelithiasis. In addition, changes in the expression of transcription factors, including hepatic X-receptor, farnesoid X-receptor, and membrane bile acid receptors, play an important role. It leads to increased lipogenesis in the liver and to bile cholesterol supersaturation, contributing to the development of gallstones and fatty liver. An equally important role in the pathogenesis of both diseases is played by gallbladder dysfunction, which serves as an important link between the liver and the intestine within the hepatic-gallbladder-intestinal axis and supports the metabolic homeostasis of cholesterol, triglycerides, and bile acids. It is supported by evidence that cholecystectomy increases the risk of NAFLD, contributes to insulin resistance, and promotes fat accumulation in the liver. The choice of drug therapy in patients with a combination of NAFLD and CL is based on knowledge of the general pathophysiological processes typical of both diseases. Drugs should comply with the principles of multipurpose monotherapy, targeting as many therapeutic targets as possible, and their combination should potentiate each other’s pharmacological effects. The treatment of patients with a combination of NAFLD and CL is primarily based on weight loss through exercise and a Mediterranean diet, enhanced by psyllium-containing agents and butyric acid, a key mediator of the Mediterranean diet’s positive effects. The drug of choice in patients with a combination of NAFLD and CL is ursodeoxycholic acid, exerting a pathogenetic effect on both diseases.

Keywords: non-alcoholic fatty liver disease, cholelithiasis, ursodeoxycholic acid, psyllium, butyric acid

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Авторы

Т.Б. Топчий*, М.Д. Ардатская, Л.В. Масловский, О.Н. Минушкин

ФГБУ ДПО «Центральная государственная медицинская академия» Управления делами Президента РФ, Москва, Российская Федерация
*tantop@mail.ru

________________________________________________

Tatiana B. Topchii*, Maria D. Ardatskaya, Leonid V. Maslovskii, Oleg N. Minushkin

Central State Medical Academy of the President of the Russian Federation, Moscow, Russian Federation
*tantop@mail.ru

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