Features of the enzyme system in children. Theoretical and methodological foundations of the personal development of children of senior preschool age in the process of organized communicative activity. Preparing parents for productive communication with older children

The digestive system in children is significantly different from that of adults. That is why some products should be given to children from a certain age, and then - dosed. For example, mushrooms. How does this system of the child's body change with age?

Age features of the digestive system

A characteristic feature of the children's digestive system is the tenderness of the mucous membranes of the digestive tract, abundant blood supply and underdevelopment of their elasticity.

The glands of the children's intestines and stomach before the period of school age are not fully developed and are few in number. Therefore, the concentration of hydrochloric acid in the gastric juice of a child is low, and this reduces the bactericidal properties of digestion and, of course, increases the sensitivity of children to gastrointestinal infections. The number of glands in the stomach increases intensively up to 10 years, and at 14-15 years old it almost corresponds to the level of an adult.

And the composition of the enzymes of gastric juice changes in the first years of life. So, the enzyme chymosin, which acts on milk proteins, is actively produced by the glands of the stomach in the first 2 years of life, then its production decreases. In adults, by comparison, this enzyme is almost absent. The activity of other enzymes of gastric juice increases by the age of 15-16 and at this age already reaches the adult level. The age-related feature of the child's digestive system is that up to 10 years of age, absorption processes are very active in the stomach. In adults, these processes are carried out only in the small intestine.

That is, the development of the digestive organs in children occurs in parallel with the development of the whole organism. And this development is divided into periods of the first year of life, preschool age and adolescence.

At this time, the work of the digestive organs is controlled by the nervous system and depends on the state of the cerebral cortex. In the process of the formation of the digestive system in children, reflexes are easily developed for the time of eating, its composition and quantity.

Anatomical and physiological features of the digestive system in young children

The esophagus in young children has the shape of a spindle. It is short and narrow. In children in the year of life, its length is 12 cm. There are no glands on the mucosa of the esophagus. Its walls are thin, but it is well supplied with blood.

The stomach in young children is located horizontally. And as the child develops, he takes a vertical position. By the age of 7-10, the stomach is already positioned as in adults. The gastric mucosa is thick, and the barrier activity of gastric juice is low compared to adults.

The main enzyme of gastric juice is rennet. It provides curdling of milk.

The pancreas of a young child is small. In a newborn, it is 5-6 centimeters. In 10 years, it will triple in size. This organ is well supplied with blood vessels. The pancreas produces pancreatic juice.

The largest organ of the digestive system at an early age, occupying a third of the abdominal cavity, is the liver. At 11 months, its mass doubles, by 2-3 years it triples. The capacity of the liver at this age is quite low.

The gallbladder at an early age reaches a size of 3 centimeters. It acquires a pear-shaped form by 7 months. Already at 2 years old, the children's gallbladder reaches the edge of the liver.

For children up to a year, substances that come with mother's milk are of great importance. With the introduction of complementary foods, the mechanisms of the child's enzyme systems are activated.

Anatomical and physiological features of the digestive system in preschool children

In preschool age, children continue to grow and develop the digestive organs. However, due to different rates of overall growth and development up to 3 years, the edge of the liver leaves the zone of the right hypochondrium, is easily palpated 1-2 cm below the arch of the ribs.

The baby's pancreas develops very actively up to 1 year, and then a jump in its development occurs at 5-7 years. According to its parameters, this body reaches the level of an adult only by the age of 16. The same rate of development is characteristic of the child's liver and all parts of the intestine.

In connection with the development of the digestive organs, children under 3 years of age need dietary restrictions.

It should be noted that acute digestive disorders are very common in preschool children. However, they often proceed easier than in children of the first year of life. It is important for parents of preschool children to properly feed their children, taking into account the growth of their teeth, and the regimen, and a balanced diet. Foods that are heavy for the stomach, which the stomach of an adult can easily cope with, are often rejected by the children's body, causing indigestion.

Digestion in adolescents and its features

In adolescence, the digestive organs are already well developed. They are actively functioning, and the process of digestion itself is almost the same as adults. The frequency of bowel movements in adolescence is 1-2 times a day.

At the age of 12, tuberosity appears on the previously smooth surface of the pancreas. These tubercles are due to the secretion of pancreatic lobules.

The liver of children also actively increases. So, by the age of 8, it grows 5 times compared to the size at birth, by the age of 16-17, its mass increases by 10 times. It should be noted that from the age of 7 the lower edge of this organ is not palpable in the supine position. By the age of 8, the histological structure of the child's liver is the same as in adults. The gallbladder by the age of 10-12 increases in size by almost 2 times.

It is necessary to take into account the specifics of the structure of the gastrointestinal tract of adolescents when organizing their nutrition. We are talking about the daily observance of the diet and its organization at school. After all, nutritionists state that for the development of a healthy digestive system, school-age children need to eat four times a day due to their energy costs.

Digestive disorders in children

Problems with the gastrointestinal tract in children occur quite often. This is especially true at an early age. Diarrhea or constipation not only spoil the well-being of children, but also force parents to adjust their diet. If your child in preschool age has such disorders often, then you should not rely on yourself, but you should consult a good experienced pediatrician. Parents should also contact the doctor because only a doctor can determine the onset of a serious pathology.

Diarrhea can be caused by infection, and functional diarrhea is provoked even by the stress of the child. Then his stool is mushy or liquid. It occurs 2-4 times a day, but without impurities of pus and blood.

Unwashed hands and dirty water, even accidentally swallowed while bathing, stale food or insufficiently thermally processed are the main causes of intestinal infections in children.

Symptoms of intestinal infections are vomiting and frequent diarrhea, stomach pain and fever. When a child has diarrhea, only a doctor can rule out surgical pathology and infection in the intestine.

The main danger of childhood intestinal infections is dehydration. A child with diarrhea loses a lot of fluid, and cannot drink much because of vomiting.

Prevention of intestinal infections is the observance of simple hygiene rules:

1. The use of only boiled or mineral table water.
2. Washing hands before eating and after using the toilet.
3. It is taboo to buy products from spontaneous markets, especially those sold from the ground. Lack of sanitary control can provoke serious problems with digestion. For example, milk from leukemic cows is often sold in such markets.
4. Proper storage of products and control over their expiration dates.
5. Thorough washing of fruits and vegetables before eating them.

Dietary nutrition is of great importance in the prevention of digestive disorders. Children at least up to six months of age should be fed breast milk. This is their immunity and a kind of vaccination for the digestive tract. Children under the age of three should not be fed fatty and spicy foods, chocolate and rich broths. Food for such babies should be steamed. It's good if you bake it, not fry it.

Another common digestive problem in children is constipation. It is usually provoked by an early transition to artificial feeding, the introduction of complementary foods ahead of time, and a lack of fluid in the child.

Parents should be aware of another feature of constipation in children. It is the suppression of the urge to defecate outside the home. This phenomenon is typical for shy children and can occur, for example, during the period of adaptation to the kindergarten. Over time, such a negative habit leads to hardening of feces, injury to the rectal mucosa. The result of this is the fear of defecation.

And constipation can also be the result of chronic pathologies of the digestive and endocrine systems, the frequent use of certain drugs. Therefore, parents need to monitor the baby's stool, changes in his behavior and seek help from pediatricians in time to avoid the development of chronic digestive ailments.

Especially for - Diana Rudenko

FUNCTIONAL DISORDERS

GASTROINTESTINAL TRACT IN CHILDREN

OMSK - 2010

The textbook "Functional disorders of the gastrointestinal tract in children", intended for students of the pediatric faculty, is published by decision of the Central Medical Committee of the Omsk State Medical Academy and the educational and methodological association for medical and pharmaceutical education of Russian universities.

Reviewers: Doctor of Medical Sciences, Professor Yu.G. MUKHINA

MD M.A. LIVZAN

Potrokhova E.A., Sobotyuk N.V. Functional disorders of the gastrointestinal tract in children: a textbook / E.A. Potrokhova, N.V. Sobotyuk // Omsk, 2009 - 105 p.

The manual outlines modern ideas about functional disorders of the gastrointestinal tract in children. Classifications are given, clinical and diagnostic issues are highlighted, the main groups of drugs used in the treatment of this pathology are presented.

1. INTRODUCTION…………………………………………………………………….4

2. ANATOMICAL AND PHYSIOLOGICAL FEATURES OF THE GASTROINTESTINAL TRACT IN CHILDREN…………………5

3. FUNCTIONAL DISORDERS OF THE GASTROINTESTINAL TRACT IN CHILDREN…………………………………….. 11

3.1 Background……………………………………………….…11

3.2 Epidemiology…………………………………………………...12

3.3 Etiology and pathogenesis……………………………………….….13

3.4 Classification……………………………………….………….19

3.5 Diagnosis…………………………………………………………21

3.6 Treatment………………………………………………………………28

3.6.1 Correction of neuropsychiatric disorders………………………………………………………28

3.6.2 Diet therapy………………………………..…………32

3.6.3 Drug therapy…………………………...37

4. PRIVATE PATHOLOGY…………………………………………………………………………65

4.1. Infantile regurgitation………………………………..…65

4.2 Rumination syndrome……………………………………….66

4.3 Syndrome of cyclic vomiting………………………………..…67

4.4 Infant colic…………………………………………...70

4.5 Functional diarrhea………………………………………..72

4.6 Infantile difficulty defecation (dyschezia)…………75

4.7 Functional constipation……………………………………………75

4.8 Aerophagia……………………………………………………………78

4.9 Functional dyspepsia……………………………………79

4.10 Irritable bowel syndrome………………………...83

4.11 Abdominal migraine…………………………………………87

4.12 Functional abdominal pain……………………...88

4.13 Functional fecal incontinence…………………………..91

5. DISPENSARY SUPERVISION OF CHILDREN WITH FUNCTIONAL DISORDERS OF THE GASTROINTESTINAL TRACT………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…95

6. TESTS…………………………………………………...97

7. SITUATIONAL TASKS……………………………….…………98

8. REFERENCES……………………………………………….103

INTRODUCTION

In recent years, in general, there has been an increase in the number of diseases of the gastrointestinal tract: in 1999, diseases of the digestive system in children amounted to 450 cases per 10,000 children, and in 2003 - 525, in adolescents, respectively - 402 and 412. the most common diseases of childhood, ranking second in frequency. When studying the structure of morbidity, it is noted that the first place is occupied by functional disorders of the gastrointestinal tract.

The problem of functional diseases of the gastrointestinal tract is becoming increasingly important, due to the widespread prevalence of this pathology and the numerous problems associated with it. Every second inhabitant of our planet has such disorders as functional dyspepsia, biliary tract dysfunction, irritable bowel syndrome, which significantly worsen the quality of life, limit social and labor activity. Worldwide, hundreds of millions of dollars are annually spent on the diagnosis and treatment of functional disorders of the gastrointestinal tract. At the same time, many doctors still treat this pathology as insignificant and not requiring treatment.

Diagnosis of functional disorders often causes significant difficulties for practitioners, leading to a large number of unnecessary examinations, and most importantly, to irrational therapy. In this case, one often has to deal not so much with ignorance of the problem as with its misunderstanding. In terms of terminology, it is necessary to differentiate between functional disorders and dysfunctions, two consonant, but somewhat different concepts that are closely related to each other. Violation of the function of one or another organ can be associated with any reason, including its organic damage. Functional disorders, in this light, can be considered as a special case of an organ dysfunction that is not associated with its organic damage.

Deepening the knowledge of a doctor on the problem of functional pathology of the gastrointestinal tract in childhood and adolescence, timely and high-quality preventive and dispensary observation, treatment using modern schemes, shifting the focus of helping gastroenterological patients to outpatient services is one of the conditions for the prevention of organic diseases of the gastrointestinal tract. -intestinal tract in subsequent age periods.

ANATOMICAL AND PHYSIOLOGICAL FEATURES OF THE GASTROINTESTINAL TRACT IN CHILDREN

The formation of the digestive organs begins from the 3-4th week of the embryonic period, when the primary intestine is formed from the endodermal plate. At the front end of it, a mouth opening appears on the 4th week, and a little later, an anus appears at the opposite end. The intestine quickly lengthens, and from the 5th week of the embryonic period, the intestinal tube is delimited into two sections, which are the basis for the formation of the small and large intestines. During this period, the stomach begins to stand out - as an extension of the primary intestine. At the same time, the mucous, muscular and serous membranes of the gastrointestinal tract are being formed, in which blood and lymphatic vessels, nerve plexuses, and endocrine cells are formed.

The embryo before implantation in the uterine wall is fed by reserves in the cytoplasm of the egg. The embryo feeds on the secrets of the uterine mucosa and the material of the yolk sac (histotrophic type of nutrition). Since the formation of the placenta, hemotrophic (transplacental) nutrition, provided by the transport of nutrients from the mother's blood to the fetus through the placenta, is of primary importance. It plays a leading role until the birth of a child.

In the first weeks of pregnancy, the endocrine apparatus of the gastrointestinal tract is laid in the fetus and the production of regulatory peptides begins. In the process of intrauterine development, the number of endocrine cells increases, the content of regulatory peptides in them increases (gastrin, secretin, motilin, gastric inhibitory peptide, vasoactive intestinal peptide, enteroglucagon, somatostatin, neurotensin, etc.). At the same time, the reactivity of target organs with respect to regulatory peptides increases. In the prenatal period, peripheral and central mechanisms of nervous regulation of the activity of the gastrointestinal tract are laid.

In the fetus, the gastrointestinal tract begins to function already at the 16-20th week of intrauterine life. By this time, the swallowing reflex is expressed, amylase is found in the salivary glands, pepsinogen in the stomach, and secretin in the small intestine. A normal fetus swallows a large amount of amniotic fluid, the individual components of which are hydrolyzed in the intestine and absorbed. The undigested part of the contents of the stomach and intestines goes to the formation of meconium. From 4-5 months of intrauterine development, the activity of the digestive organs begins and, together with hemotrophic, amniotrophic nutrition occurs. The daily amount of liquid absorbed by the fetus in the last months of pregnancy can reach more than 1 liter. The fetus absorbs amniotic fluid containing nutrients (proteins, amino acids, glucose, vitamins, hormones, salts, etc.) and hydrolyzing enzymes. Some enzymes enter the amniotic fluid from the fetus with saliva and urine, the second source is the placenta, the third source is the mother's body (enzymes through the placenta and, bypassing it, can enter the amniotic fluid from the blood of a pregnant woman).

Part of the nutrients are absorbed from the gastrointestinal tract without prior hydrolysis (glucose, amino acids, some dimers, oligomers and even polymers), since the intestinal tube of the fetus has a high permeability, fetal enterocytes are capable of pinocytosis. This is important to consider when organizing the nutrition of a pregnant woman in order to prevent allergic diseases. Some of the nutrients of the amniotic fluid are digested by its own enzymes, that is, the autolytic type of digestion plays an important role in the amniotic nutrition of the fetus. Amniotrophic nutrition of the type of own abdominal digestion can be carried out from the 2nd half of pregnancy, when pepsinogen and lipase are secreted by the cells of the stomach and pancreas of the fetus, although their level is low. Amniotrophic nutrition and the corresponding digestion are important not only for the supply of nutrients to the blood of the fetus, but also as a preparation of the digestive organs for lactotrophic nutrition.

In newborns and children in the first months of life, the oral cavity is relatively small, the tongue is large, the muscles of the mouth and cheeks are well developed, in the thickness of the cheeks there are fatty bodies (Bish's lumps), which are distinguished by significant elasticity due to the predominance of solid (saturated) fatty acids in them. These features provide full breast sucking. The mucous membrane of the oral cavity is tender, dryish, rich in blood vessels (easily vulnerable). The salivary glands are poorly developed, produce little saliva (submandibular, sublingual glands function to a greater extent in infants, in children after a year and adults - parotid). The salivary glands begin to function actively by the 3-4th month of life, but even at the age of 1 year, the volume of saliva (150 ml) is 1/10 of the amount in an adult. The enzymatic activity of saliva at an early age is 1/3-1/2 of its activity in adults, but it reaches the level of adults within 1-2 years. Although the enzymatic activity of saliva at an early age is low, its action on milk contributes to its curdling in the stomach with the formation of small flakes, which facilitates the hydrolysis of casein. Hypersalivation at 3-4 months of age is due to teething, saliva may flow from the mouth due to the inability of children to swallow it. The reaction of saliva in children of the first year of life is neutral or slightly acidic - this can contribute to the development of thrush of the oral mucosa if it is not properly cared for. At an early age, saliva contains a low content of lysozyme, secretory immunoglobulin A, which determines its low bactericidal activity and the need for proper oral care.

The esophagus in young children has a funnel-shaped form. Its length in newborns is 10 cm, with age it increases, while the diameter of the esophagus becomes larger. The relatively short esophagus contributes to the fact that part of the stomach is located in the chest cavity, and part - in the abdominal cavity. There are 3 physiological constrictions in the esophagus: in the area of ​​​​contact of the esophagus with the posterior wall of the left ventricle (during esophagoscopy, when the endoscope passes through this section, various heart rhythm disturbances can be observed); when passing through the diaphragm; at the level of the tracheal bifurcation. The transition of the esophagus to the stomach in all periods of childhood is located at the level of the X and XI thoracic vertebrae.

The stomach in infants is located horizontally, its bottom and cardia are poorly developed, there is no tight coverage of the esophagus by the legs of the diaphragm, all these features, combined with increased intragastric pressure, explain the tendency of children of the first year of life to regurgitation and vomiting. As the child begins to walk, the axis of the stomach becomes more vertical, and by 7-11 years it is located in the same way as in an adult. The capacity of the stomach in a newborn is 30-35 ml, by the year it increases to 250-300 ml, by the age of 8 it reaches 1000 ml. The secretory apparatus of the stomach in children of the 1st year of life is not sufficiently developed, in the gastric mucosa they have 2.5 times fewer glands per 1 kilogram of body weight compared to adults. Although the composition of gastric juice in children is the same as in adults (hydrochloric acid, lactic acid, pepsin, rennet, lipase), but the acidity and enzymatic activity are lower, which determines the low barrier function of the stomach and pH of gastric juice (pH of gastric juice in the first 6-12 hours - 1.0-2.0 due to lactic acid, then very quickly within a few days rises to 6.0; by the end of the first week - pH 4.0-6.0; by the end of 1 year - pH 3.0-4.0; in adults, pH 1.5-2.2). The high pH of the stomach, on the one hand, preserves the integrity of anti-infective factors, including immunoglobulins, supplied with breast milk, on the other hand, leads to insufficient breakdown of proteins in the stomach by pepsin (the required pH for pepsin activity is 1-1.5), so proteins they are cleaved mainly by cathepsins and gastrixin produced by the gastric mucosa, their optimum action is at pH 4-5. Lipase of the stomach (produced by the pyloric part of the stomach, the optimum activity at pH - 4.0-8.0) breaks down in an acidic environment, together with lipase of human milk, up to half of the fats of human milk. These features must be taken into account when prescribing various types of nutrition to a child. With age, the secretory activity of the stomach increases. Motility of the stomach in children of the first months of life is slowed down, peristalsis is sluggish. The timing of the evacuation of food from the stomach depends on the nature of feeding. Women's milk lingers in the stomach for 2-3 hours, cow's - 3-4 hours, which indicates the difficulties of digesting the latter.

The intestines in children are relatively longer than in adults. Newborns do not have omental processes, the bands of the colon are barely visible, haustra are absent up to 6 months. The caecum is mobile due to the long mesentery, the appendix, therefore, can be located in the right iliac region, shift to the small pelvis and to the left half of the abdomen, which creates difficulties in diagnosing appendicitis in young children. The appendix is ​​shorter (4-5 cm in newborns , in adults 9-12 cm), has a large inlet diameter, is easily drained, so appendicitis rarely develops in young children. The mesentery of the small intestine is longer and more easily distensible, which can lead to torsion, intussusception, and other pathological processes. The weakness of the ileocecal valve also contributes to the occurrence of intussusception in young children. A feature of the intestines in children is the better development of the circular muscles than the longitudinal ones, which predisposes to intestinal spasms and intestinal colic. Weak development of small and large omentums leads to the fact that the infectious process in the abdominal cavity (appendicitis, etc.) is often complicated by the development of diffuse peritonitis. The ascending part of the colon in newborns is short, the descending part is slightly mobile. The sigmoid colon is relatively long, which predisposes to constipation in children, especially if the mother's milk contains an increased amount of fat. The rectum in children in the first months of life is also relatively long, with weak fixation of the mucous and submucosal layers, and therefore, with tenesmus and persistent constipation, prolapse of the mucous membrane through the anus is possible. The ampulla of the rectum is poorly differentiated, fatty tissue is not developed, as a result of which the ampulla is poorly fixed. The anus in children is located more dorsally than in adults at a distance of 20 mm from the coccyx.

Digestion processes are intensively occurring in the intestine, represented by 3 types: extracellular (cavity), membrane (parietal) and intracellular. Extracellular (cavity) digestion is carried out in the intestinal cavity, where enzymes are secreted from large and small food glands; membrane (parietal) digestion is carried out in space by enterocyte enzymes themselves, as well as enzymes of pancreatic origin, absorbed by various layers of the glycocalyx; intracellular digestion is carried out in special vacuoles of the cytoplasm of the epithelium with the help of pinocytosis. In children of the first year of life, there is a low activity of the cavity and a high activity of the membrane and intracellular processes of digestion.

The intestinal secretory apparatus is generally formed at the time of the birth of the child, the same enzymes are found in the intestinal juice as in adults (enterokinase, alkaline phosphatase, lipase, erypsin, amylase, maltase, lactase, nuclease, etc.), but their activity is low. Under the influence of intestinal enzymes, mainly the pancreas, there is a breakdown of proteins, fats and carbohydrates. However, the pH of duodenal juice in young children is slightly acidic or neutral, so the breakdown of protein by trypsin is limited (for trypsin, the optimal pH is alkaline). Especially intense is the process of digestion of fats due to the low activity of lipolytic enzymes. In children who are breastfed, lipids emulsified by bile are cleaved by 50% under the influence of maternal milk lipase. Digestion of carbohydrates occurs in the small intestine under the influence of pancreatic amylase and intestinal juice disaccharidases. The processes of putrefaction in the intestines do not occur in healthy infants. The peculiarities of the structure of the intestinal wall and its large area determine in young children a higher absorption capacity than in adults and, at the same time, an insufficient barrier function due to the high permeability of the mucous membrane for toxins and microbes.

The motor function of the gastrointestinal tract in young children also has a number of features. The peristaltic wave of the esophagus and the mechanical irritation of its lower section with a food lump cause a reflex opening of the entrance to the stomach. Motility of the stomach consists of peristalsis (rhythmic waves of contraction from the cardiac section to the pylorus), peristoles (resistance exerted by the walls of the stomach to the tensile action of food) and fluctuations in the tone of the stomach wall, which appears 2-3 hours after eating. Motility of the small intestine includes pendulum movement (rhythmic oscillations that mix intestinal contents with intestinal secretions and create favorable conditions for absorption), fluctuations in the tone of the intestinal wall and peristalsis (worm-like movements along the intestine that promote the promotion of food). Pendulum and peristaltic movements are also noted in the large intestine, and antiperistalsis in the proximal sections, which contributes to the formation of fecal masses. The time of passage of food gruel through the intestines in children is shorter than in adults: in newborns - from 4 to 18 hours, in older ones - about a day. It should be noted that with artificial feeding, this period is extended. The act of defecation in infants occurs reflexively without the participation of a volitional moment, and only by the end of the first year of life does defecation become arbitrary.

For a newborn in the first 7 days after birth, physiological dyspepsia (physiological intestinal catarrh) is characteristic. The first act of defecation is characterized by the release of original feces, or meconium, in the form of a thick mass of dark olive color and odorless. In the future, as the intestines are populated with a variety of microflora, stools increase up to 5 times, the stools become watery, frothy with abundant wetting of diapers (transitional stools). By the 7th day, a normal microbial landscape is established and milk stools appear - mustard-like, doughy consistency with a sour smell from 1 to 4-5 times a day. At an older age, the chair becomes decorated, 1 time per day.

The intestines of a child in the first hours of life are free from bacteria. In the future, the gastrointestinal tract is populated by microflora, while 3 stages are distinguished: 1 - (aseptic) - lasts 10-20 hours from the moment of birth; 2 - (settlement) - 2-4 days; 3 - (stabilization) - 1-1.5 months. In the oral cavity of an infant, staphylococci, streptococci, pneumococci, Escherichia coli and some other bacteria can be found. E. coli, bifidobacteria, lactic acid bacilli, etc. appear in the feces. With artificial and mixed feeding, the phase of bacterial infection occurs faster.

Functions of microflora

Protective - a barrier against microbial contamination, reducing the permeability of the intestinal mucosa for macromolecules

Immune - stimulation of the maturation of the lymphoid apparatus of the intestine, maturation of phagocytes.

Metabolic

Synthesis of vitamins of group B, K

Metabolism of iron, bile acids, participation in lipid and carbohydrate metabolism

Digestive breakdown of carbohydrates, enzyme synthesis, parietal digestion, absorption regulation, stimulation of gastrointestinal motility.

Gut bacteria contribute to the processes of enzymatic digestion of food. With natural feeding, bifidobacteria, lactic acid bacilli predominate, and in a smaller amount - Escherichia coli. With artificial and mixed feeding, due to the predominance of putrefaction processes in feces, there are a lot of E. coli, fermentative flora (bifidoflora, lactic acid bacilli) are present in smaller quantities.

The liver in children is relatively large, in newborns it is about 4% of body weight (in adults - 2% of body weight). In young children, bile formation is less intense than in older children. The bile of children is poor in bile acids, cholesterol, lecithin, salts and alkali, but rich in water, mucin, pigments and urea, and also contains more taurocholic than glycocholic acid. It is important to note that taurocholic acid is an antiseptic. Bile neutralizes the acidic food slurry, which makes possible the activity of pancreatic and intestinal secretions. In addition, bile activates pancreatic lipase, emulsifies fats, dissolves fatty acids, turning them into soaps, and enhances peristalsis of the large intestine.

Thus, the system of the digestive organs in children is distinguished by a number of anatomical and physiological features that affect the functional ability of these organs. In a child in the first year of life, the need for food is relatively greater than in older children. Although the child has all the necessary digestive enzymes, the functional capacity of the digestive organs is limited and can only be sufficient if the child receives physiological food, namely human milk. Even small deviations in the quantity and quality of food can cause digestive disorders in an infant (they are especially frequent in the 1st year of life) and ultimately lead to a lag in physical development.

Propaedeutics of childhood diseases: Textbook for pediatric faculties of medical universities / Comp.: S.J. Bokonbaeva, T.D. Happy, H.M. Sushanlo, N.M. Aldasheva, G.P. Afanasenko. - Bishkek.: Kyrgyz-Russian Slavic University (KRSU), 2008. - 259 p.

Chapter 10. Anatomical and physiological features of the digestive system in children. Research methodology. Semiotics and lesion syndromes

The period of intrauterine formation of the digestive organs

The laying of the digestive organs occurs at a very early stage of embryonic development: from the 7th day to the 3rd month of intrauterine life of the fetus. By the 7–8th day, the organization of the primary intestine begins from the endoderm, and on the 12th day, the primary intestine is divided into 2 parts: intraembryonic (future digestive tract) and extraembryonic (yolk sac). Initially, the primary gut has oropharyngeal and cloacal membranes. At the 3rd week of intrauterine development, the oropharyngeal membrane melts, at the 3rd month - the cloacal membrane. In the process of development, the intestinal tube passes the stage of a dense "cord", when the proliferating epithelium completely closes the intestinal lumen. Then the process of vacuolization occurs, ending with the restoration of the lumen of the intestinal tube. With partial or complete violation of vacuolization, the intestinal lumen remains (almost or completely) closed, which leads either to stenosis or to atresia and obstruction. By the end of 1 month intrauterine development, 3 parts of the primary intestine are outlined: anterior, middle and posterior; there is a closure of the primary intestine in the form of a tube. From the 1st week, the formation of various sections of the digestive tract begins: the pharynx, esophagus, stomach and part of the duodenum with the rudiments of the pancreas and liver develop from the foregut; part of the duodenum, jejunum and ileum are formed from the middle intestine, all sections of the large intestine develop from the hindgut.

In the antenatal period, the foregut develops most intensively and gives many bends. In the third month of fetal development, the small intestine (from right to left, behind the superior mesenteric artery) and large intestine (from left to right of the same artery) move, which is called intestinal rotation.

Distinguish three periods of intestinal rotation:

1) turn by 90 °, the large intestine is on the left, the small intestine is on the right;
2) turn by 270º, the large and small intestines have a common mesentery;
3) fixation of the intestine ends, the small intestine acquires a separate mesentery.

If the process of intrauterine rotation of the intestine stops at the first stage, then volvulus of the midgut may occur. The time of occurrence of volvulus is different: from the prenatal period to extreme old age. If the second period of rotation is violated, there may be: a failed turn of the intestine, obstruction of the duodenum and other anomalies. If the third stage of rotation is disturbed, the fixation of the intestine changes, which leads to the formation of defects in the mesentery, as well as various pockets and bags, predisposing to infringement of the intestinal loops and to internal hernias.

At the same time, vessels leading to the yolk sac and the intestinal tract are formed. Arteries branch off from the aorta. The veins go directly to the venous sinus.

Week 10 the laying of the gastric glands begins, however, their differentiation both morphologically and functionally by the birth of a child is not completed.

Between the 10th and 22nd weeks of intrauterine development, the formation of intestinal villi occurs - most of the enzymes of membrane digestion appear, but the activation of some of them, such as lactase, occurs only by 38-40 weeks of pregnancy.

From 16–20 weeks the beginning of the functioning of the system as a digestive organ: the swallowing reflex is already expressed, gastric juice contains pepsinogen, intestinal - trypsinogen.

The fetus swallows and digests a large amount of amniotic fluid, which is similar in composition to extracellular fluid and serves as an additional source of nutrition for the fetus (amniotic nutrition).

Morphological and physiological features of the digestive organs in children especially pronounced in infancy. In this age period, the digestive apparatus is adapted mainly for the assimilation of breast milk, the digestion of which requires the least amount of enzymes (lactotrophic nutrition). The baby is born with a well-defined sucking and swallowing reflex. The act of sucking is provided by the anatomical features of the oral cavity of the newborn and infant. When sucking, the baby's lips tightly grasp the nipple of the mother's breast with the areola. The jaws squeeze it, and the communication between the oral cavity and the outside air stops. A cavity with negative pressure is created in the child's mouth, which is facilitated by the lowering of the lower jaw (physiological retrognathia) along with the tongue down and back. Breast milk enters the rarefied space of the oral cavity.

Oral cavity the child is relatively small, filled with tongue. The tongue is short, wide and thick. When the mouth is closed, it comes into contact with the cheeks and the hard palate. The lips and cheeks are relatively thick, with sufficiently developed muscles and dense fatty lumps of Bish. There are ridge-like thickenings on the gums, which also play a role in the act of sucking.

The mucous membrane of the oral cavity is delicate, richly supplied with blood vessels and relatively dry. Dryness is caused by insufficient development of the salivary glands and a deficiency of saliva in children up to 3–4 months of age. The oral mucosa is easily vulnerable, which should be taken into account when carrying out the toilet of the oral cavity. The development of the salivary glands ends by 3–4 months, and from that time on, an increased secretion of saliva begins (physiological salivation). Saliva is the result of the secretion of three pairs of salivary glands (parotid, submandibular and sublingual) and small glands of the oral cavity. The reaction of saliva in newborns is neutral or slightly acidic. From the first days of life, it contains an amylolytic enzyme. It contributes to the sliming of food and foaming, from the second half of life its bactericidal activity increases.

Entrance to larynx in an infant, it lies high above the lower edge of the palatine curtain and is connected to the oral cavity; due to this, food moves to the sides of the protruding larynx through the communication between the oral cavity and the pharynx. Therefore, the baby can breathe and suck at the same time. From the mouth, food passes through the esophagus to the stomach.

Esophagus. At the beginning of development, the esophagus looks like a tube, the lumen of which is filled due to the proliferation of cell mass. At 3–4 months of intrauterine development, the laying of glands is observed, which begin to actively secrete. This contributes to the formation of a lumen in the esophagus. Violation of the recanalization process is the cause of congenital narrowing and strictures in the development of the esophagus.

In newborns, the esophagus is a spindle-shaped muscular tube lined from the inside with a mucous membrane. The entrance to the esophagus is located at the level of the disc between the III and IV cervical vertebrae, by the age of 2 - at the level of the IV-V cervical vertebrae, at 12 years - at the level of the VI-VII vertebrae. The length of the esophagus in a newborn is 10-12 cm, at the age of 5 years - 16 cm; its width in a newborn is 7-8 mm, by 1 year - 1 cm and by 12 years - 1.5 cm (the dimensions of the esophagus must be taken into account when conducting instrumental studies).

In the esophagus there are three anatomical constrictions- in the initial part, at the level of the bifurcation of the trachea and diaphragmatic. Anatomical narrowing of the esophagus in newborns and children of the first year of life are relatively weakly expressed. The features of the esophagus include the complete absence of glands and insufficient development of muscular-elastic tissue. Its mucous membrane is tender and richly supplied with blood. Outside the act of swallowing, the passage of the pharynx into the esophagus is closed. Peristalsis of the esophagus occurs during swallowing movements. The transition of the esophagus to the stomach in all periods of childhood is located at the level of the X-XI thoracic vertebrae.

Stomach is an elastic sac-like organ. It is located in the left hypochondrium, its cardial part is fixed to the left of the X thoracic vertebra, the pylorus is located near the midline at the level of the XII thoracic vertebra, approximately in the middle between the navel and the xiphoid process. This position varies considerably depending on the age of the child and the shape of the stomach. The variability of the shape, volume and size of the stomach depends on the degree of development of the muscle layer, the nature of nutrition, and the impact of neighboring organs. In infants, the stomach is located horizontally, but as soon as the child begins to walk, he assumes a more vertical position.

By the time the child is born, the fundus and cardial section of the stomach are not sufficiently developed, and the pyloric section is much better, which explains frequent regurgitation. Regurgitation is also facilitated by swallowing air during sucking (aerophagy), with improper feeding technique, a short frenulum of the tongue, greedy sucking, too rapid release of milk from the mother's breast.

The capacity of the stomach of a newborn is 30-35 ml, by the age of 1 it increases to 250-300 ml, by the age of 8 it reaches 1000 ml.

The mucous membrane of the stomach tender, rich in blood vessels, poor in elastic tissue, contains few digestive glands. The muscular layer is underdeveloped. There is a meager secretion of gastric juice, which has low acidity.

digestive glands The stomach is divided into fundic (main, parietal and additional), secreting hydrochloric acid, pepsin and mucus, cardiac (additional cells) releasing mucin, and pyloric (main and additional cells). Some of them begin to function in utero (parietal and main), but in general, the secretory apparatus of the stomach in children of the first year of life is underdeveloped and its functional abilities are low.

The stomach has two main functions– secretory and motor. The secretory activity of the stomach, consisting of two phases - neuro-reflex and chemical-humoral - has many features and depends on the degree of development of the central nervous system and the quality of nutrition.

Gastric juice an infant contains the same components as the gastric juice of an adult: rennet, hydrochloric acid, pepsin, lipase, but their content is reduced, especially in newborns, and increases gradually. Pepsin breaks down proteins into albumins and peptones. Lipase breaks down neutral fats into fatty acids and glycerol. Rennet (the most active of the enzymes in infants) curdles milk.

General acidity in the first year of life, it is 2.5–3 times lower than in adults, and is equal to 20–40. Free hydrochloric acid is determined during breastfeeding after 1-1.5 hours, and with artificial - after 2.5-3 hours after feeding. The acidity of gastric juice is subject to significant fluctuations depending on the nature and diet, the state of the gastrointestinal tract.

An important role in the implementation of the motor function of the stomach belongs to the activity of the pylorus, due to the reflex periodic opening and closing of which the food masses pass in small portions from the stomach to the duodenum. In the first months of life, the motor function of the stomach is poorly expressed, peristalsis is sluggish, the gas bubble is enlarged. In infants, it is possible to increase the tone of the muscles of the stomach in the pyloric region, the maximum manifestation of which is pylorospasm. At an older age, sometimes there is cardiospasm.

Functional insufficiency decreases with age, which is explained, firstly, by the gradual development of conditioned reflexes to food stimuli; secondly, the complication of the child's diet; thirdly, the development of the cerebral cortex. By the age of 2, the structural and physiological features of the stomach correspond to those of an adult.

Intestines starts from the pylorus of the stomach and ends with the anus. Distinguish between small and large intestine. The first is subdivided into a short duodenum, jejunum and ileum. The second - on the blind, colon (ascending, transverse, descending, sigmoid) and rectum.

Duodenum the newborn is located at the level of the 1st lumbar vertebra and has a rounded shape. By the age of 12, it descends to the III-IV lumbar vertebra. The length of the duodenum up to 4 years is 7–13 cm (in adults up to 24–30 cm). In young children, it is very mobile, but by the age of 7, adipose tissue appears around it, which fixes the intestine and reduces its mobility.

In the upper part of the duodenum, acidic gastric chyme is alkalized, prepared for the action of enzymes that come from the pancreas and are formed in the intestine, and mixed with bile (bile comes from the liver through the bile ducts).

The jejunum occupies 2/5, and the ileum 3/5 of the length of the small intestine without the duodenum. There is no clear boundary between them.

The ileum ends at the ileocecal valve. In young children, its relative weakness is noted, and therefore the contents of the caecum, the richest in bacterial flora, can be thrown into the ileum. In older children, this condition is considered pathological.

Small intestine in children it occupies an unstable position, which depends on the degree of its filling, body position, tone of the intestines and abdominal muscles. Compared to adults, it is relatively long, and the intestinal loops are more compact due to the relatively large liver and underdevelopment of the small pelvis. After the first year of life, as the pelvis develops, the arrangement of the loops of the small intestine becomes more constant.

The small intestine of an infant contains a relatively large amount of gas, which gradually decreases in volume and disappears by the age of 7 (adults normally do not have gas in the small intestine).

To others bowel features in infants and young children include:

• greater permeability of the intestinal epithelium;
• poor development of the muscle layer and elastic fibers of the intestinal wall;
• tenderness of the mucous membrane and a high content of blood vessels in it;
• good development of the villi and folding of the mucous membrane with insufficiency of the secretory apparatus and incomplete development of the nerve pathways.

This contributes to the easy occurrence of functional disorders and favors the penetration into the blood of unsplit food components, toxic-allergic substances and microorganisms.

After 5–7 years, the histological structure of the mucous membrane no longer differs from its structure in adults.

The mesentery, very thin in newborns, increases significantly in length during the first year of life and descends along with the intestine. This, apparently, causes the child to have relatively frequent torsion of the intestines and intussusceptions.

The lymph flowing from the small intestine does not pass through the liver, so the products of absorption, together with the lymph through the thoracic duct, enter directly into the circulating blood.

Colon has a length equal to the height of the child. Parts of the colon are developed to varying degrees. The newborn has no omental processes, the bands of the colon are barely marked, haustra are absent until the age of six months. The anatomical structure of the colon after 3–4 years of age is the same as in an adult.

Cecum, having a funnel-shaped form, it is located the higher, the younger the child. In a newborn, it is located directly under the liver. The higher the caecum is located, the more underdeveloped the ascending one. The final formation of the cecum ends by the year.

Appendix in a newborn it has a conical shape, a wide open entrance and a length of 4-5 cm, by the end of 1 year - 7 cm (in adults 9-12 cm). It has greater mobility due to the long mesentery and can be located in any part of the abdominal cavity, but most often occupies the retrocecal position.

Colon in the form of a rim surrounds the loops of the small intestine. The ascending part of the colon in a newborn is very short (2-9 cm), begins to increase after a year.

transverse part the colon in a newborn is located in the epigastric region, has a horseshoe shape, a length of 4 to 27 cm; by the age of 2, it approaches a horizontal position. The mesentery of the transverse colon is thin and relatively long, making it easy for the intestine to move when the stomach and small intestine are full.

Descending part the colon in newborns is narrower than the rest of the colon; its length doubles by 1 year, and by 5 years it reaches 15 cm. It is slightly mobile and rarely has a mesentery.

Sigmoid colon- the most mobile and relatively long part of the large intestine (12–29 cm). Up to 5 years, it is usually located in the abdominal cavity due to an underdeveloped small pelvis, and then descends into the small pelvis. Its mobility is due to the long mesentery. By the age of 7, the intestine loses its mobility as a result of the shortening of the mesentery and the accumulation of adipose tissue around it.

Rectum in children of the first months it is relatively long and, when filled, can occupy the small pelvis. In a newborn, the ampulla of the rectum is poorly differentiated, fatty tissue is not developed, as a result of which the ampulla is poorly fixed. The rectum occupies its final position by the age of 2 years. Due to the well-developed submucosal layer and weak fixation of the mucous membrane, prolapse is often observed in young children.

anus in children it is located more dorsally than in adults, at a distance of 20 mm from the coccyx.

The process of digestion, which begins in the mouth and stomach, continues in the small intestine under the influence of pancreatic juice and bile secreted into the duodenum, as well as intestinal juice. The secretory apparatus of the intestine as a whole is formed. Even the smallest in the intestinal juice secreted by enterocytes, the same enzymes are determined as in adults (enterokinase, alkaline phosphatase, erepsin, lipase, amylase, maltase, nuclease), but their activity is low.

The duodenum is the hormonal center of digestion and exerts a regulatory influence on the entire digestive system through hormones secreted by the glands of the mucous membrane.

In the small intestine, the main stages of the complex process of splitting and absorption of nutrients are carried out with the combined action of intestinal juice, bile and pancreatic secretions.

The breakdown of food products occurs with the help of enzymes both in the cavity of the small intestine (cavitary digestion) and directly on the surface of its mucous membrane (parietal or membrane digestion). The infant has a special abdominal intracellular digestion, adapted to lactotropic nutrition, and intracellular, carried out by pinocetosis. The breakdown of foodstuffs occurs mainly under the influence of the secret of the pancreas, which contains trypsin (acting proteolytically), amylase (breaks down polysaccharides and turns them into monosaccharides) and lipase (breaks down fats). Due to the low activity of the lipolytic enzyme, the process of digesting fats is especially intense.

Absorption is closely related to parietal digestion and depends on the structure and function of the cells of the surface layer of the mucous membrane of the small intestine; it is the main function of the small intestine. Proteins are absorbed in the form of amino acids, but in children of the first months of life, their partial absorption in unchanged form is possible. Carbohydrates are digested as monosaccharides, fats as fatty acids.

The peculiarities of the structure of the intestinal wall and its relatively large area determine in young children a higher absorption capacity than in adults, and at the same time, due to high permeability, an insufficient barrier function of the mucous membrane. The components of women's milk are most easily absorbed, the proteins and fats of which are partially absorbed unsplit.

In the large intestine, the absorption of digested food and mainly water is completed, and the remaining substances are broken down under the influence of both enzymes from the small intestine and bacteria that inhabit the large intestine. Juice secretion of the colon is insignificant; however, it sharply increases with mechanical irritation of the mucous membrane. In the large intestine, feces are formed.

The motor function of the intestine (motility) consists of pendulum movements that occur in the small intestine, due to which its contents are mixed, and peristaltic movements that promote the movement of chyme towards the large intestine. The large intestine is also characterized by anti-peristaltic movements, which thicken and form fecal masses.

Motor skills in children early age is very energetic, which causes frequent bowel movements. In infants, defecation occurs reflexively; in the first 2 weeks of life up to 3-6 times a day, then less often; by the end of the first year of life, it becomes an arbitrary act. In the first 2-3 days after birth, the baby excretes meconium (original feces) of a greenish-black color. It consists of bile, epithelial cells, mucus, enzymes, swallowed amniotic fluid. On day 4-5, the stool becomes normal. The feces of healthy breastfed newborns have a mushy texture, golden yellow or yellow-greenish color, sour smell. The golden-yellow color of feces in the first months of a child's life is due to the presence of bilirubin, greenish - biliverdin. In older children, the chair is decorated, 1-2 times a day.

The intestines of the fetus and newborn are free from bacteria for the first 10–20 hours. The formation of intestinal microbial biocenosis begins from the first day of life, by the 7–9th day in healthy full-term breastfed babies, a normal level of intestinal microflora is reached with a predominance of B. bifidus, with artificial feeding - B. Coli, B. Acidophilus, B Bifidus and Enterococci.

Pancreas- parenchymal organ of external and internal secretion. In a newborn, it is located deep in the abdominal cavity, at the level of the Xth thoracic vertebra, its length is 5–6 cm. In infants and older children, the pancreas is located at the level of the 1st lumbar vertebra. Iron grows most intensively in the first 3 years and in the puberty period. By birth and in the first months of life, it is not sufficiently differentiated, abundantly vascularized and poor in connective tissue. In a newborn, the head of the pancreas is most developed. At an early age, the surface of the pancreas is smooth, and by the age of 10–12, tuberosity appears, due to the isolation of the boundaries of the lobules.

Liver- the largest digestive gland. In children, it has a relatively large size: in newborns - 4% of body weight, while in adults - 2%. In the postnatal period, the liver continues to grow, but more slowly than body weight.

Due to the different rate of increase in liver and body weight in children from 1 to 3 years of age, the edge of the liver comes out from under the right hypochondrium and is easily palpable 1-2 cm below the costal arch along the mid-clavicular line. From the age of 7, in the supine position, the lower edge of the liver is not palpable, and along the midline does not go beyond the upper third of the distance from the navel to the xiphoid process.

The liver parenchyma is poorly differentiated, the lobular structure is revealed only by the end of the first year of life. The liver is plethoric, as a result of which it rapidly increases with infection and intoxication, circulatory disorders and is easily reborn under the influence of adverse factors. By the age of 8, the morphological and histological structure of the liver is the same as in adults.

The role of the liver in the body is varied. First of all, it is the production of bile, which is involved in intestinal digestion, stimulating the motor function of the intestine and sanitizing its contents. Bile secretion is noted already in a 3-month-old fetus, however, bile formation at an early age is still insufficient.

Bile relatively poor in bile acids. A characteristic and favorable feature of the bile of a child is the predominance of taurocholic acid over glycocholic acid, since taurocholic acid enhances the bactericidal effect of bile and accelerates the separation of pancreatic juice.

The liver stores nutrients, mainly glycogen, but also fats and proteins. As needed, these substances enter the bloodstream. Separate cellular elements of the liver (stellate reticuloendotheliocytes, or Kupffer cells, portal vein endothelium) are part of the reticuloendothelial apparatus, which has phagocytic functions and is actively involved in the metabolism of iron and cholesterol.

The liver performs a barrier function, neutralizes a number of endogenous and exogenous harmful substances, including toxins from the intestines, and takes part in the metabolism of medicinal substances.

Thus, the liver plays an important role in carbohydrate, protein, bile, fat, water, vitamin (A, D, K, B, C) metabolism, and during fetal development it is also a hematopoietic organ.

In young children, the liver is in a state of functional insufficiency, its enzymatic system is especially untenable, resulting in transient neonatal jaundice due to incomplete metabolism of free bilirubin formed during hemolysis of erythrocytes.

Spleen- lymphoid organ. Its structure is similar to the thymus gland and lymph nodes. It is located in the abdominal cavity (in the left hypochondrium). The pulp of the spleen is based on reticular tissue that forms its stroma.

Features of examination of the digestive system. The main symptoms of the lesion

Features of collecting anamnesis. A carefully collected history is the basis for diagnosing diseases of the gastrointestinal tract.

Among the complaints dominated by abdominal pain, dyspeptic syndrome, symptoms of intoxication.

Stomach ache in children are a common symptom, they are often recurrent in nature, occur in about 20% of children older than 5 years. The largest localization of pain in preschool and primary school age - the navel area, which can be observed in various diseases. This is due to the age characteristics of the central and autonomic nervous system of the child.

When children develop abdominal pain, each time it is necessary to carry out differential diagnosis between the following groups of diseases:

• surgical diseases (acute appendicitis, peritonitis, diverticulitis, intestinal obstruction - intussusception, hernia, etc.);
• infectious pathology (enterocolitis, hepatitis, yersiniosis, pseudotuberculosis, infectious mononucleosis, etc.);
• diseases of the digestive system (at an early age, the so-called "infantile colic" is common, at an older age - diseases of the gastroduodenal zone, pathology of the hepatobiliary system and pancreas, intestinal diseases, etc.);
• somatic diseases (pneumonia, myocarditis, urinary tract diseases, manifestations of neuro-arthritic diathesis, Schonlein-Genoch disease, neurocirculatory dysfunction, etc.).

With abdominal pain find out:

Time of appearance, duration, frequency. Early pain - during a meal or within 30 minutes after a meal is characteristic of esophagitis and gastritis. Late pain that occurs on an empty stomach during the day 30-60 minutes after eating or at night is characteristic of gastritis of the antrum, duodenitis, gastroduodenitis, duodenal ulcer;

Connection with food intake and its character. The intensity of pain can be influenced by eating itself. With antral gastritis, gastroduodenitis, peptic ulcer of the duodenal bulb, after eating, the intensity of pain decreases. But after a while, the pain intensifies again. These are the so-called Moiningan pains. Pain often arises or intensifies when taking spicy, fried, fatty, sour foods, when using concentrated, extracted broths, spices, etc.

Location of pain. Pain in the epigastric region is characteristic of eosophagitis and gastritis. In pyloroduodenal - antral gastritis, gastroduodenitis, duodenal ulcer. Pain in the right hypochondrium is characteristic of diseases of the biliary tract (dyskinesia, cholecystocholangitis). Girdle pains with predominant localization on the left, above the navel, are noted with pancreatitis. Pain throughout the abdomen is usually observed with enterocolitis. Pain in the right iliac region is characteristic of appendicitis, proximal colitis, ileitis.

Characteristics of pain. There are paroxysmal, stabbing, constant, dull, aching and nocturnal (with peptic ulcer) pain. In the first year of life, abdominal pain is manifested by general anxiety, crying. As a rule, children kick their legs, which often happens with flatulence, and after the passage of gases, they calm down.

Relationship with physical, emotional stress and other factors.

Among the dyspeptic phenomena, the gastric and intestinal form of disorders is distinguished.

• At gastric dyspepsia children have: belching, nausea, heartburn, vomiting, regurgitation. They reflect a violation of the motility of the gastrointestinal tract and are not a strictly specific symptom of any disease.
• Belching is a consequence of an increase in intragastric pressure with insufficiency of the cardiac sphincter. Occurs with esophagitis, hiatal hernia, cardia insufficiency, chronic gastritis, gastroduodenitis, peptic ulcer. In the 1st year of life in children, due to the weakness of the cardiac sphincter, belching of air (aerophagia) is often noted, this may also be due to a violation of the feeding technique.
• Nausea in children is more often the result of increased intraduodenal pressure. Occurs in diseases of the duodenum (duodenitis, gastroduodenitis, peptic ulcer of the duodenal bulb). Preceded by vomiting.
• Heartburn observed with gastroesophageal reflux, esophagitis, due to the reflux of acidic stomach contents into the esophagus.
• Vomit- a complex reflex act, during which there is an involuntary ejection of the contents of the stomach through the esophagus, pharynx, mouth out. Vomiting can be of nervous origin (with damage to the central nervous system, meningitis, intoxication, irritation of the vomiting center with various infections), and with damage to the gastroduodenal zone (acute and chronic gastritis, gastroduodenitis, peptic ulcer, intestinal infections, food toxic infections). With force-feeding, “habitual vomiting” can form. A variety of vomiting in children of the first year of life is regurgitation, which occurs without effort, i.e. without abdominal tension. Often regurgitation occurs in practically healthy children at 1 year of age, but may be a sign of an incipient intestinal infection. They also occur with a "short" esophagus and achalasia of the cardia. Rarely, in children with intellectual disabilities, rumination occurs - chewing gum, characterized by the fact that vomit regurgitated into the oral cavity is swallowed again by the child. Vomiting fountain - a typical sign of pyloric stenosis, while there is no admixture of bile in the vomit. Intestinal dyspepsia manifested by diarrhea, less often by constipation, flatulence, rumbling.

In the first 1-2 days of life in healthy newborns, meconium - stool, which is a thick viscous mass of dark olive color, odorless, accumulated in the intestines before the birth of the child, before the first application to the breast. The absence of epithelial cells in the composition of meconium may be a sign of intestinal obstruction in the newborn. The admixture of meconium to the amniotic fluid at the beginning of labor indicates intrauterine asphyxia. The type of feces in children of the first year of life on breastfeeding is mushy, golden yellow in color with a slightly acidic odor. The number of bowel movements - up to 7 times a day in the first half of the year, and 2-3 times a day - in the second.

With artificial feeding, the feces are thicker, putty-like, light yellow in color, with an unpleasant odor, the number of bowel movements is 3-4 times a day for up to 6 months and 1-2 times a day for up to a year. In older children, the stool is decorated (a type of sausage), dark brown in color, does not contain pathological impurities (mucus, blood). The chair happens 1-2 times a day. With various diseases, the nature of the stool changes, there are:

• dyspeptic stool, liquid with an admixture of mucus, greenery, white lumps, frothy, sour smell (it happens with simple dyspepsia - "fermentative dyspepsia");
• "Hungry" stool, meager, reminiscent of dyspeptic, but thicker, darker (it happens with malnutrition);
• stool with toxic dyspepsia is watery, light yellow in color with an admixture of mucus;
• with colienteritis, the stool is liquid, ocher-yellow (less often greenish) with an admixture of mucus and white lumps;
• with salmonellosis - the stool is liquid, green (like swamp greens), there is a small amount of mucus, there is no blood;
• with dysentery, the stool is quickened (up to 15 times), contains a large amount of mucus, pus and streaks of blood, there are almost no feces, defecation is accompanied by tenesmus;
• with typhoid fever, the stool is quickened (up to 10 times), liquid, fetid, in the form of pea puree, occasionally contains an admixture of bile;
• with cholera, the stool is almost continuous (up to 100 times a day), plentiful, in the form of rice water, never contains blood;
• with food poisoning, the stool is liquid, frequent, abundant, greenish-yellow in color with an admixture of mucus (rarely streaked with blood);
• with amoebiasis, the stool is quickened, the color of raspberry jelly;
• with giardiasis, stools 3-4 times a day, yellow-green in color, soft in consistency;
• with viral hepatitis, the stool is acholic, gray-clay in color, without pathological impurities;
• for malabsorption syndromes, polyfecalia is characteristic (when the amount of feces exceeds 2% of the food eaten and the liquid drunk). This syndrome is observed in disaccharide deficiency (lactose and sucrose), celiac disease (gluten intolerance, gliadin), cow's milk protein intolerance, and chronic pancreatitis;
• melena (black homogeneous stool), occurs when bleeding in the upper gastrointestinal tract (esophagus, stomach, duodenum, small intestine);
• scarlet blood in the stool appears with bleeding in the terminal sections of the ileum and colon (with intestinal polliposis, intussusception, Crohn's disease, at the 2-3rd week of typhoid fever, with anal fissures (where blood is located separately from feces);
• constipation (stool retention for more than 48 hours) are of organic and functional origin. If there is no stool for 1–3 days in a newborn child from birth, one should think about congenital anomalies in the development of the intestine (megacolon, Hirschsprung's disease, megasigma, anal atresia, etc.). At an older age, constipation is noted with colitis, hypothyroidism and other conditions.

Flatulence- bloating, like rumbling, occurs due to a violation of the absorption of gases and liquid contents in the terminal ileum and the proximal colon, it is more common with enterocolitis, intestinal dysbacteriosis.

Reveal signs of intoxication:

• the presence of lethargy, fatigue, loss of appetite;
• increase in body temperature;
• changes in the leukocyte formula, acute phase reactions of the blood.

It is extremely important to establish the relationship between the above syndromes. An important role in the development of diseases is played and requires clarification when history taking:

Inspection. In older children, the examination begins with the oral cavity, and in young children, this procedure is carried out at the end of the examination, in order to avoid a negative reaction and anxiety. Pay attention to the color of the mucous membrane of the oral cavity, pharynx and tonsils. In healthy children, the mucosa is pale pink, shiny. With stomatitis, the mucosa is locally hyperemic, the shine disappears (catarrhal stomatitis), and mucosal defects in the form of aphthae or ulcers (aphthous or ulcerative stomatitis) can also be detected. The Filatov-Koplik symptom is determined (the mucous membrane of the cheeks against the small molars, less often the gums, is covered with a coating in the form of semolina), which indicates a prodrome of measles. You can detect inflammatory changes in the gums - gingivitis, or lesions of the tongue - glossitis (from catarrhal to ulcerative necrotic). When examining the tongue, it is revealed that it is clean (normal) or coated (in diseases of the gastrointestinal tract). Plaque on the tongue can be located over the entire surface or only at the root of the tongue. Have a different color: white, gray or dirty, and density: be thick or superficial. The appearance of the tongue in various diseases is peculiar: with anemia, atrophy of the papillae is noted, and it resembles a “polished” tongue; with scarlet fever - crimson, especially the tip; in acute intestinal and other infections, the tongue is dry, coated with a coating; with exudative-catarrhal diathesis, the language is "geographical". With a strong cough, accompanied by reprisals, sores appear on the mucous membrane of the frenulum of the tongue, as it is traumatized against the lower anterior incisors. Find out the condition of the teeth (formula, caries, defects, enamel, malocclusion).

Examination of the abdomen . First of all, attention should be paid to the participation in the act of breathing of the abdominal wall. With local peritonitis (acute appendicitis, cholecystitis), movements are limited, and with diffuse peritonitis, the anterior abdominal wall does not take part in breathing, it is tense. In children of the first months with pyloric stenosis, gastric peristalsis in the epigastric region in the form of an hourglass can be noted. Intestinal peristalsis is observed with intestinal obstruction.

Normally, the anterior abdominal wall does not go beyond the plane, which, as it were, is a continuation of the chest.

Abdominal enlargement in volume observed in obesity, flatulence, ascites, pseudoascites, chronic tuberculous peritonitis, a significant increase in the liver and spleen, tumors of the abdominal cavity, anomalies in the development of the intestine (megacolon). With hepatosplenomegaly, the abdomen increases in the upper sections. With tumors, asymmetry of the abdomen is observed. Retraction of the abdominal wall is characteristic of acute peritonitis, it occurs with severe exhaustion, dysentery, tuberculous meningitis.

A pronounced venous network on the anterior abdominal wall in newborns may be a sign of umbilical sepsis. In children older than a year, a pronounced venous network often indicates portal hypertension (intrahepatic - with cirrhosis of the liver, extrahepatic - with v.portae thrombosis), while there is difficulty in the outflow of blood through the v.portae system and the inferior vena cava. Swelling of the anterior abdominal wall in newborns is noted with umbilical sepsis, sometimes septic enterocolitis, and in children older than a year - with ascites and tuberculous peritonitis.

Palpation of the abdomen. When examining the organs of the abdominal cavity, their topography is important when projected onto the anterior wall of the abdomen. To this end, it is customary to distinguish between different areas of the abdomen. The abdominal cavity is conventionally divided by two horizontal lines into three sections: epigastrium, mesogastrium and hypogastrium. The first line of division connects the Xth ribs, and the second - the iliac spines. Two vertical, running along the outer edge of the rectus abdominis muscles, additionally divide the abdominal cavity into 9 parts: left and right hypochondria; proper epigastric region (epigastrium), left and right lateral regions (flanks), umbilical, left and right iliac regions, suprapubic. Conditionally produce a division of the abdomen into sections : epigastric, mesogastric and hypogastric. epigastric region It is divided into the central zone - the epigastrium, as well as the left and right hypochondria. Mesogastrium - on the umbilical zone, left and right flanks. Hypogastrium- on the suprapubic zone, left and right iliac regions.

For proper palpation, the doctor sits to the right of the patient, facing him. The child should lie on his back with legs slightly bent at the hip and knee joints. The arms should be extended along the body, the head should be at the same level with the body, it is desirable to distract the child.

Superficial or approximate palpation is carried out by light pressure on the anterior abdominal wall, and all parts of the abdomen are sequentially examined, moving clockwise or counterclockwise, depending on the presence and localization of abdominal pain. Palpation should begin with an area that does not hurt. Both or one hand is placed with the palmar surface on the abdominal wall, pressure is applied with 2–3–4–5 fingers of the palpating hand. This method reveals the tension of the abdominal wall, tumor formations, pain.

The tension of the anterior abdominal wall can be active and passive. To exclude active tension, it is necessary to divert the attention of the child. It can be used as a distraction technique by changing the posture, transferring the child to a sitting position. At the same time, active tension disappears during palpation, while passive tension remains. In children during the neonatal period, the umbilical ring and paraumbilical vessels should be palpated.

Of great importance in the examination of pain zones are zones of skin sensitivity - Zakharyin - Geda zones. When examining areas of hyperesthesia in older children, one should slide over the skin, lightly stroking the skin with both hands in symmetrically located areas to the right and left of the white line of the abdomen.

There are the following zones of hyperesthesia :

• choledochoduodenal zone- right upper square (the area bounded by the right costal arch, the white line of the abdomen and the line passing through the navel perpendicular to the white line of the abdomen).
• epigastric zone- occupies the epigastrium (the area of ​​\u200b\u200bthe abdomen above the line connecting the right and left costal arches).
• Chauffard zone, which is located between the white line of the abdomen and the bisector of the upper right square.
• pancreatic zone- a zone in the form of a strip occupying the mesogastrium from the navel to the spine.
• Pain zone of the body and tail of the pancreas- occupies the entire upper left square.
• appendicular zone- lower right square.
• sigmal zone- lower left square.

With the help of superficial palpation, the asymmetry of the thickness of the subcutaneous tissue is also determined, for which, at the level of the navel on both sides, the skin and subcutaneous tissue are folded with the first and second fingers. After superficial indicative palpation, they move on to deep sliding, topographic methodical palpation according to Obraztsov and Strazhesko.

deep palpation carried out in a certain order: sigmoid colon and descending colon, blind, ascending colon, terminal ileum, appendix, transverse colon. Deep palpation is completed by probing the pancreas, liver and spleen.

Palpation of the large intestine. Palpation of the sigmoid colon - the examiner's right hand is placed flat with fingers slightly bent on the left iliac region so that the terminal phalanges of the fingers are perpendicular to the length of the sigmoid colon. During inhalation, with a superficial movement of the fingers, the skin moves slowly, forming a fold, from the outside to the inside and from the bottom up. During exhalation, the fingers sink as deep as possible, and then with the movement of the brush from the inside to the outside and from top to bottom, together with the skin of the anterior abdominal wall, they roll through the intestine. Typically, the sigma is located along the bisector of the lower left quadrant.

Determine the consistency, mobility, elasticity, soreness of the sigmoid colon. The limited mobility of the sigma may be due to the inflammatory process (perisigmoiditis), as well as a short mesentery. A dense, thin, painful intestine is palpated with spastic colitis, dysentery. Thicker than normal, the S-shaped intestine occurs when it is filled with feces; with atony, with the development of the pericolytic process. A very dense sigmoid colon is observed in tuberculosis, ulcerative colitis.

Palpation of the caecum- the palpation technique is the same as with the sigmoid colon, but is performed in the right iliac region. The direction of the caecum is from the right from top to bottom to the left. Simultaneously with the caecum, the ascending colon is also palpated.

The displacement of the caecum is several centimeters. Displacement limitation can be caused by an inflammatory process (peritiflitis) or a congenital short mesentery. Soreness on palpation indicates an inflammatory process and occurs in various pathologies (influenza, dysentery, typhoid fever, tuberculosis, etc.). A dense caecum is palpated with a delay in fecal masses (fecal stones), with an ulcerative inflammatory process.

Palpation of the final segment of the ileum carried out after the palpation of the caecum. Palpation of other parts of the small intestine is difficult due to the resistance of the abdominal press. The examiner puts his hand at an obtuse angle and probes from the inside to the outside and from top to bottom. A feature of palpation of the final section is its peristalsis under the palpating hand.

With spastic contraction, the ileum is dense, thin. With enteritis, pain and rumbling are noted (because gases and liquid are present). With terminal ileitis (Crohn's disease), the terminal segment is painful and thickened. A bumpy, uneven surface of the ileum can be observed in patients with typhoid fever, lymphogranulomatosis, lymphosarcomatosis. To distinguish damage to the cecum from terminal ileitis or mesoadenitis, it is necessary to palpate the caecum with the right hand, and with the left hand to probe the ileum medially to the shifted caecum. If the greatest pain is noted in the lateral region, one can think of a lesion of the caecum or appendix. With mesoadenitis, the greatest pain is manifested medially (under the left arm).

Palpation of the transverse colon done with two hands. The fingers are set parallel to the course of the intestine 2-3 cm above the navel on both sides in the region of the outer edge of the rectus muscles, slightly shifting them to the center and plunging the fingers deep into the abdominal cavity on exhalation. Then a sliding movement of the hands from top to bottom is made.

On palpation of any part of the large intestine it is necessary to note the following properties of the palpated department: localization, shape, consistency, size, surface condition, mobility, the presence of rumbling and pain.

In healthy children, the intestine is palpable in the form of a soft cylinder. Rumbling indicates the presence of gas and liquid.

A dense and crowded intestine occurs with fecal retention (constipation), painful - with colitis. The presence of a spastically reduced, with separate places of compaction, the transverse colon indicates ulcerative colitis. With atony, the intestine is palpated in the form of a soft cylinder with flaccid walls. In megacolon, the transverse colon is greatly enlarged and can occupy almost the entire abdominal cavity.

Palpation of the stomach possible only with deep palpation, but not always. The greater curvature is palpated slightly above the umbilicus. The correctness of palpation of the stomach and its location is assessed using the phenomenon of splashing, as well as percussion.

Omission of the greater curvature of the stomach is observed with gastroptosis, expansion and atony of the stomach, with pyloric stenosis. Palpation of the pylorus is of particular importance for the diagnosis of pyloric stenosis. The infant is given expressed milk or tea, and at this time the pylorus is palpated on the right - at the edge of the liver and the outer edge of the right abdominal muscle, trying to penetrate with the fingertips to the posterior abdominal wall. In the early stages of pyloric stenosis, a thickened pylorus is found under the rectus abdominis on the right. With a significant increase in the stomach, it shifts laterally and downward. Palpation reveals a dense spindle-shaped movable formation up to 2–4 cm long.

Palpation of the pancreas according to the Grotto method, it is carried out in the position of the child lying down. The doctor's right hand clenched into a fist is brought under the patient's lower back. The patient's legs are bent at the knees. The examiner's fingers enter the abdominal cavity between the navel and the left hypochondrium (the outer edge of the left rectus abdominis muscle in the left upper quadrant). Palpation is carried out on exhalation (the abdominal muscles are relaxed) towards the spinal column. The pancreas is palpated in the form of a cord with a diameter of about 1 cm obliquely overlapping the spinal column. With its inflammation, the patient experiences pain radiating to the back, spine. Diagnostic value, as already mentioned, is the definition of the pain zone of Chauffard, where the body of the pancreas is projected, as well as pain points.

Desjardins point- pain point of the head of the pancreas, located on the border of the middle and lower thirds of the bisector of the right upper quadrant.

Mayo–Robson point- painful point of the tail of the pancreas, located on the border of the upper and middle thirds of the bisector of the left upper quadrant.

Kucha point- pain point of the pancreas, located on the left edge of the rectus abdominis muscle 4-6 cm above the navel.

Obraztsov's symptom- soreness and rumbling on palpation in the right iliac region.

Palpation of the liver. Until the age of three, the liver in children in a calm position protrudes from under the edge of the costal arch along the midclavicular line by 2-3 cm, and at the age of 5-7 years - by 1-2 cm. At the height of inspiration, you can feel the lower edge of the liver in children and at an older age. But usually in healthy children older than 7 years, the liver is not palpable. There are two main types of liver palpation: sliding (sliding) palpation of the liver according to Strazhesko and the second - according to Strazhesko-Obraztsov. The position of the patient lying on his back with legs slightly bent, the pillow is removed. The arms are either extended along the body or lie on the chest. The fingers of the doctor's palpating hand form one line - parallel to the lower border of the liver and make a slight sliding movement from top to bottom. With sliding movements, you should feel the entire surface of the liver accessible to palpation. Especially often the sliding technique of palpation of the liver is used in infants and young children.

After that, they go to liver palpation according to the Obraztsov-Strazhesko method. The right (palpating) hand is placed flat on the area of ​​the right half of the abdominal wall at the level of the navel or below. The left hand covers the right half of the chest in the lower section. Leaving the right hand, deeply inserted on the exhale into the abdominal cavity, on the spot they ask the child to take a deep breath. When inhaling, the palpating hand is removed from the abdominal cavity in the direction forward and upward. At the same time, the lower edge of the liver, sliding down, tends to bypass the palpating fingers. At this moment, the shape and outlines of the edge of the liver, its consistency and soreness are determined.

In a healthy child, the lower edge of the liver is painless, sharp, and softly elastic. With various diseases, the density of the lower edge of the liver may increase, and its soreness appears.

Liver shrinkage characteristic of its acute dystrophy (with viral hepatitis B), first the upper dome of the liver is flattened, and then its lower edge. With the predominance of dystrophic processes in the cirrhotic liver, it can also decrease in size and not be palpated. The disappearance of hepatic dullness occurs when a duodenal ulcer or stomach ulcer is perforated.

A dense hard edge of the liver, up to stonyness, is noted with cirrhosis, with congenital fibrocholangiocystosis, leukemia, lymphogranulomatosis, while in many cases the surface of the liver is uneven. A smooth, even, soft surface of the liver with a rounded edge, rarely painful on palpation, occurs in acute blood stasis, due to cardiovascular insufficiency, hepatitis, cholangitis, cholecystocholangitis. A sharp pain when feeling the surface of the liver is characteristic of perihepatitis (with involvement of the liver capsule in the inflammatory process).

gallbladder children are not palpable. In diseases of the gallbladder (cholecystitis), pain in the area of ​​​​its projection (t. Kera) is determined.

On palpation, a number of symptoms are determined that indirectly indicate damage to the biliary tract or other organs:

• soreness on inspiration at the Kerah point or bladder point (with pathology of the gallbladder) - the place where the outer edge of the rectus abdominis muscle intersects with the right costal arch;
• Murphy's symptom - the appearance of a sharp pain on palpation at the time of inspiration in the gallbladder (the place where the outer edge of the rectus abdominis muscle intersects with the costal arch);
• arenicus-symptom (Mussy symptom) - pain when pressed between the legs of the right sternocleidomastoid muscle;
• Boas' symptom - soreness with pressure in the region of the transverse processes of the 8th thoracic vertebra on the right back;
• Openhovsky's symptom - pressure in the area of ​​the spinous processes of 10-11-12 thoracic vertebrae on the back, soreness is typical for peptic ulcer of the stomach and duodenum.

In differential diagnosis, to exclude surgical pathology, the symptoms of an "acute abdomen" are determined:

• Shchetkin-Blumberg symptom- the occurrence of acute pain in the abdomen at the time of the rapid removal of the palm from its surface after soft pressing - indicates irritation of the peritoneum in the area under study;
• Rovsing's sign- increased pain in the region of the caecum (in the case of appendicitis) with jerky pressure in the left iliac region;
• Sitkovsky's symptom- increased pain in the right iliac region (with appendicitis) when turning the patient to the left side.

percussion method used to determine the boundaries of the liver, which is carried out along three lines: anterior axillary, midclavicular and anterior median. The upper border of the liver is determined by percussing from top to bottom along the linea axillaris anterior dextra until a clear lung sound passes into a dull (hepatic) sound, normally on the IV-VII rib. Along linea medioclavicularis dextra on the 5th-6th rib. The upper border of the liver along the anterior midline is determined approximately - it is located at the level of continuation along the corresponding intercostal space of the upper border of the liver, determined along the midclavicular line. The lower border of the liver is determined along the same lines. The finger-plessimeter is placed parallel to the borders of the liver, percussed in the direction from a clear sound to a dull one, from bottom to top. The distance between the upper and lower borders of the liver is measured along all 3 lines.

In young children, the upper edge of the liver is determined by the method quiet percussion, and the bottom is better defined by palpation along the indicated lines. And if the lower edge is not palpable, then it is determined by percussion. As already noted, depending on age, the lower edge of the liver in children can protrude along the midclavicular line 1-2 cm below the edge of the costal arch, and along the anterior midline it does not go beyond the upper third of the line connecting the xiphoid process with the navel.

For a more accurate control of changes in the size of the liver in dynamics, in children from 5-7 years of age, the method for determining the size of the liver according to Kurlov is used.

Percussion of the borders of the liver and measurement of its size according to Kurlov is carried out along three lines:

• along the midclavicular from above to the upper border of the liver, which in children is located on the V-VI rib, below the level of the navel (or lower) towards the costal arch;
• along the anterior midline - from above to the upper border of the liver, which is located at the beginning of the xiphoid process and from below from the navel up to the upper third of the distance from the end of the xiphoid process to the navel;
• along the oblique line - the left costal arch, percussing along it from bottom to top from the left midclavicular line towards the sternum.

The record of the liver measurement results looks like this: 9x8x7 ± 1cm. Depending on the age of the child, the size of the liver may be smaller and the main guidelines should be the upper limit - 5-6 ribs and the lower limit - the costal arch.

With various diseases, the dynamics of the size of the liver changes. So, with right-sided exudative pleurisy, the lower edge of the liver shifts down, and with flatulence, ascites - up.

Percussion can reveal the following pathological symptoms:

• symptom of Ortner-Grekov - tapping with the edge of the palm along the right costal arch is painful with damage to the gallbladder or liver;
• Mendel's symptom tapping on the anterior surface of the abdomen in the epigastric region. The patient should take a deep breath through the abdominal type in order to bring the stomach closer and make it more accessible for examination. Mendel's symptom allows you to topographically determine the location of a stomach ulcer, if any;
• Frenkel's sign nausea and back pain during percussion of the xiphoid process of the sternum (positive for acute cholecystitis, gastritis, peptic ulcer).

It is also necessary to conduct a study to detect the presence of free fluid in the abdominal cavity. Palpation determine the free fluid in the abdominal cavity using undulation. To do this, the left hand is placed flat on the lateral surface of the abdominal wall on the right, and with the fingers of the right hand, a short blow is applied to the abdominal wall on the other side. This impact causes fluctuations in the fluid, which are transmitted to the other side and perceived by the left hand in the form of a so-called wave. In order to make sure that the wave is transmitted along the fluid and not along the abdominal wall or intestinal loops, it is recommended that the physician assistant place the palm of the hand edge on the middle of the abdomen and lightly press, this technique eliminates the transmission of the wave along the abdominal wall or intestines.

Percussion can also determine the presence of fluid in the abdominal cavity. To do this, a sick child is placed on his back. Percussion is carried out along the anterior abdominal wall in the direction from the navel to the lateral parts of the abdomen (flanks). The study is conducted using mediocre percussion. The plessimeter finger is located parallel to the white line of the abdomen in the navel and gradually moves to the flanks, first to the right, then to the left, while percussion is applied to the plessimeter with the middle finger of the right hand. The presence of bilateral shortening in the area of ​​the flanks may indicate the presence of free fluid in the abdominal cavity.

For differential diagnosis of ascites and dullness in the abdominal cavity due to other causes (full intestine, tumor, etc.), it is necessary to turn the child on his side and percussion of the abdomen in the same sequence. If the bluntness in the superior flank disappears, one can think of fluid in the abdominal cavity, if it remains, the shortening is due to another reason.

On auscultation of the abdomen in a healthy child, intestinal peristalsis can be heard, the intensity of these sound phenomena is low. With pathology, sound phenomena can increase or decrease and disappear.

With help mixed method research - auscultation and percussion (auscultafriction) can determine the boundaries of the stomach. The stethoscope is placed in the epigastric region - the region of the stomach and stroking with one finger from top to bottom along the white line of the abdomen from the xiphoid process to the navel. In the region of the stomach, the audibility of sound in the stethoscope increases sharply. The zone of best listening corresponds to the borders of the stomach.

Diagnostic value has a method of examination of the stomach, called "splash noise". Its essence is that when the stomach is shaken, where air and liquid are simultaneously located, a kind of noise occurs. When blows are applied to the area where there is no stomach, the splashing noise will stop. This technique before x-ray examination allows you to diagnose gastroptosis.

Features of laboratory and instrumental examination of the gastrointestinal tract. The volume of the necessary laboratory and instrumental examination is determined individually, taking into account the nature of the alleged disease. When studying the esophagogastroduodenal zone, various methods are used.

Fractional sounding of the stomach - continuous aspiration of fasting, basal and stimulated (histamine 0.008 mg/kg, pentagastrin 6 μg/kg) gastric secretions with an assessment of volume, titration acidity and calculation of debit-hour. Fractional study of gastric juice is performed on an empty stomach. They take a probe (the size depends on the age of the child), measure the length from the corner of the mouth to the navel (plus 1 cm), make a mark. The child is helped to swallow the tube. Immediately after swallowing, they begin to suck out gastric juice. First, the entire contents of the stomach are sucked off - an empty stomach or "O" portion. Then the juice is slowly sucked off for one hour: 4 servings every 15 minutes. This is the basal secretion. At the end of the hour, a 0.1% histamine solution or a 0.25% petagastrin solution is injected subcutaneously (as an irritant). After 5 minutes, again for 1 hour, 4 portions are aspirated every 15 minutes and stimulated secretion is obtained. Thus, 9 servings are sent to the laboratory, where they are filtered and titrated with 0.1% sodium hydroxide solution in the presence of indicators to determine the concentration of hydrogen ions and the acid-forming function of the stomach. The method for studying the enzyme-forming function of the stomach is based on determining the proteolytic activity of gastric contents in relation to the protein substrate. Indicators of gastric secretion are given in table. 24.

Table 24 Normal indicators of gastric secretion in children older than 5 years

Indicators	Basal	Stimulated with meat broth	stimulated by pentagastrin
Volume (ml/h)
Free hydrochloric acid (titr units)
Total acidity (titer units)
Acid production (debit-hour HCl)
pH of the body of the stomach / alkaline time (min.)
antrum pH				Various quantity
Mucus, epithelium, worm eggs	Missing
Leukocytes	Single

Changes in the coprogram make it possible to identify a number of coprological syndromes (Table 28).

Table 28 Coprological syndromes in children

	Data of macro- and microscopy of feces
Gastrogenic	Unaltered muscle fibers, intracellular starch, connective tissue
Pyloroduodenal	Unaltered muscle fibers, connective tissue, vegetable fiber
pancreatic insufficiency	Liquid, greasy yellow-gray stools, neutral fat, altered muscle fibers, extracellular starch
Insufficiency of bile secretion	The stools are grey. Soaps and crystals of fatty acids, no reaction to stercobilin
Enteral	Lots of epithelium, fatty acid crystals, extracellular starch
Ileocecal	Mucus, abundance of digestible fiber, starch grains, iodophilic flora
Kolitny	Mucus, leukocytes, erythrocytes, epithelium

D-xylose test - reflects the activity of absorption in the intestine, estimated by urinary excretion for 5 hours of D-xylose given through the mouth (norm: in children of the 1st year of life - more than 11%, in children older than a year - more than 15%).

Lactose- (sucrose-, maltose-, isomaltose-) tolerance test - detection of violations of the breakdown or absorption of products of hydrolysis of disaccharides by studying the dynamics of glycemia after an oral load of this disaccharide (at a dose of 50 g / m 2).

Hydrogen breath test - detection of a violation of the fermentation of carbohydrates in the intestine by an increase in the hydrogen content in the exhaled air of more than 0.1 ml / min.

Thin layer chromatography sugars in the urine allows you to determine the qualitative nature of mellituria;

Enterokinase activity in the contents of the small intestine - normally is 130-150 units / ml, if the production of the enzyme is disturbed, the indicator decreases.

Radioisotope method assessment of excretion of albumin labeled with iodine-31 with feces - normally, excretion is no more than 5% of the amount of the isotope taken, in case of malabsorption, the indicator increases.

Daily excretion of fat with feces (according to Van de Kamer ) - against the background of taking 80 - 100 g of fat per day, normal excretion does not exceed 3 g; with violations of hydrolysis and absorption, the excretion of fat increases.

Immunohistological and enzymohistological methods studies of biopsy specimens of the mucous membrane of the proximal small intestine.

Perfusion of the small intestine with carbohydrate solutions, protein and fat emulsions - detection of violations of the enzymatic cleavage of the substrate and violations of the absorption of the products of its hydrolysis.

Colonoscopy, sigmoidoscopy - endoscopy of the lower intestine: allows you to detect inflammatory and destructive changes, pathological formations of the mucous membrane, anomalies in the structure.

Irrigography - X-ray contrast study of the colon. Allows you to evaluate the relief of the mucous membrane, intestinal motility, identify abnormalities, tumors, etc.

Bacteriological examination of feces - assessment of the biocenosis of the colon, detection of dysbacteriosis.

The data of the anamnesis and survey allow to formulate the preliminary diagnosis. Based on the laboratory and instrumental results, a clinical diagnosis of the disease is established.

Importance of digestion.

Metabolism is a complex complex of various interdependent and interdependent processes that occur in the body from the moment these substances enter it and until the moment they are released. Metabolism is a necessary condition for life. It is one of its mandatory manifestations. For the normal functioning of the body, it is necessary to supply organic food material, mineral salts, water and oxygen from the external environment. For a period equal to the average life expectancy of a person, he consumes 1.3 tons of fat, 2.5 tons of proteins, 12.5 tons of carbohydrates and 75 tons of water. Metabolism consists of the processes of substances entering the body, their changes in the digestive tract, absorption, transformations inside cells and excretion of their decay products. The processes associated with the transformation of substances inside cells are called intracellular or intermediate metabolism. As a result of intracellular metabolism, hormones, enzymes and a wide variety of compounds are synthesized, which are used as a structural material for building cells and intercellular substance, which ensures the renewal and growth of a developing organism. The processes that result in the formation of living matter are called anabolism or assimilation. The other side of the metabolism is that the substances that form the living structure undergo splitting. This process of destruction of living matter is called catabolism or dissimilation. The processes of assimilation and dissimilation are very closely related, although they are opposite in their final results. Thus, it is known that the breakdown products of various substances contribute to their enhanced synthesis. Oxidation of cleavage products serves as a source of energy that the body constantly spends even in a state of complete rest. In this case, the same substances that are used for the synthesis of larger molecules can undergo oxidation. For example, in the liver, glycogen is synthesized from a part of the breakdown products of carbohydrates, and the energy for this synthesis is provided by another part of them, which is included in metabolic or metabolic processes. The processes of assimilation and dissimilation occur with the obligatory participation of enzymes.

The role of vitamins in nutrition

Vitamins were discovered at the turn of the 19th and 20th centuries as a result of studies of the role of various nutrients in the life of the body. The founder of vitaminology can be considered the Russian scientist N.I. Lunin, who in 1880 was the first to prove that in addition to proteins, fats, carbohydrates, water and minerals, some other substances are needed, without which the body cannot exist. These substances were called vitamins (vita + amin - "amines of life" from Latin), since the first vitamins isolated in their pure form contained an amino group in their composition. And although later it turned out that not all vitamin substances contain an amino group and nitrogen in general, the term "vitamin" has taken root in science.

According to the classical definition, vitamins are low molecular weight organic substances necessary for normal life that are not synthesized by an organism of a given species or are synthesized in an amount insufficient to ensure the life of the organism.

Vitamins are necessary for the normal course of almost all biochemical processes in our body. They provide the functions of the endocrine glands, that is, the production of hormones, increase mental and physical performance, support the body's resistance to the effects of adverse environmental factors (heat, cold, infections, and many others).

All vitamin substances are conditionally divided into vitamins proper and vitamin-like compounds, which are similar in their biological properties to vitamins, but are usually required in larger quantities. In addition, deficiency of vitamin-like substances is extremely rare, since their content in everyday food is such that even in the case of a very unbalanced diet, a person receives almost all of them in sufficient quantities.

According to their physical and chemical properties, vitamins are divided into two groups: fat-soluble and water-soluble. Each of the vitamins has a letter designation and a chemical name. In total, 12 true vitamins and 11 vitamin-like compounds are currently known.

At present, vitamins can be characterized as low-molecular organic compounds, which, being a necessary component of food, are present in it in extremely small quantities compared to its main components.

Vitamins are a necessary element of food for humans and a number of living organisms because they are not synthesized or some of them are synthesized in insufficient quantities by this organism. Vitamins are substances that ensure the normal course of biochemical and physiological processes in the body. They can be attributed to the group of biologically active compounds that have an effect on the metabolism in negligible concentrations.

Diseases of the gastrointestinal tract in children

Recently, there has been a significant increase in the number of diseases of the digestive system in children. Many factors contribute to this:

1. bad ecology,

2. unbalanced diet,

3. heredity.

Sweets and confectionery products with a high content of preservatives and artificial colors, fast food, carbonated drinks, so beloved by many, cause great harm to the child's body. The role of allergic reactions, neuropsychic factors, and neuroses is growing. Doctors note that intestinal diseases in children have two age peaks: at 5-6 years and at 9-11 years. The main pathological conditions are:

Constipation, diarrhea

Chronic and acute gastritis and gastroenteritis

Chronic duodenitis

Chronic enterocolitis

Peptic ulcer of the stomach and duodenum

· Chronic cholecystitis

· Chronic pancreatitis

Diseases of the biliary tract

Chronic and acute hepatitis

Of great importance in the occurrence and development of gastrointestinal diseases is the insufficient ability of the child's body to resist infections, since the child's immunity is still weak. The formation of immunity is greatly influenced by proper feeding in the first months of life.

The best option is breast milk, with which protective bodies are passed from mother to child, increasing the ability to resist various infections. Formula-fed babies are more susceptible to various diseases and have a weakened immune system. The cause of violations in the digestive system can be irregular feeding or overfeeding of the child, early introduction of complementary foods, non-compliance with hygiene standards.

A separate group consists of acute intestinal diseases in children (dysentery, salmonellosis). Their main clinical manifestations are dyspeptic disorders, dehydration (dehydration) of the body and symptoms of intoxication. Such manifestations are very dangerous and require immediate hospitalization of a sick child.

Intestinal infections are especially often diagnosed in childhood, this is due to the imperfection of protective mechanisms, the physiological characteristics of the digestive organs and the lack of sanitary and hygienic skills in children. Especially negative acute intestinal infections affect young children and can lead to a significant decrease in immunity, delayed physical development, and complications.

Their onset is accompanied by characteristic signs: a sharp increase in temperature, abdominal pain, diarrhea, vomiting, loss of appetite. The child becomes restless, or, on the contrary, lethargic and inhibited. The clinical picture largely depends on which parts of the intestine are affected. In any case, the child needs emergency medical care and antibiotic therapy.

The treatment of diseases of the digestive system in babies is handled by a pediatric gastroenterologist, it is he who should be contacted when unfavorable symptoms appear.

Age features of the digestive system in children and adolescents.

The most significant morphological and functional differences between the digestive organs of an adult and a child are observed only in the first years of postnatal development. The functional activity of the salivary glands is manifested with the appearance of milk teeth (from 5-6 months). A particularly significant increase in salivation occurs at the end of the first year of life. During the first two years, the formation of milk teeth is intensively going on. At the age of 2-2.5 years, the child already has 20 teeth and can eat relatively coarse food that requires chewing. In subsequent years, starting from the age of 5-6, milk teeth are gradually replaced by permanent ones. In the first years of postnatal development, the formation of other digestive organs is intensively going on: the esophagus, stomach, small and large intestines, liver and pancreas. Their size, shape and functional activity change. Thus, the volume of the stomach from birth to 1 year increases 10 times. The shape of the stomach in a newborn is round, after 1.5 years the stomach becomes pear-shaped, and from 6-7 years old its shape is no different from the stomach of adults. The structure of the muscular layer and the mucous membrane of the stomach changes significantly. In young children, there is a weak development of muscles and elastic elements of the stomach. The gastric glands in the first years of a child's life are still underdeveloped and few in number, although they are able to secrete gastric juice, in which the content of hydrochloric acid, the number and functional activity of enzymes are much lower than in an adult. So, the number of enzymes that break down proteins increases from 1.5 to 3 years, then at 5-6 years and at school age up to 12-14 years. The content of hydrochloric acid increases up to 15-16 years. A low concentration of hydrochloric acid causes weak bactericidal properties of gastric juice in children under 6-7 years of age, which contributes to an easier susceptibility of children of this age to gastrointestinal infections. In the process of development of children and adolescents, the activity of the enzymes contained in it also changes significantly. The activity of the enzyme chymosin, which acts on milk proteins, changes especially significantly in the first year of life. In a child of 1-2 months, its activity in conventional units is 16-32, and in 1 year it can reach 500 units, in adults this enzyme completely loses its significance in digestion. With age, the activity of other enzymes of gastric juice also increases, and at senior school age it reaches the level of an adult organism. It should be noted that in children under 10 years of age, absorption processes are actively going on in the stomach, while in adults these processes are carried out mainly only in the small intestine. The pancreas develops most intensively up to 1 year and at 5-6 years. According to its morphological and functional parameters, it reaches the level of an adult organism by the end of adolescence (at the age of 11-13, its morphological development is completed, and at the age of 15-16, its functional development). Similar rates of morphofunctional development are observed in the liver and all parts of the intestine. Thus, the development of the digestive organs goes in parallel with the general physical development of children and adolescents. The most intensive growth and functional development of the digestive organs is observed in the 1st year of postnatal life, in preschool age and in adolescence, when the digestive organs in their morphological and functional properties approach the level of an adult organism. In addition, in the course of life, children and adolescents easily develop conditioned food reflexes, in particular, reflexes at the time of eating. In this regard, it is important to accustom children to strict adherence to the diet. Important for normal digestion is the observance of "food aesthetics".

43. Age features of the structure of the digestive organs in children.

The development of the digestive organs in children occurs in parallel with the development of the whole organism. And this development is divided into periods of the first year of life, preschool age and adolescence. At this time, the work of the digestive organs is controlled by the nervous system and depends on the state of the cerebral cortex. In the process of the formation of the digestive system in children, reflexes are easily developed for the time of eating, its composition and quantity. The esophagus in young children has the shape of a spindle. It is short and narrow. In children in the year of life, its length is 12 cm. There are no glands on the mucosa of the esophagus. Its walls are thin, but it is well supplied with blood. The stomach in young children is located horizontally. And as the child develops, he takes a vertical position. By the age of 7-10, the stomach is already positioned as in adults. The gastric mucosa is thick, and the barrier activity of gastric juice is low compared to adults. The main enzyme of gastric juice is rennet. It provides curdling of milk. The pancreas of a young child is small. In a newborn, it is 5-6 centimeters. In 10 years, it will triple in size. This organ is well supplied with blood vessels. The pancreas produces pancreatic juice. The largest organ of the digestive system of a young child, occupying a third of the abdominal cavity, is the liver. At 11 months, its mass doubles, by 2-3 years it triples. The capabilities of the liver of a child at this age are low. The gallbladder at an early age reaches a size of 3 centimeters. It acquires a pear-shaped form by 7 months. Already at 2 years old, the child's gallbladder reaches the edge of the liver. For children up to a year, substances that come with mother's milk are of great importance. With the introduction of complementary foods to the child, the mechanisms of the child's enzyme systems are activated.

Importance of digestion.

The body needs a regular supply of food. Food contains nutrients: proteins, carbohydrates and fats. In addition, the composition of food includes water, mineral salts and vitamins. Nutrients are necessary for building the living matter of body tissues and serve as a source of energy, due to which all vital processes are performed (muscle contractions, heart function, nervous activity, etc.). In short, nutrients are plastic and energy material for the body. Water, mineral salts and vitamins are not nutrients and a source of energy, but are part of cells and tissues and participate in various life processes. Proteins, carbohydrates and fats in food are complex organic substances and are not absorbed by the body in this form. In the digestive canal, food is subjected to mechanical and chemical influences, as a result of which nutrients are broken down into simpler and more water-soluble substances that are absorbed into the blood or lymph and absorbed by the body. This process of processing food in the alimentary canal is called digestion. Mechanical processing of food consists in its crushing and grinding, which contributes to mixing with digestive juices (food liquefaction) and subsequent chemical processing. Chemical processing - the breakdown of complex substances into simpler ones - occurs under the influence of special substances contained in digestive juices - digestive enzymes. Water, mineral salts and vitamins are not subjected to special treatment in the digestive canal and are absorbed in the form in which they arrive.

44. Neurohumoral regulation of the digestive system.

45. Importance of metabolism and energy.

In newborns, the gastrointestinal tract is adapted for the digestion and assimilation of mother's milk. The esophagus is already formed by birth. The entrance to the esophagus is located at the level of the VI-VII vertebrae. The esophagus is short, and the anatomical narrowing of the esophagus is weakly expressed. The smaller the child, the worse developed the cardiac sphincter, which is located above the level of the diaphragm. Only by the age of 8 is the cardiac section formed as in an adult - below the diaphragm. Therefore, children in the first months of life often regurgitate food. They also have not formed the muscular part of the esophagus, it matures later, which is associated with the intake of thicker food.

The stomach in young children is adapted to receive human milk. Its capacity after birth increases rapidly: from approximately 10 ml on the first day of life to 40-50 ml by the 4th day of life and up to 80 ml by the 10th day. In the future, its volume increases by 25 ml every month. On this basis

P. F. Filatov proposed a formula for calculating the volume of a single meal for infants:

V - 30 ml + 30 ml * n, where n is the number of months of a child's life.

By the end of the 1st year of life, the volume of the stomach increases to 250 ml, by 3 years - up to 400-600, by 10-15 years - up to 1300-1500 ml.

The pyloric section of the stomach in children of the first months of life is functionally well developed, and with insufficiently developed cardia, this also contributes to regurgitation and vomiting. Therefore, to prevent spitting up, children are placed in bed with their heads high or laid on their stomachs.

The mucous membrane of the stomach in children is relatively thick. With age, the number of gastric pits gradually increases, into which the openings of the gastric glands open.

The functional epithelium of the stomach (main and parietal cells) in a child develops with age as enteral nutrition increases. By adulthood, the number of gastric glands increases 25 times compared to the neonatal period.

In a newborn, the length of the entire intestine in relation to the length of the body is greater than in older children and adults. The ratio of intestinal length to body length in newborns is 8.3:1; in the first year of life 7.6:1; at 16 years old 6.6:1; in adults 5.4:1.

The length of the small intestine in a child of the first year of life is 1.2 - 2.8 m. In terms of 1 kg of weight, the child has 1 m of the small intestine, and in an adult only 10 cm. This is due to the adaptation of the child to lactotrophic nutrition, when digestion mostly wall.

The area of ​​​​the inner surface of the small intestine in children in the first week of life is approximately 85 cm 2 (40-144 cm 2), and in adults - 3.3 * 103 cm 2. The surface area increases due to the development of functional epithelium and microvilli, which increase the area of ​​the small intestine by 20 times. The surface area of ​​the small intestine decreases from the proximal (head) to the distal (away from the head) part of the intestine. The small intestine is divided into three sections. The first is the duodenum (duodenum). Its length in a newborn is 7.5-10 cm, in an adult - 24-30 cm. The duodenum has a number of sphincters (pulps). The first sphincter is bulboduodenal, the second is medioduodenal (Kapanji) and the third is Okener. The main function of the sphincters is to create areas of low pressure where food comes in contact with the pancreas. Then come the second and third sections - the jejunum and ileum. The jejunum occupies approximately 2/5 of the length of the intestine from the duodenum to the ileocecal valve, and the ileum the remaining 3/5.

Digestion of food and absorption of its ingredients take place in the small intestine. The intestinal mucosa is very thin, richly vascularized, epithelial cells are rapidly renewed. Circular folds are initially found only at the beginning of the small intestine, with age they also appear in the distal sections.

Intestinal glands in children are larger than in adults. Lymphoid tissue and its sprouts are scattered throughout the intestine. Only with age, Peyer's patches begin to form. In the small intestine of children, the lymphatic system is well developed.

The large intestine consists of sections and develops after birth. So, ribbons (tenia coli) in newborns are poorly expressed, haustras are absent up to 6 months. There is no complete filling of the colon in the right iliac region. In children under 4 years of age, the ascending colon is longer than the descending colon. Only after 4 years the structure of the large intestine is the same as in adults.

The caecum in children is located above the right iliac fossa, so the ascending knee of the colon in children is often undeveloped. The mesentery of this organ is mobile. Only by the end of the first year does the formation of the caecum come to an end. The appendix in children is relatively long, located higher than in adults, there are no sphincters in it, and the muscular layer is poorly developed. Lymph nodes in the appendix mature only by 10-14 years.

The colon in children in the form of a rim goes around the loops of the small intestine. Its ascending part in newborns is short. After a year, its size increases.

Next comes the transverse part of the large intestine. By the year, its length is 23-28 cm, by the age of 10 it increases to 35 cm. The descending part is narrower than the previous sections, with age it grows in length.

The sigmoid, or S-shaped, intestine in newborns is long and mobile. With age, its growth continues. In young children, it is located in the abdominal cavity (due to underdevelopment of the small pelvis), only from the age of 5 it is located in the small pelvis.

The rectum in children of the first months of life is relatively long. In newborns, the rectal ampulla is not developed, the anal columns and sinuses are not formed, and the surrounding fatty tissue is poorly developed. The rectum occupies its final position by two years of age. Therefore, in young children, prolapse of the rectal mucosa easily occurs, which is facilitated by a poorly developed muscular layer of the rectum.

In children, as in adults, the secretion of juice in the large intestine is small, but it increases sharply with mechanical irritation of the intestine. In the large intestine, absorption mainly occurs and feces are formed. Functionally, all digestive organs are interconnected.

The pancreas in newborns is not completely formed either anatomically or functionally. In the process of growth, its size increases, the activity of secreted enzymes increases, and exocrine function develops.

The liver in a newborn is one of the largest organs. In young children, it occupies 1/3-1/2 of the volume of the abdominal cavity. With age, the relative size of the liver increases even more. So, by 11 months, its mass doubles, by 2-3 years it triples, by 7-8 years it increases by 5 times, by 16-17 years - by 10 times, by 20-30 years by 13 times. Due to the large size in children under 5-7 years old, the liver comes out from under the costal margin by 2-3 cm. From the age of 7, the lower edge of the liver remains within the costal arch.

After birth, there is a further formation of the functional unit of the liver - liver lobules. With age, it begins to resemble a limited hexagon.

The gallbladder in newborns is usually covered by the liver. Therefore, its palpation is impossible. The main function is the accumulation and secretion of hepatic bile. It is usually pear-shaped or cylindrical in shape, but may be fusiform (S-shaped). With age, the size of the gallbladder increases. Its function changes - it begins to secrete bile of a different composition than at a younger age. The cystic duct merges with the hepatic duct at the level of the gallbladder neck to form the common bile duct, which increases in length with age.

The development and activity of the gastrointestinal tract are determined to a greater extent by hormones produced in the duodenum. In addition, they affect the autonomic nervous system and the endocrine apparatus of the child. More than 20 gastrointestinal hormones have been described so far.

So, gastrin and enteroglucagon contribute to the development and differentiation of the mucous membrane, cholecystokinin and pancreatic polypeptide - to the development of the endocrine function of the pancreas. There is a connection between the hormonal activity of the gastrointestinal tract and the hormonal activity of the brain, carried out by neuropeptides that are involved in the mechanism of imprinting and memory.

Features of digestion in children

A newborn baby feeds on mother's milk. The mechanisms of regulation and functioning of lactotrophic nutrition are activated immediately after the first attachment of the child to the breast. Since the newborn begins to receive liquid food, his salivary glands are just beginning to function. With age, the salivary and enzyme-forming functions of the salivary glands begin to increase. So, salivation in a newborn on an empty stomach is 0.01-0.1 ml / min, and when sucking - 0.4 ml / min. The activity of α-amylase in saliva in newborns is low, but by the age of 2 it reaches its highest activity. When breastfeeding, the baby receives most of the enzymes from mother's milk. In addition to α-lactase, milk also contains lipase, which breaks down fat. In the stomach of an infant, 1/3 of women's milk is hydrolyzed. Other enzymes are also found in milk and are activated in the child's gastrointestinal tract.

Enzyme-forming function of the pancreas in young children is low. The activity of its enzymes is sufficient to break down mother's milk. The activity of pancreatic enzymes increases by 5-6 months, i.e. by the time of the introduction of complementary foods. If the child is bottle-fed, then the enzymatic activity of the pancreas increases faster than breast-fed, but in the future this may cause inhibition of the enzymatic function of the pancreas. By the age of 4-5, the activity of all enzymes of the gastrointestinal tract increases. So, in the stomach, the activity of pepsin increases, in the small intestine - pancreatic enzymes: trypsin, chymotrypsin, lipase, amylase, phospholipase, intestinal enzymes, including disaccharidases.

The liver in children in the age aspect is included in digestion gradually, for example, the secretion of bile acids increases with time. Therefore, the smaller the child, the more fatty acids, soaps, neutral fat in his feces.

With age, membrane digestion also develops in the intestine. Intracellular digestion is better developed in young children (due to pinocytosis). This, in particular, is associated with a high frequency of allergic dermatoses in artificially fed children, which occurs due to the ingestion of cow's milk protein, which is an allergen.

For a child in the first days and weeks of life, the autolytic process that occurs in human milk is important, in which nutrients are hydrolyzed at the expense of substances contained in human milk itself. Only gradually, with the introduction of complementary foods, the mechanisms of their own enzyme systems are activated.

In young children, the absorption of food ingredients has features. So, especially lactoglobulins, practically in an unchanged state penetrate into the blood. Caseinogen is first curdled under the influence of the enzyme chymosin (rennet) in the stomach. Further, in the proximal small intestine, it begins to break down into peptides and amino acids, which are activated and absorbed. Part of the peptides is absorbed by pinocytosis. Therefore, when feeding with artificial mixtures in young children, sensitization to cow's milk easily occurs.

Digestion of fat also depends on the type of feeding. Human milk contains short chain fats (C12). Cow's milk mainly contains long-chain fats, which must be broken down not by autolytic, but by pancreatic lipase in the presence of bile acids. In children, the lipolytic function of the pancreas is low.

Absorption of fat occurs in the proximal and middle sections of the small intestine. Hydrolysis of milk sugar (lactose) in children occurs in the area of ​​the brush border of the intestinal epithelium. Human milk contains β-lactose, while cow's milk contains α-lactose. Therefore, with artificial feeding, the carbohydrate composition of food changes, and the child must adapt to this. Up to 30% of children have transient lactase deficiency. This is associated with a large number of diarrhea in mixtures containing β-lactose.

The absorption of vitamins occurs in the small intestine, but in a child in the first weeks and months of life, all parts of the small intestine take part in the absorption of food ingredients. Only With age, there is a shift in absorption, mainly to the proximal sections.

Examination of the digestive organs

An anamnesis of diseases of the digestive system is collected from the words of both the child and his relatives caring for him.

The first thing they ask is if there is pain in the abdomen; and if the child differentiates them, then what is their character - blunt or sharp. They find out the dependence of their appearance on the time of eating, the connection with defecation.

The next question is about the localization of pain. If young children do not localize pain, then children after 3-5 years begin to localize pain. Abdominal pain can also be psychogenic and associated with kidney disease.

The third question is about the nature of the pain syndrome. Pain can be paroxysmal, constant, stabbing, dull, aching. In young children, abdominal pain may be manifested by general anxiety, while the child "knocks" his legs. Most often this is due to increased gas formation in the intestines, therefore, after the passage of gases, children calm down.

Pain is an integrative function of the body, mobilizing a variety of functional systems to protect against a harmful factor.

The following symptoms that a sick child or his parents are asked about are dyspeptic: belching and regurgitation, nausea and vomiting, heartburn, decreased or increased appetite, hiccups. Then they find out if there are diarrhea, constipation, unstable stool (constipation replaces diarrhea), flatulence, rumbling.

Researches of a pancreas are made for the purpose of studying exocrine and endocrine functions. For this, enzyme activity, secretion volume, bicarbonate capacity are studied in pancreatic juice. Along with this, the rate of hydrolysis by pancreatic enzymes is studied using radiocapsules. Often examine the enzymes of the pancreas in the blood.

Biochemical methods examine the content of bilirubin and its fractions, the protein-forming function of the liver.