The gastrointestinal tract is formed in the newborn. Diseases of the gastrointestinal tract in newborns, treatment. Motor function of the gastrointestinal tract in young children

The digestive system begins to form very early - already from the 7-8th day of intrauterine development of the fetus, so by the time of birth it is already a fairly mature system. But, despite this, the digestive system is adapted only to the assimilation of breast milk or special nutritional mixtures, and in no case food consumed by an adult. In terms of its components, the digestive system of a child does not differ from that of an adult. It includes the gastrointestinal tract directly and includes the oral cavity, pharynx, esophagus, stomach, кишечник!} and digestive Specialized organs or a group of cells that synthesize and secrete substances - secrets. Depending on the place of secretion, there are endocrine glands (endocrine), which do not have special excretory ducts and secrete the substances they produce - hormones - directly into the blood or lymph, and external secretion glands (exocrine), which have excretory ducts through which the secret is excreted either on the surface of the body (sweat, lacrimal, milk), or in hollow organs (for example, in the gastrointestinal tract and genitourinary system).

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip5" id="jqeasytooltip5" title=" (!LANG:Glands">железы!}, which form and secrete active substances that digest the nutrients that enter the body.

The wall of the organs of the gastrointestinal tract is formed by three components: internal - Mucous membrane. Razg. A thin membrane lining the inner surface of the hollow organs of animals and humans (for example, the stomach, ureters, paranasal sinuses, etc.) and moistened by the secretion of the glands.

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip16" id="jqeasytooltip16" title=" (!LANG:Mucosa">слизистая оболочка , средняя - мышечный слой и наружная - се­розная оболочка. Несмотря на кажущуюся общность строения, пище­варительная система ребенка очень сильно отличается от пищеварительной системы взрослого человека.!}

After birth, the child feeds only on mother's milk or a mixture during the act of sucking due to the peculiarities of the structure of the oral cavity. The oral cavity of a child is very small compared to that of an adult, and most of it is occupied by the tongue. The tongue is relatively large, short, wide and thick.

The muscles of the cheeks and lips are very well developed, in addition, the presence of dense fatty lumps (bish fat lumps) in the cheeks makes them look plump or even thick. On the gums, as well as on the cheeks, there are dense areas resembling the appearance of rollers. It is thanks to this structure of the oral cavity of the infant that the process of sucking becomes possible.

The inner surface of the oral cavity is covered with a mucous membrane, which also has its own characteristics: it is very delicate, easily injured and richly supplied with blood vessels. Up to 3-4 months of age слюнные железы!} the child is not yet sufficiently developed, which causes some dryness of the mucous membrane, but after this age Selection. 1. The release of the human or animal body from the end products of metabolism (eg carbon dioxide, urea), excess water, or salts and organic. Comm., received in the body with food or formed in the body; necessary to maintain homeostasis; in humans it is carried out through the kidneys, lungs, skin, digestion. tract. Synonym: excretion. 2. End products of metabolism, foreign substances and excess water, salts, etc., from which the body is released through the excretory system, for example, urine, feces, sweat, etc. Syn.: excreta.

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip20" id="jqeasytooltip20" title=" (!LANG:Select">выделение!} saliva increases significantly, so much so that the child simply does not have time to swallow it, and it flows out.

The structural features of the esophagus in children are as follows: it is short, narrow and highly located.

The esophagus in a newborn begins at the level of the III-IV cervical vertebrae, by the age of 2 years it reaches the IV-V cervical vertebrae, and by the age of 12 it is at the level of the VI-VII vertebrae, that is, it has the same location as in adults. The length and width of the esophagus also increase with age, and if in an infant it is 10-12 cm, and the width is 5 cm, then by the age of 5 the esophagus lengthens to 16 cm and expands to 1.5 cm. The esophagus is very well supplied with blood, but its muscular layer is poorly developed. The stomach of the child also has its own characteristics. First of all, the location of the stomach itself changes with age. If in newborns it is horizontal, then by the age of 1-1.5 years, when the child begins to walk, it is located more vertically. Of course, with age, the volume of the stomach also increases: from 30-35 ml at birth to 1000 ml by 8 years. Mothers are well aware that infants very often swallow air and spit up, but few people know that these processes are also due to the peculiarities of the structure of the stomach, or rather, the place where the esophagus passes into the stomach: the entrance to the stomach closes the muscle roller, the excessive development of which does not allow food to quickly enter the stomach and make regurgitation possible.

The inner mucous layer of the stomach is well supplied with blood, as it contains a huge number of blood vessels. The development of the muscle layer is inhibited, it remains underdeveloped for a long time. The stomach glands are underdeveloped, and their number is significantly inferior to the number of glands in an adult, which leads to a low content of gastric digestive juice in children of the first month of life and a decrease in its acidity. However, despite the small digestive activity, the gastric juice contains a sufficient amount of a substance that breaks down the components of breast milk well. However, by the age of 2, the child's stomach becomes, in terms of its structural and physiological features, almost the same as in an adult.

Iron begins to grow most intensively in adolescence.

The pancreas is practically undivided into lobules, but by the age of 10-12, the boundaries become clearly visible.

The liver, like many other organs of newborns, is functionally immature, even though it is relatively large and protrudes from under the edge of the right costal arch by 1-2 cm. For example, in newborns, the liver is 4% of body weight, while in adults - only 2%. I Just like the pancreas, the liver acquires a lobed structure only by 1-2 years. By the age of 7, the lower edge of the liver is already at the level of the costal arch, and by the age of 8, its structure corresponds to that of an adult. The main role of the liver for the body is education. Also, most of the substances absorbed in the intestine are neutralized in the liver, nutrients accumulate (a complex polysaccharide, the molecules of which are built from glucose residues. It is a rapidly mobilized energy reserve of living organisms, it accumulates mainly in the liver and muscles. Glycogen breakdown - glycogenolysis - is carried out in several ways , and in the liver a significant part of it is hydrolyzed with the formation of free glucose entering the blood.

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip4" id="jqeasytooltip4" title=" (!LANG:Glycogen">гликоген) и образуется !} желчь!}, which in turn is involved in the digestion of food. As the child grows older and a variety of foods are introduced into his diet, the amount of bile secreted gradually increases. Another component of the digestive system is the intestines. The intestine consists of the small and large intestines.

The main functions of the small intestine are the digestion of proteins, carbohydrates and, as well as the absorption of substances necessary for the body obtained from them, however, in children, it remains immature for a long time, and therefore does not work well. In addition, the small intestine in children occupies a non-permanent

position, which is determined by the degree of its filling and relatively longer length than that of an adult.

The large intestine also remains immature at birth. During the first 12-24 hours after birth, the child's intestines remain sterile, but after 4-5 days through the Mouth, mouth; m. (pl. mouths, mouths, mouths). Biol. Entrance to the alimentary canal in women and humans

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip12" id="jqeasytooltip12" title=" (!LANG:Mouth">рот , верхние дыхательные пути и прямую кишку в кишечник попадают различные !} Kingdom microscopic., preim. unicellular, aerobic and anaerobic organisms related to prokaryotes; have different shape: rod-shaped (bacilli), spherical (cocci), spiral (spirochetes, spirilla, vibrios), star-shaped and annular; are immobile or can move with the help of flagella; some B. form spores to wait out unfavorable conditions; distributed everywhere - in water, air, soil

" data-tipmaxwidth="500" data-tiptheme="tipthemeflatdarklight" data-tipdelayclose="1000" data-tipeventout="mouseout" data-tipmouseleave="false" class="jqeasytooltip jqeasytooltip19" id="jqeasytooltip19" title=" (!LANG:Bacteria">бактерии!} such as bifidum bacteria, lactobacilli and a small amount of Escherichia coli. The colonization of the intestines with bacteria leads to improved digestion of food and education.

Common features of the intestine in infants and young children are its increased permeability, underdevelopment of the muscle layer and innervation, rich blood supply and increased vulnerability. Due to the fact that the muscle cells in the child's body are poorly trained, food moves slowly through the gastrointestinal tract.

The frequency of defecation acts in a newborn child is equal to the frequency of feeding and is 6-7 times a day, in an infant - 4-5, in a child of the second half of life - 2-3 times a day. By the age of two, the frequency of bowel movements becomes the same as that of an adult: 1-2 times a day.

Introduction: Congenital malformations of the gastrointestinal tract are one of the most difficult problems of neonatology and related specialties of pediatric surgery, resuscitation, intensive care, etc. Their prevalence is very uneven and, according to WHO, ranges from 3.1 to 20 per 1000 newborns. Over the past decades, significant progress has been made in the diagnosis and treatment of these diseases. The most important in clinical practice are malformations of the esophagus, stomach, duodenum and small intestine.

Intestinal development Surgical diseases of the gastrointestinal tract and other abdominal organs often create great diagnostic difficulties, especially in young children. In order to facilitate the diagnosis, it is recommended to be guided by a clear examination plan. As an example, we give the recommendation of I. M. Berkovich and M. B. Kossyura for examining the digestive tract. Such examinations are carried out, whenever possible, for specific indications. Anomalies in the development of the digestive tract are relatively frequent and account for about 1/3 of the total number of anomalies. The first period until the 8th week of embryonic development. Until the 5th week of development, the intestine is located in the sagittal plane on the primary dorsal mesentery; grows faster than the abdominal cavity and enters the umbilical cord in the form of a temporary physiological umbilical hernia. Subsequently, the conglomerate of intestinal loops rotates to the left, the loops of the small and large intestines grow in length, the growing sections of the intestine are displaced relative to each other and relative to the walls of the body, and fusion occurs, fixing the results of rotation, growth and displacement of the intestines. The first period ends on the 8th week by turning the midgut counterclockwise by 90° and moving from the sagittal to the horizontal plane. The second period until the completion of the rotation of the intestine. The abdominal cavity grows in the sagittal direction, and by the 10th week, part of the intestinal loops is self-reset; the counterclockwise rotation continues up to 180 °, the caecum is in the epigastric region. With further rotation up to 270°, the cecum passes into the right upper quadrant, is located under the superior mesenteric artery, and the large intestine is in front. The third period, the caecum descends into the right iliac region, the small intestine is not yet fixed to the posterior wall of the abdominal cavity. The fourth period is followed by the attachment of the intestine to the posterior abdominal wall. The mesentery of the small intestine fuses along a line starting in the upper left quadrant just above the superior mesenteric artery and going obliquely down to the lower right quadrant. Violations that occur in certain periods of development: in the first period, a hernia of the umbilical cord; in the II period, violation of the rotation of the intestine; in the III period, the high position of the caecum, the location of the process behind the caecum; in the IV period, insufficient (narrow) attachment of the mesentery of the small intestine, "common mesentery", mobile caecum. Bowel rotation stops after the first 90° counterclockwise rotation. The small intestine is located on the right, the blind and ascending colon on the left. Stop after turning 180° counterclockwise, or so-called malrotation I. The lower part of the duodenum passes under the root of the mesentery, the caecum and ascending colon are located in the midline, anterior to the duodenum or to the right, next to the spine. After a normal rotation of 00° counterclockwise, further rotation is in the opposite direction, i.e. clockwise, by 90180°. The lower part of the duodenum is located in front of the mesentery malrotation P. Lyadd's syndrome: congenital volvulus of the midgut and compression of the duodenal lumen by peritoneal bands or the caecum passing across the duodenum. Violation of the rotation of the stomach and duodenum: occurs both in the usual (counterclockwise) and in the opposite direction.

Congenital obstruction of the gastrointestinal tract - a violation of the motor-evacuation function of the stomach and intestines, due to congenital malformations, mainly manifests itself in newborns. According to the causes of congenital obstruction of the gastrointestinal tract, anomalies of the gastrointestinal tract are classified as follows: 1. Disadvantages of the digestive tube. 2. Disadvantages of the wall of the digestive canal. 3. Violation of the rotation of the intestine. 4. Other anomalies leading to impaired patency of the gastrointestinal tract (annular or horseshoe-shaped pancreas; aberrant vessels, tumors, cysts; congenital malformations of the vitelline duct; cystofibrosis of the pancreas (due to the fact that it is accompanied by meconium ileus). According to the mechanism, congenital obstruction of the gastrointestinal tract is divided into external and internal stenosis, downstream into acute, subacute, chronic ileus, according to the degree of violation of the patency of the intestinal tube into complete and partial ileus. small intestine) and low (obstruction of the derivatives of the middle and posterior intestines from the initial sections of the small intestine).

Pyloric stenosis Pyloric stenosis is one of the most common causes of vomiting in newborns. A relationship was noted between the frequency of cases and the consanguinity of the parents. Family - hereditary predisposition was revealed in 6.9%, predominant (4:1) disease of males was established. The defect develops in the early stages of embryogenesis (week 67) due to excessive laying of the muscles of the pyloric part of the stomach and a violation of the parasympathetic innervation of this area. The severity and time of onset of symptoms of pyloric stenosis are determined by the degree of narrowing of the pylorus and the compensatory capabilities of the child's stomach. Clinical manifestations of the disease usually occur at 3-4 weeks of life. Vomiting "fountain" appears after almost every feeding. The volume of vomit exceeds the volume of the last feeding. Characteristic is the absence of bile impurities in them. The stool is scanty, dark green in color due to the low content of milk and the predominance of bile and secretion of the intestinal glands. The amount of urine excreted and the number of urinations are reduced. Urine concentrated, intensively stains diapers. Note the age-related deficiency of body weight. In severe cases, there is a violation of water - electrolyte metabolism and CBS as a result of the loss of chlorine with hydrochloric acid during vomiting. The latter leads to an increase in alkaline reserves in the blood and the appearance of moderate alkalosis. Diagnosis of pyloric stenosis is based on the history, examination of the patient, and in difficult cases on the use of special research methods. Particular attention in pyloric stenosis is paid to examination of the abdomen, in which it is possible to detect an increase in the epigastric region compared to the sunken lower sections, to identify the characteristic hourglass symptom due to deep peristalsis of the distended stomach. Clarification of the diagnosis is carried out by palpation of the pylorus. The pylorus should be palpated at the outer edge of the right rectus muscle or under it at the level of the middle of the line connecting the xiphoid process and the navel. Palpation should be deep, almost to the posterior abdominal wall, which is possible with the complete calm of the child. It is advisable to conduct a study after feeding, because the empty stomach contracts and displaces the pylorus under the liver, where it is not always possible to detect it. The thickened pylorus is palpated in the form of a dense, oval, rather mobile formation. In combination with clinical manifestations, palpation detection of an enlarged pylorus is a direct indication for surgical intervention.

X-ray examination in pyloric stenosis as a special diagnostic method is given less and less importance. The radiological symptoms of pyloric stenosis are varied: retention of a contrast mass in the stomach for more than 24 hours, "segmenting peristalsis" of the stomach, the symptom of "antral beak", "antennae", "curly bracket", etc. However, symptoms pathognomonic for pyloric stenosis based on contrasting the narrowed pyloric canal occur only in 18% of sick children. This currently forces to limit the indications for the use of the X-ray method as much as possible. In recent years, gastroscopy has been widely used to diagnose pyloric stenosis. Endoscopically, in all patients, a sharp narrowing of the pylorus entrance and the absence of its peristalsis are noted. The altered pylorus cannot be opened by air insufflation or directly by the endoscope, even after the administration of atropine. A certain relationship between the state of the cardia and the severity of the course of pyloric stenosis was revealed. A severe form of the disease is observed when pyloric stenosis is combined with normal function of the cardial part of the stomach, which leads to a long delay in food in the stomach, hypersecretion and a more significant loss of chlorine and potassium. The manifestations of esophagitis in these children are moderate. The combination of pyloric stenosis with cardiac insufficiency leads to early onset of frequent regurgitation, less congestion in the stomach and, accordingly, less loss of electrolytes, but to more severe forms of esophagitis. The use of the endoscopic method is progressive, because it contributes to the early diagnosis of pyloric stenosis and allows you to determine the scheme of rational preoperative preparation of the patient. Differential diagnosis of pyloric stenosis is carried out with conditions that in infants are accompanied by vomiting. Most often it is necessary to distinguish congenital pyloric stenosis from pylorospasm. Despite the great similarity of these diseases, it is possible to differentiate pyloric stenosis on the basis of clinical data without great difficulties. This is largely facilitated by the well-known table of N. I. Langovoy, as well as the use of antispastic therapy and neuroplegic agents (pipolphen 2.5 mg 3 times a day orally). Endoscopic criteria for the differential diagnosis of pyloric stenosis and pylorospasm have been developed. With pyloric stenosis, there is food content in the stomach on an empty stomach, a persistent narrowing of the pyloric canal does not allow the optical system to pass into the duodenum, and the segmenting peristalsis of the stomach is clearly visible. With pylorospasm, the cavity of the stomach on an empty stomach is free from food contents, the peristalsis of the pylorus is well traced, and the pyloric sphincter freely allows a gastroduodenoscope to be passed outside the stomach. Pyloric stenosis is sometimes differentiated from a salt-losing form of adreno-genital syndrome (Debre Fibiger's syndrome). Common are the characteristic onset from the 34th week of life, profuse vomiting, progressive weight loss, pronounced homeostasis disturbances. Differential diagnosis is based on a biochemical study of urine. Excessive (by 210 mg/day) excretion of 17-KS in the urine is of great diagnostic value, because it is considered pathognomonic for adrenogenital syndrome. Differential diagnosis of pyloric stenosis is carried out with frenopyloric syndrome, which gives a fairly similar clinical picture. The basis of this disease is a hernia of the esophageal opening of the diaphragm with the movement of part of the stomach into the chest cavity and spastic contraction of the pyloric canal. X-ray method is of decisive diagnostic value. It should be remembered about such malformations of the intestine as congenital stenosis of the duodenum, compression of its lumen by an abnormally located vessel or annular pancreas, congenital prepyloric stenosis, and others that give a clinical picture similar to pyloric stenosis. The diagnosis in each case is made on the basis of an X-ray examination. Treatment of pyloric stenosis is surgical. The treatment results are good.

Malformations of the duodenum Complete obstruction of the duodenum can be due to atresia, severe forms of agangliosis, annular pancreas and aberrant vessel. The clinical manifestations of these diseases are similar. The leading symptom is vomiting, which occurs at the end of the 1st day. The first portion of the vomit in most cases consists of swallowed amniotic fluid and stomach contents, but an admixture of bile is possible. Meconium is observed in almost all children, but its amount is somewhat less. It is lighter in color and contains many mucous plugs. A child with complete obstruction of the duodenum is usually calm, sucks satisfactorily, and his general condition in the first days of life is slightly disturbed. On examination, pay attention to the appearance of the abdomen. When the stomach and duodenum are full of contents, there is swelling of the epigastric region and retraction of the remaining parts of the abdomen, over which a shortened percussion tone is determined. In rare cases, you can see the peristalsis of the stomach. After vomiting, the swelling disappears, the abdominal wall appears to be evenly retracted. On palpation, the abdomen is soft throughout, while the child remains calm. On auscultation, peristaltic noises are not heard. Diagnosis is confirmed by radiography. Produce a direct and lateral survey radiography of the chest and abdomen in the vertical position of the child. A characteristic symptom for complete obstruction of the duodenum is the presence of two horizontal levels of liquid and two gas bubbles corresponding to a distended stomach and duodenum. There is no gas in the rest of the abdominal cavity. One level belonging to the stomach can be detected, which is equally possible with duodenal atresia and pyloric atresia of the stomach. For the purpose of differential diagnosis of these conditions, a probe is inserted into the stomach, its contents are aspirated and the x-ray examination is repeated. When a second gas bubble appears on the second radiograph, a diagnosis of complete obstruction of the duodenum is made. With the preservation of one air bubble, a diagnosis of pyloric atresia of the stomach is established. Partial obstruction of the duodenum in newborns may be due to incomplete rotation of the midgut, internal membrane having a hole, congenital stenosis, and abnormal origin of the superior mesenteric artery. The absence of pathognomonic signs, the variety of clinical symptoms and the atypical time of their appearance make the diagnosis of partial obstruction quite difficult. In most cases, the main symptoms are intermittent vomiting, regurgitation, and abdominal pain that is intermittent and recurs over time. Clinical examination does not allow to confirm or reject the diagnosis of obstruction and identify the cause of the disease. Decisive for the diagnosis is an X-ray examination, which is performed in several stages. Initially, a survey radiography of the abdominal and thoracic cavities is performed in a vertical position. Then exclude or confirm the presence of incomplete rotation of the midgut, as the most common cause of partial obstruction in newborns. For this purpose, irrigography with air is carried out. The study allows you to locate the dome of the caecum. Its location in the liver indicates the presence of an incomplete turn or Ledd's syndrome. In cases where irrigography reveals the normal location of the colon, resort to the final stage of the study of the gastrointestinal tract with barium suspension. During the study, the shape, position and condition of the esophagus, stomach and other parts of the digestive tract are consistently evaluated. An indicator of impaired passage is the presence of a contrast mass in the stomach for more than 3 hours. As a rule, the study takes 68 hours. This time is quite enough to make a diagnosis of intestinal obstruction at the level of not only the duodenum, but also at a lower one. Partial obstruction of the duodenum requires surgical treatment. The final cause of obstruction is clarified at the operation.

Ledd's syndrome Recurrent ileus due to volvulus of the "midgut" around the superior mesenteric artery and high fixation of the caecum. The pathogenesis of Ladd's syndrome. In a surgical sense, the middle intestine includes the sections of the intestine from the duodenum to the middle of the transverse colon. Intestinal obstruction occurs as a result of compression of the duodenum by an abnormally fixed caecum, followed by volvulus of the middle intestine, has a common mesentery, by degrees counterclockwise. in - untwisting inversion; d - the volvulus is straightened, but there is an external compression of the duodenum by the caecum that has not made a turn; processing is carried out according to the Ladd method, i.e. incision of the peritoneum on the right side of the caecum and its displacement to the left and downward; e - final view; the duodenum descends to the right and the large intestine to the left

Clinic of Ledda's syndrome It is distinguished by the instability of the manifestation of symptoms. The first signs are vomiting and regurgitation of bile in children of the first months of life. Periodically there are bouts of pain in the abdomen, accompanied by frequent vomiting. In some cases, one of the recurrences of volvulus leads to the development of acute intestinal obstruction with a progressive deterioration in the child's condition, up to a collaptoid state. There are: 1. Paroxysmal severe pain in the abdomen. 2. Delay of a chair and gases. 3. Repeated vomiting. 4. Swelling of the epigastric region and retraction of the lower abdomen. 5. Palpation is uninformative. X-ray diagnosis of Ledd's syndrome At a survey radiography of the abdominal organs, there are two levels of fluid in the stomach and duodenum, a small amount of gas in the intestine. When radiography of the abdominal organs with contrast (barium sulfate) - the contrast accumulates in the distended stomach and duodenum and is distributed in small portions along the loops of the small intestine, having the appearance of a conglomerate. When irrigography - it turns out the caecum, fixed under the liver. Computed tomography can reveal volvulus of the midgut around the common bridging artery.

Treatment of Ledd syndrome Preoperative management Children with continuous vomiting may be 10-15% dehydrated, have signs of hypovolemia and hypochloremia, resulting in the need for rapid rehydration with saline. Long-term infusion, however, is not indicated because rapid laparotomy is critical to the survival of the child. Additional measures, such as placement of a nasogastric tube, provision of satisfactory venous access, and parenteral administration of antibiotics, should be done as soon as possible. Surgical Treatment Ledda's operation corrects major anomalies in malrotation with or without volvulus of the midgut. This operation consists of several important steps that must be carried out in the correct sequence: 1. Evisceration of the midgut and revision of the root of the mesentery; 2. Derotation (reversal) inversion counterclockwise; 3. Cutting the peritoneal weights of Ledd with straightening of the duodenum parallel to the right abdominal canal; 4. Appendectomy; 5. Location of the caecum in the left lower quadrant. With severe necrosis of the small intestine, the operation may be unpromising.

Malformations of the small intestine The main malformations are atresia (complete and membranous), congenital stenosis, doubling, torsion, impaired innervation of the wall. In the neonatal period, malformations are more often detected, accompanied by complete obstruction. Clinical symptoms are acute and, depending on the level of obstruction, appear on the 12th day of life. The leading symptom is also vomiting. Its first portions contain swallowed amniotic fluid, then an admixture of bile joins, and in advanced cases, intestinal contents. The child's condition progressively worsens, exsicosis and toxicosis increase. Aspiration of vomit may lead to pneumonia. The abdomen is evenly swollen. Percussion tympanitis throughout. Auscultation determines increased peristalsis, which is sometimes visible through the abdominal wall. The chair can be 23 times a day, of the same nature as in patients with complete obstruction of the duodenum. The diagnosis is confirmed by X-ray examination. Characteristic signs of complete obstruction of the small intestine are the presence on the survey radiograph of many levels in the upper abdominal cavity and the complete absence of gas in the lower ones (symptom of the "silent zone"). X-ray data are so convincing that they make it unnecessary to use radiopaque suspensions to clarify the diagnosis.

Malformations of the colon Malformations of the colon are partly manifested and must be corrected immediately after the birth of the child, partly at a later date. The first group includes the acute form of Hirschsprung's disease, rare cases of colon atresia, congenital absence of the anus and rectum, and the second group includes other anorectal malformations. Hirschsprung's disease in newborns occurs in an acute form, because clinical symptoms appear on the 23rd day of life. The first symptoms of the disease may be the absence of a chair and a gradual progressive increase in bloating. In later periods, vomiting with bile appears. When trying to get a stool with an enema, the flushing waters are difficult to return or they are not received at all. The abdomen is sharply swollen, enlarged in size as a result of pronounced flatulence of the leading sections of the intestine. Plain abdominal x-ray reveals dilated bowel loops and multiple levels of fluid. The diagnosis is specified by the method of contrast irrigography. The purpose of the study is to establish the spastic zone, determine its length and degree of narrowing, as well as the diameter of the enlarged colon. Similar clinical manifestations and diagnostic methods are used in newborns with suspected colonic atresia. The treatment of these diseases is surgical. Atresia of the anus and rectum (simple). The first signs of the disease appear 10-12 hours after birth and consist in the child's anxiety, periodic straining, and sleep disturbance. The chair is missing. If the defect is not recognized, then a clinic of low intestinal obstruction develops. For timely recognition of atresia, a preventive examination of the perineum at birth and in the absence of meconium in the first 610 hours is necessary. The level of atresia is established by X-ray examination. With atresia of the anus, it is urgent to transfer the child from the maternity hospital to the surgical department. Atresia of the anus and rectum (with fistulas). In the absence of an anus and rectum, fistulas most often open into the reproductive system. A similar pathology is observed exclusively in girls. The fistula often communicates with the vestibule of the vagina, less often with the vagina. The main sign of atresia with a fistula into the reproductive system is the release of meconium and gases through the genital slit from the first days of a child's life. The decision on treatment tactics is made by the surgeon. If the fistula is short and wide enough and the child has more or less regular stools, then the defect is corrected at an older age. If the fistula is narrow and complete emptying of the intestine does not occur, then the defect is eliminated in the first weeks of life. A similar tactic is followed with fistulas that open to the perineum. Their diagnosis is not particularly difficult.

Diaphragmatic hernia is a malformation characterized by a hernial protrusion of the abdominal organs into the chest cavity through a defect in the diaphragm. The average frequency of the defect is 1 case per 2500 newborns. Isolated forms of diaphragmatic hernia have a multifactorial origin. Often diaphragmatic hernia is a part of known chromosomal and gene syndromes. Diaphragmatic hernias can be true or false. True hernias are understood as a saccular protrusion into the chest cavity of a thinned diaphragm. The hernial sac in this form of hernia consists of a thinned diaphragm, peritoneal sheet and visceral pleura. True hernias are rare. More often, false hernias are determined: they do not have a hernial sac, and the abdominal organs penetrate into the chest through an enlarged natural opening or an embryonic defect in the diaphragm; it is usually located on the left. Diaphragm defects are of various sizes - from small to complete absence of the diaphragm dome. Depending on the size of the opening, the spleen, stomach, intestinal loops, and the left lobe of the liver move into the chest cavity. These organs compress the lung and displace the organs of the mediastinum, and the heart is not only displaced, but also rotated around the longitudinal axis, while the vena cava is stretched and deformed. Omphalocele is a congenital malformation characterized by protrusion of the intestine and other abdominal organs into the cavity of the umbilical cord. Omphalocele is a relatively common anomaly in newborns, its frequency is 1 in 4-6 thousand births. More often the birth of children with this defect is observed in older women. The etiology of the defect is heterogeneous. The isolated defect meets sporadically more often. Many studies point to the possibility of a teratogenic occurrence of the defect (taking the anticonvulsants of valproic acid during the first trimester of pregnancy). Omphalocele is also a symptom of some hereditary syndromes. An omphalocele is a hernia of the umbilical cord. The size of the umbilical ring defect ranges from small (1-2 cm in diameter) to a massive defect covering the entire abdominal wall. The walls of the hernial sac are represented by stretched and thinned elements of the peritoneum and amnion. The hernial sac is usually intact, but in % of cases it may rupture during childbirth or shortly after birth. The contents of the hernia are usually loops of the small intestine, such hernias are small. Sometimes the hernial sac contains other internal organs of the abdominal cavity (liver, spleen). With a giant hernia, the liver is centrally localized and completely occupies the hernial sac. The abdominal cavity in the case of giant hernias is usually reduced in size. Children with a giant hernia are also characterized by a small, bell-shaped chest cavity, lung hypoplasia, and respiratory disorders. Mortality in omphalocele is % mainly due to cases of large hernias, prematurity occurs in % of cases. In recent decades, the survival rate of children with omphalocele has been steadily increasing due to the improvement in the quality of treatment and nursing of children with this defect. Gastroschisis is a defect characterized by protrusion of the abdominal organs, more often intestinal loops that are not covered by membranes through an abdominal wall defect located lateral to the umbilical cord. The frequency of the defect, according to various sources, ranges from 0.94 to 4.7 per birth. Some reports mention an increase in the frequency of the defect in recent years.

Vomit is a complex reflex act involving the vomiting center, which is located in the medulla oblongata, near it are the respiratory, vasomotor, cough-left and other autonomic centers. All centers are functionally interconnected, so vomiting is accompanied by a change in breathing, circulatory disorders, and the release of a large amount of saliva.

regurgitation- the release of food eaten without effort, without contractions of the muscles of the anterior abdominal wall, immediately after feeding or after a short period of time. The general condition of the child is not disturbed, there are no vegetative symptoms, appetite and mood do not change.
In newborns and children in the first months of life, there is a tendency to regurgitation, which is due to the anatomical and physiological characteristics of the stomach in newborns - weakness of the cardiac sphincter with a well-developed pyloric sphincter, the horizontal position of the stomach and the child itself, high pressure in the abdominal cavity, a large amount of food (1/5 body weight per day). Contribute to regurgitation overfeeding and aerophagia.

At overfeeding regurgitation occurs immediately after feeding or after a certain period of time in a small amount of unchanged or slightly curdled milk. The general condition of the child does not suffer, he gains weight. During the control weighing, the volume of milk eaten by the newborn is determined, which is much more than required by the norm. When overfeeding, it is recommended to change the time of breastfeeding or first express the part of the milk that is easily suctioned, but less rich in food ingredients.

Aerophagia- swallowing a large amount of air during feeding, occurs in hyperexcitable, eagerly sucking children, from the 2-3rd week of life with a small amount of milk in the mammary gland or bottle, when the child does not capture the areola, with a large hole in the nipple, the horizontal position of the bottle when the nipple is not completely filled with milk, with general muscular hypotension associated with the immaturity of the body.

Aerophagia is more common in neonates with low or very high birth weight. Children are restless after feeding, there is swelling in the epigastric region. 5-10 minutes after feeding, regurgitation of unchanged milk is noted. With aerophagia, it is necessary to have a conversation with the mother about the correct feeding technique. After feeding, it is necessary to hold the child upright for 15-20 minutes, which contributes to the discharge of air swallowed during feeding. It is recommended to lay children with an elevated head end.
Regurgitation and vomiting can be one of the important symptoms in many diseases associated with the pathology of the gastrointestinal tract itself (primary) and causes outside the digestive tract (secondary). Functional and organic vomits are also distinguished. Organic vomiting is associated with malformations of the gastrointestinal tract. There are 3 main groups of causes leading to secondary vomiting:

1. infectious diseases,
2. cerebral pathology,
3. metabolic disorders.

Functional forms of vomiting

The most common functional pathology of the gastrointestinal tract is insufficiency of the cardia. Newborns do not have a pronounced sphincter in the area of ​​​​the transition of the esophagus to the stomach, the closure of the cardia occurs by the valvular apparatus. Insufficiency of the cardia may be due to a violation of the innervation of the lower part of the esophagus (often observed in perinatal encephalopathy), an increase in intra-abdominal and intragastric pressure in certain diseases.
With cardia insufficiency, regurgitation occurs immediately after feeding, in the horizontal position of the child, frequent, not abundant. Reflux esophagitis, which develops with this pathology, can cause the development of cardiovascular insufficiency. The child develops cyanosis, weakness, adynamia, tachyarrhythmia, shortness of breath, liver enlargement, oliguria, wheezing appears in the lungs.

Treatment. It is recommended to lay the child on the stomach with the head end raised by 10°, fractional nutrition of 40-50 ml up to 10 times a day, prevention of aerophagia. Of the medicines prescribed: bethanechol, domperidone (motilium), cerucal or raglan 30 minutes before meals 3 times a day.

Achalasia of the esophagus (cardiospasm)- persistent narrowing of the cardiac section due to impaired innervation as a manifestation of congenital pathology or various diseases. At the same time, the opening of the cardia during swallowing is disturbed, atony of the esophagus is noted, food lingers over the spasmodic cardia, and the esophagus gradually expands.
The main symptom in newborns is vomiting during feeding with freshly eaten milk, difficulty in swallowing, it seems that the child is “choking” while eating. Repeated aspiration may result in pneumonia.
The diagnosis is confirmed by endoscopic and x-ray examination.
Treatment. Recommended fractional meals up to 10 times a day, large doses of vitamin B: intramuscularly, antispasmodics, sedatives, 0.25% solution of novocaine 1 teaspoon before each feeding, 2.5% solution of chlorpromazine and pipolfen, 0.25 % solution of droperidol with novocaine - appoint 1 tsp. 3 times a day 30 minutes before meals.

Pylorospasm- spasm of the pylorus muscles, leading to difficulty emptying the stomach. Increased tone of the pyloric section is associated with hypertonicity of the sympathetic section of the nervous system due to perinatal encephalopathy, hypoxia. Usually, children with pylorospasm are hyperexcitable, intermittent regurgitation appears from the first days of life, as the amount of food increases, vomiting appears. Vomiting is daily, not the same number of times during the day, vomiting appears closer to the next feeding, vomit is abundant, curdled sour contents without bile, the volume does not exceed the volume of food eaten. The child, in spite of vomiting, gains weight, although not enough, as a result of which malnutrition develops. The chair is normal. The diagnosis is confirmed radiographically.
Treatment. At the beginning of feeding, you can give 1 teaspoon of 10% semolina, which contributes to the mechanical opening of the pylorus. Spasmolytic and sedative therapy.

Organic forms of vomiting (malformations of the gastrointestinal tract)

Esophageal atresia- one of the most common malformations of the esophagus, often combined with a lower tracheoesophageal fistula. Clinical manifestations: from the first hours of life, foamy mucus is secreted from the mouth and nose of the child, which, after suction, accumulates again, aspiration pneumonia develops. It is possible to diagnose esophageal atresia using probing, the probe does not pass into the stomach (an obstacle is felt), the air quickly injected with a syringe through the probe exits with noise back through the nose or mouth, and with normal patency it silently passes into the stomach. Treatment is operative.

Congenital intestinal obstruction.
The causes of congenital intestinal obstruction may be malformations of the intestinal tube itself (atresia, stenosis, membranes), malformations of other organs leading to intestinal compression, blockage by thick viscous meconium.
Clinically, congenital intestinal obstruction manifests itself acutely in newborns from the first days or hours of life. Depending on the level of obstruction is divided into high and low intestinal obstruction. In the presence of an obstruction in the duodenum, intestinal obstruction manifests itself as an upper one, and in the presence of an obstruction in the jejunum, ileum, and large intestine, as a low one.
With high intestinal obstruction, the contents that accumulate in the stomach and duodenum are released outward with vomiting and regurgitation. Vomiting appears on the first day or hours of life, profuse, gastric contents (sometimes mixed with bile), infrequent; if the child is fed, then vomiting appears after feeding, the amount of vomit approximately corresponds to the amount of milk received by the child during feeding. Excessive vomiting can lead to dehydration and the development of aspiration pneumonia. Meconium is passed, and there is no stool in the future, there is a long-term discharge of meconium (within 5-6 days) in small portions. There is bloating in the upper sections, which disappears after vomiting or emptying during probing, and then reappears. In other departments, the abdomen may be sunken. Exicosis symptoms are noted.
The diagnosis is confirmed radiographically.
Low intestinal obstruction. Almost immediately after birth, abdominal distention is noted, which does not disappear after vomiting or artificial emptying of the stomach. Meconium does not pass, lumps of mucus, slightly green in color, are noted instead of stool. Vomiting appears on the 2-3rd day of life, in the vomit there may be an admixture of intestinal contents ("fecal" vomiting), vomiting is more frequent than with high obstruction, but less abundant. The general condition suffers significantly, symptoms of intoxication are expressed, with late diagnosis of the disease, symptoms of peritonitis appear: a sharply swollen abdomen, deep palpation is not available, the subcutaneous venous network on the abdomen is pronounced, swelling of the subcutaneous tissue in the anterior abdominal wall, especially in the lower sections, cyanotic shade of skin covers on the abdomen.
The diagnosis of low intestinal obstruction is confirmed radiographically.
Preoperative preparation in the maternity hospital: the abolition of enteral nutrition, install a gastric tube for regular emptying of the stomach.

Atresia of the anus and rectum.

Allocate:

1. atresia of the anus and rectum without fistulas;
2. atresia of the anus and rectum with fistulas (external - perineal, internal - fistulas with the urinary, reproductive system).

With atresia of the anus and rectum, the absence of the anus can be seen and the absence of meconium discharge is noted.
Treatment is surgical or conservative specialized in the surgical department.

Secondary forms of vomiting (symptomatic)

Vomiting can be one of the symptoms of an infectious, cerebral disease, metabolic disorders.

Vomiting associated with cerebral pathology. The most common cause of vomiting and regurgitation in newborns is the pathology of the central nervous system of hypoxic, traumatic or infectious origin. In addition to vomiting, symptoms of brain damage are noted in newborns: a monotonous weak cry or a piercing cry, groaning, bulging and tension of the large fontanelle, syndromes of depression or excitation of the central nervous system, convulsive syndrome, etc. Vomiting in case of damage to the central nervous system is associated with both central mechanisms: increased intracranial pressure, edema brain cells, irritation of the vomiting center, and with disorders of the autonomic system that regulates the functions of the digestive organs, which leads, in particular, to pylorospasm.
Vomiting in the pathology of the central nervous system can be persistent "fountain" or manifested by regurgitation.
Treatment of vomiting syndrome against the background of cerebral pathology - the underlying disease is treated.

Alimentary dyspepsia. In view of the existing physiological characteristics of the digestive system of newborns, any errors in nutrition can lead to dyspeptic disorders:

1. quick transition to artificial feeding,
2. feeding with unadapted mixtures,
3. non-compliance with the rules for the preparation and storage of mixtures,
4. overfeeding,
5. irregular feeding.

In violation of the breakdown of carbohydrates, which often happens when a child is supplemented with sweet tea, overfeeding with sweet mixtures, bloating, anxiety, regurgitation, stools are liquid, watery, frothy, yellow, there may be an admixture of greenery, with a sour smell, in the analysis of feces a large number of iodophilic bacteria.
In violation of protein digestion, the stool is loose, yellow-brown, with a sharp unpleasant odor, bloating, constipation is noted. X newborns are rare.
The most common type of dyspepsia in newborns is a violation of the digestion and absorption of fats. At the same time, the stool has a shiny appearance with white curdled lumps; in the analysis of feces, neutral fat and fatty acids are found.
Nutritional dyspepsia in newborns can lead to insufficient weight gain, but with this form of dyspepsia there is practically no weight loss and dehydration, there are no symptoms of intoxication.
Treatment. Within 8-12 hours, a fractional drink is prescribed (glucose-salt solutions, water, 5% glucose solution). Then breastfeeding is resumed, starting with S of the prescribed volume and brought to the full volume within 2-3 days. The number of feedings is increased up to 8-10 times. If it is impossible to feed the baby with breast milk, an adapted milk formula is selected. Assign bifidumbacterin, pancreatin, festal and more.
Apply decoctions of herbs with astringent action: rhizome of cinquefoil, burnet, serpentine, fruits of bird cherry, blueberries, alder seedlings; herbs with anti-inflammatory action - chamomile flowers, St. John's wort, mint; carminative action - dill grass, caraway fruits, fennel, yarrow stems, chamomile flowers, mint. Steam 10 g per 200 ml of water, boil in a water bath for 30 minutes, cool and bring the volume to 200 ml with boiled water. Give children 5 ml 3-4 times a day 15 minutes before feeding.

Dysbacteriosis. The fetus is sterile in utero during physiological pregnancy, begins to be colonized by microorganisms during childbirth in the birth canal, after birth, microorganisms from the environment enter the gastrointestinal tract of the child. By the end of the first day, the intestines of the child are populated by various microorganisms - cocci, enterobacteria, yeast, conditionally pathogenic and pathogenic - and transient dysbacteriosis develops. By the 7th-8th day of life, the intestinal microbiocenosis of the newborn is established: the main microflora is 95% bifidobacteria, the accompanying microflora is lactobacilli and normal strains of Escherichia coli, the residual microflora is saprophytes and opportunistic microbes (enterococci, non-pathogenic staphylococci, proteus, yeast, etc. .), this part should not be more than 1%.
The process of establishing normal intestinal microflora has become longer, which is associated with dysbiocenosis of the vagina and intestines of the mother and staff of maternity hospitals, non-compliance with hygiene standards when caring for newborns, late attachment of the child to the breast, a decrease in the overall immunological reactivity of the newborn in pathology (asphyxia, birth trauma, intrauterine infections, HDN, blood loss, etc.), antibiotic therapy.
Dysbacteriosis is a qualitative and quantitative change in the composition of the intestinal microflora.
Dysbacteriosis is manifested by persistent dyspeptic disorders. There is bloating, regurgitation, appetite decreases, stools are liquefied, quickened, with greens, undigested particles, an unpleasant odor, slow recovery of body weight is noted, poor weight gain during the first month of life.
Treatment. It is best to feed a child with breast milk; in the absence of breastfeeding, mixtures with bioactive additives are shown - lysozyme, bifidobacteria, immunoglobulins; milk mixtures enriched with protective factors - adapted with the addition of acidophilus bacillus, lacto- or bifidobacteria, lysozyme, immunoglobulins ("Malyutka", "Bifidolact", etc.).
Drug treatment is carried out in 2 stages:
Stage I - suppression of the growth of opportunistic microorganisms. If there is a predominant growth of staphylococcus, Escherichia coli or Proteus, then the appropriate bacteriophage is prescribed. If there is an increase in several types of microbes, then furadonin or furazolidone, bactisubtil are prescribed for 5-7 days.
Stage II - normalization of the intestinal microflora: bifidumbacterin, lactobacterin, bactisubtil, pancreatin, festal and more. The duration of treatment of stage II is selected individually, on average 3-4 weeks.

Complications.
Dehydration is the most common and severe complication of gastroenteritis. Loss of water and electrolytes (sodium, chloride, potassium) through the intestines with diarrhea. Allocate 3 degrees of dehydration, respectively, weight loss: I - up to 5% of the mass; II - 6-10%; III - more than 10%.
With moderate dehydration, there may be a slight retraction of the large fontanel, eyeballs, dry mouth of the mucous membranes, and a decrease in diuresis. BP is usually normal, and the child may be lethargic or agitated.
Blood pressure may decrease, the pulse quickens, weak filling, a decrease in diuresis is characteristic. The child is very lethargic, there may be convulsions, later - loss of consciousness, coma. Increased hematocrit and hemoglobin in the blood, hyponatremia, hypokalemia. With severe diarrhea, the child can lose more than 15% of the weight in a few hours, which is usually accompanied by hypovolemic shock.

Other complications in acute intestinal infections are less common: sepsis, DIC, pneumonia, urinary tract infection, otitis, meningitis.
In the diagnosis, the seeding of a pathogenic agent from feces is of decisive importance. In the study of stools, the best results are obtained with sowing in the early stages of the disease before the start of antibiotic therapy. For research, the most altered particles of fresh feces are selected.
Specific diagnosis of viral diarrhea is carried out by electron microscopy of feces and various immunological methods.

Treatment of acute intestinal infections

Basic principles of treatment of acute intestinal infections in children:

1. Diet.
2. rehydration therapy.
3. Enzyme therapy.
4. Symptomatic therapy.
5. Etiotropic therapy.
6. syndromic therapy.
7. Surveillance and control.

The digestive system is daily exposed to the pathological effects of exogenous factors, so gastrointestinal diseases occur in almost everyone. It is worth noting that the digestive system includes the gastrointestinal tract, liver and pancreas. We suggest that you consider in detail the diseases of the gastrointestinal tract and understand their causes. We also superficially outline the methods for diagnosing and treating pathologies of the gastrointestinal tract.

The structure of the digestive system and the functions of each organ

The structure of the gastrointestinal tract

The gastrointestinal tract is a system for processing food and obtaining nutrients, vitamins and minerals from it, as well as removing residues. The length of the digestive tract of an adult is on average 9 meters. The gastrointestinal tract starts at the mouth and ends at the anus. Main sites: oral cavity and pharynx, esophagus, stomach, small and large intestine.

Diseases of the oral cavity are a separate issue and the dentist deals with their treatment. These include diseases of the teeth, oral mucosa, salivary glands. Of the diseases of the pharynx, tumors can most often be found, but the percentage of their detection is small.

Functions of the digestive tract

Each organ of the gastrointestinal tract performs its own function:

• The esophagus is responsible for delivering the crushed food bolus to the stomach. Between the stomach and the esophagus there is a special esophageal-gastric sphincter, problems with which are the cause of diseases of the esophagus.
• In the stomach, the protein fractions of food are broken down by the action of gastric juice. Inside the stomach is an acidic environment, and in other parts of the gastrointestinal tract - alkaline. Next, the food bolus moves through the sphincter into the duodenum 12.
• The duodenum stimulates the active breakdown of food due to bile acids and pancreatic enzymes that enter there through the major duodenal papilla.
• The remaining sections of the small intestine (jejunum and ileum) ensure the absorption of all nutrients except water.
• In the large intestine, feces are formed due to the absorption of water. There is a rich microflora here, which provides the synthesis of nutrients and vitamins absorbed through the colon mucosa.

Diseases of the esophagus and stomach

The esophagus is a hollow tube that connects the mouth and stomach. His diseases are associated with pathologies of other organs, in particular, the esophageal-gastric sphincter and stomach. The esophagus also suffers from malnutrition, like other parts of the gastrointestinal tract. Fatty, fried, spicy food disrupts the function of the stomach and contributes to the reflux of acidic gastric contents into the esophagus. This pathology is called reflux or gastroesophageal reflux disease (GERD).

How does reflux from the stomach into the esophagus occur?

Interesting: Heartburn is a sign of acidic stomach contents entering the esophagus. The manifestation is a symptom of reflux esophagitis, but not an independent disease.

More than half of the population has GERD, and if left untreated with age, the disease leads to the formation of atypical areas of the epithelium on the esophageal mucosa - Barett's esophagus develops. This is a precancerous condition that, without treatment, turns into a malignant oncopathology.

Tip: So, seemingly harmless gastritis can make a person disabled. Therefore, it is worth considering, perhaps the principles of proper nutrition should still be followed?

Diseases of the stomach are known to all. This is gastritis and peptic ulcer. However, we also often do not think about their complications. Why can they be dangerous? Both of these pathologies are accompanied by a violation of the integrity of the gastric wall and sooner or later reach the choroid plexuses. When the defect affects several vessels, gastric bleeding appears. This emergency surgical pathology is manifested by the following symptoms:

• Nausea, vomiting with an admixture of blood;
• Weakness, cold sweat;
• Black stools are the main sign of bleeding from the upper GI tract.

Important: peptic ulcer of the stomach and duodenum is dangerous for the development of perforation - rupture of the wall of a hollow organ with the release of its contents into the abdominal cavity and the development of peritonitis. This complication is treated only by open surgery.

Pathology of the small intestine

The most common pathology of the small intestine is duodenal ulcer. Much is known about this gastrointestinal problem, so we suggest that you consider the less common, but still dangerous, diseases of the small intestine.

• Enteritis is an inflammation of the small intestine that develops as a result of the use of low-quality products. This is an acute disease, which in most cases has a mild course, especially if the provoking factor is eliminated. The manifestations of the disease are vomiting and diarrhea, as well as deterioration of the general condition due to intoxication. Enteritis often resolves without treatment, but cases with a prolonged course, uncontrollable vomiting and dehydration require specialized care.
• Celiac disease is an intolerance to the protein gluten found in wheat, rye and barley. Given that most foods contain these substances, the life of a person with gluten-free enteropathy is difficult. The disease has no cure. The main thing is to identify and eliminate provoking factors in time. Pathology manifests itself in childhood from the moment the intolerable foods are introduced into the diet. With a timely appeal to the pediatrician, the identification of celiac disease is not difficult, and people who follow a special diet forget about their problem forever.
• Crohn's disease is a chronic autoimmune disease. The disease begins with acute pain, similar to appendicitis. Due to chronic inflammation, the absorption of nutrients is impaired, which leads to general exhaustion. In addition to pain, the symptoms of Crohn's disease include diarrhea and blood in the stool, and patients can report up to 10 bowel movements per day.

Of course, the most dangerous are tumors of the small intestine. For a long time, these diseases of the gastrointestinal tract occur without symptoms. Often, specialists detect them only when the patient addresses for intestinal obstruction, which is due to the complete blockage of the intestinal lumen by a growing tumor. Therefore, if there have been cases of oncopathologies of the intestine in your family, or if you are regularly worried about constipation, followed by diarrhea and vague abdominal pain, contact a specialist for a preventive examination.

Colon diseases

It is difficult to write all diseases of the gastrointestinal tract in one article, so we will single out the most serious pathologies of the large intestine - this is ulcerative colitis, polyposis and diverticulosis.

Nonspecific ulcerative colitis refers to chronic diseases of the gastrointestinal tract that have an autoimmune nature, like Crohn's disease. Pathology is multiple ulcers on the colonic mucosa that bleed. The main symptom of the disease is diarrhea mixed with blood and mucus. The disease requires long-term hormone therapy and diet. With timely detection and proper management of the patient, ulcerative colitis is completely controlled, which allows patients to lead a normal life.

Intestinal polyposis is often asymptomatic and is detected only when cancer develops against the background of long-term polyps. Polyposis is found on colonoscopy. Often polyps are incidental findings during examination for other pathologies.

Important: Polyps are often found in members of the same family, so if your relatives suffered from polyposis or oncopathologies of the colon, after 40 years, you should undergo preventive examinations. At a minimum, this is a fecal occult blood test, and ideally a colonoscopy.

Diverticulosis is a pathology in which multiple protrusions - diverticula - form in the intestinal wall. The disease may be asymptomatic, but with inflammation of the diverticula (diverticulitis), there is pain in the abdomen, blood in the stool, and a change in the nature of the feces. Especially dangerous complications of diverticulosis are intestinal bleeding and perforation of the colon, as well as acute or chronic intestinal obstruction. With timely treatment to the clinic, pathology is easily diagnosed and treated.

What do colonic diverticula look like?

Among other common pathologies in the large intestine, Crohn's disease can also develop. The disease, as indicated, begins in the small intestine, but without treatment spreads to the entire digestive tract.

Remember: A disease found early in its development is the easiest to treat.

Causes of digestive problems

Why do diseases of the digestive tube develop? The main reason is malnutrition. Specifically, the factors that disrupt the functioning of the gastrointestinal tract include:

• Poor quality food, fast food, the use of semi-finished products;
• Irregular meals, overeating;
• Eating a large amount of spicy, fried, smoked foods, canned foods;
• Abuse of alcohol, carbonated drinks.

Another cause of gastrointestinal diseases is the uncontrolled use of drugs. When prescribing therapy for chronic diseases, medications should be taken reasonably, if necessary, under the guise of proton pump inhibitors (Omez). Also, you should not use any medications on your own. This is especially true of non-steroidal anti-inflammatory drugs (NSAIDs), which patients often take uncontrollably for headaches. All NSAIDs increase the acidity of gastric contents, creating an aggressive flora inside the stomach, causing erosion and ulcers.

Methods for diagnosing gastrointestinal diseases

Diseases of the gastrointestinal tract have similar symptoms. Then it is important for the specialist to understand which part of the digestive tube is affected. There are diagnostic methods that allow for a targeted examination of the upper or lower gastrointestinal tract (FEGDS and colonoscopy), as well as those that are suitable for examining the entire digestive tube (radiography with contrast and capsule endoscopy).

• FEGDS for examination of the mucous membrane of the esophagus, stomach and duodenum 12. The method allows to establish such diagnoses as gastroesophageal reflux disease, esophagitis, gastritis, gastric ulcer and duodenal ulcer.
• Colonoscopy is used to diagnose colon pathologies. Like FEGDS, the technique allows you to take a section of the intestinal mucosa or neoplasm for histological examination.
• A contrast-enhanced X-ray is performed by taking a series of images after the patient drinks a barium solution, which is completely safe. Barium gradually envelops the walls of all organs of the gastrointestinal tract, allows you to identify constrictions, diverticula, and neoplasms.
• Capsule endoscopy is a modern method for diagnosing gastrointestinal diseases, which is not performed in every clinic. The bottom line is that the patient swallows a special capsule with a video camera. She moves through the intestines, recording images. As a result, the doctor receives the same data as after FEGDS and colonoscopy, but without discomfort for the patient. The method has two significant disadvantages: high cost and the impossibility of taking a biopsy.

What does a capsule for endoscopic diagnostics of the digestive tract look like?

In addition to instrumental methods for the diagnosis of diseases of the gastrointestinal tract, various tests are prescribed.

In the extrauterine period, the gastrointestinal tract is the only source of obtaining nutrients and water necessary both for maintaining life and for the growth and development of the fetus.

Features of the digestive system in children

Anatomical and physiological features of the digestive system

Young children (especially newborns) have a number of morphological features common to all parts of the gastrointestinal tract:

• thin, tender, dry, easily injured mucous membrane;
• richly vascularized submucosal layer, consisting mainly of loose fiber;
• underdeveloped elastic and muscle tissue;
• low secretory function of the glandular tissue that separates a small amount of digestive juices with a low content of enzymes.

These features of the digestive system make it difficult to digest food if the latter does not correspond to the age of the child, reduce the barrier function of the gastrointestinal tract and lead to frequent diseases, create the prerequisites for a general systemic reaction to any pathological effect and require very careful and thorough care of the mucous membranes.

Child's oral cavity

In a newborn and a child in the first months of life, the oral cavity has a number of features that ensure the act of sucking. These include: a relatively small volume of the oral cavity and a large tongue, good development of the muscles of the mouth and cheeks, roller-like duplication of the mucous membrane of the gums and transverse folds on the mucous membrane of the lips, fatty bodies (Bish's lumps) in the thickness of the cheeks, which are characterized by considerable elasticity due to the predominance of they contain solid fatty acids. The salivary glands are underdeveloped. However, insufficient salivation is mainly due to the immaturity of the nerve centers that regulate it. As they mature, the amount of saliva increases, and therefore, at the age of 3-4 months, the child often has the so-called physiological salivation due to the automatism of swallowing it that has not yet been developed.

In newborns and infants, the oral cavity is relatively small. The lips of newborns are thick, on their inner surface there are transverse ridges. The circular muscle of the mouth is well developed. The cheeks of newborns and young children are rounded and convex due to the presence between the skin and the well-developed buccal muscle of a rounded fatty body (Bish's fat lumps), which subsequently, starting from the age of 4, gradually atrophies.

The hard palate is flat, its mucous membrane forms weakly expressed transverse folds, and is poor in glands. The soft palate is relatively short, located almost horizontally. The palatine curtain does not touch the posterior pharyngeal wall, which allows the child to breathe during sucking. With the appearance of milk teeth, a significant increase in the size of the alveolar processes of the jaws occurs, and the arch of the hard palate rises, as it were. The tongue of newborns is short, wide, thick and inactive; well-defined papillae are visible on the mucous membrane. The tongue occupies the entire oral cavity: when the oral cavity is closed, it comes into contact with the cheeks and hard palate, protrudes forward between the jaws in the vestibule of the mouth.

The mucous membrane of the oral cavity

The mucous membrane of the oral cavity in children, especially at an early age, is thin and easily vulnerable, which must be taken into account when treating the oral cavity. The mucous membrane of the bottom of the oral cavity forms a noticeable fold, covered with a large number of villi. A protrusion in the form of a roller is also present on the mucous membrane of the cheeks in the gap between the upper and lower jaws. In addition, there are transverse folds (rollers) on the hard palate, roller-like thickenings on the gums. All these formations provide sealing of the oral cavity in the process of sucking. On the mucous membrane in the region of the hard palate along the midline in newborns there are Bohn's nodules - yellowish formations - retention cysts of the salivary glands, disappearing by the end of the first month of life.

The mucous membrane of the oral cavity in children of the first 3-4 months of life is relatively dry, which is due to the insufficient development of the salivary glands and the deficiency of saliva. The salivary glands (parotid, submandibular, sublingual, small glands of the oral mucosa) in the newborn are characterized by low secretory activity and secrete a very small amount of thick, viscous saliva necessary for gluing the lips and sealing the oral cavity during sucking. The functional activity of the salivary glands begins to increase at the age of 1.52 months; in 34-month-old children, saliva often flows out of the mouth due to the immaturity of the regulation of salivation and swallowing of saliva (physiological salivation). The most intensive growth and development of the salivary glands occurs between the ages of 4 months and 2 years. By the age of 7, a child produces as much saliva as an adult. The reaction of saliva in newborns is often neutral or slightly acidic. From the first days of life, saliva contains osamylase and other enzymes necessary for the breakdown of starch and glycogen. In newborns, the concentration of amylase in saliva is low; during the first year of life, its content and activity increase significantly, reaching a maximum level at 2-7 years.

Throat and larynx in a child

The pharynx of a newborn has the shape of a funnel, its lower edge is projected at the level of the intervertebral disc between C I | and C 1 V . By adolescence, it descends to the level C vl -C VII. The larynx in infants also has a funnel-shaped shape and is located differently than in adults. The entrance to the larynx is located high above the lower posterior edge of the palatine curtain and is connected to the oral cavity. Food moves to the sides of the protruding larynx, so the baby can breathe and swallow at the same time without interrupting sucking.

Sucking and swallowing in a child

Sucking and swallowing are innate unconditioned reflexes. In healthy and mature newborns, they are already formed by the time of birth. When suckling, the baby's lips tightly grasp the nipple of the breast. The jaws squeeze it, and the communication between the oral cavity and the outside air stops. Negative pressure is created in the child's oral cavity, which is facilitated by the lowering of the lower jaw along with the tongue down and back. Then breast milk enters the rarefied space of the oral cavity. All elements of the masticatory apparatus of a newborn are adapted for the process of breast sucking: the gingival membrane, pronounced palatine transverse folds and fatty bodies in the cheeks. The adaptation of the oral cavity of the newborn to sucking is also physiological infantile retrognathia, which later turns into orthognathia. In the process of sucking, the child makes rhythmic movements of the lower jaw from front to back. The absence of the articular tubercle facilitates the sagittal movements of the child's mandible.

Child's esophagus

The esophagus is a spindle-shaped muscular tube lined from the inside with a mucous membrane. By birth, the esophagus is formed, its length in a newborn is 10-12 cm, at the age of 5 years - 16 cm, and at 15 years - 19 cm. The ratio between the length of the esophagus and body length remains relatively constant and is approximately 1:5. The width of the esophagus in a newborn is 5-8 mm, at 1 year old - 10-12 mm, by 3-6 years old - 13-15 mm and by 15 years old - 18-19 mm. The dimensions of the esophagus must be taken into account during fibro-esophago-gastroduodenoscopy (FEGDS), duodenal sounding and gastric lavage.

Anatomical narrowing of the esophagus in newborns and children of the first year of life is weakly expressed and is formed with age. The wall of the esophagus in a newborn is thin, the muscular membrane is poorly developed, it grows intensively up to 12-15 years. The mucous membrane of the esophagus in infants is poor in glands. Longitudinal folds appear at the age of 2-2.5 years. The submucosa is well developed, rich in blood vessels.

Outside the act of swallowing, the passage of the pharynx into the esophagus is closed. Peristalsis of the esophagus occurs during swallowing movements.

Gastrointestinal tract and size of the esophagus in children depending on age.

During anesthesia and intensive care, probing of the stomach is often performed, so the anesthesiologist must know the age dimensions of the esophagus (table).

Table. The size of the esophagus in children depending on age

In young children, there is a physiological weakness of the cardiac sphincter and, at the same time, a good development of the muscle layer of the pylorus. All this predisposes to regurgitation and vomiting. This must be remembered during anesthesia, especially with the use of muscle relaxants, since in these cases regurgitation is possible - a passive (and therefore late noticed) leakage of the contents of the stomach, which can lead to its aspiration and the development of severe aspiration pneumonia.

The capacity of the stomach increases in proportion to age up to 1-2 years. A further increase is associated not only with the growth of the body, but also with the peculiarities of nutrition. Approximate values ​​of the capacity of the stomach in newborns and infants are presented in the table.

Table. Gastric capacity in young children

What is the size of the esophagus in children?

These values ​​are very approximate, especially in pathological conditions. For example, with obstruction of the upper gastrointestinal tract, the walls of the stomach can stretch, which leads to an increase in its capacity by 2-5 times.

The physiology of gastric secretion in children of different ages, in principle, does not differ from that in adults. The acidity of the gastric juice may be somewhat lower than in adults, but this often depends on the nature of the diet. pH of gastric juice in infants is 3.8-5.8, in adults at the height of digestion up to 1.5-2.0.

Motility of the stomach under normal conditions depends on the nature of nutrition, as well as on neuroreflex impulses. High activity of the vagus nerve stimulates gastrospasm, and the splanchnic nerve stimulates pyloric spasm.

The time of passage of food (chyme) through the intestines in newborns is 4-18 hours, in older children - up to a day. Of this time, 7-8 hours are spent passing through the small intestine and 2-14 hours through the large intestine. With artificial feeding of infants, the digestion time can reach up to 48 hours.

baby stomach

Features of the stomach of a child

The stomach of a newborn has the shape of a cylinder, a bull horn or a fishhook and is located high (the inlet of the stomach is at the level of T VIII -T IX, and the pyloric opening is at the level of T x1 -T x | 1). As the child grows and develops, the stomach descends, and by the age of 7 years, its inlet (with the body upright) is projected between T X | and T X|| , and the output - between T x || and L. In infants, the stomach is located horizontally, but as soon as the child begins to walk, it gradually assumes a more vertical position.

Cardiac part, fundus and pyloric part of the stomach in a newborn are weakly expressed, the pylorus is wide. The entrance part of the stomach is often located above the diaphragm, the angle between the abdominal part of the esophagus and the wall of the fundus of the stomach adjacent to it is not sufficiently pronounced, the muscular membrane of the cardial part of the stomach is also poorly developed. Gubarev's valve (a mucosal fold protruding into the esophageal cavity and preventing the return of food) is almost not expressed (it develops by 8-9 months of life), the cardiac sphincter is functionally inferior, while the pyloric part of the stomach is functionally well developed already at birth.

These features determine the possibility of reflux of the contents of the stomach into the esophagus and the development of peptic lesions of its mucous membrane. In addition, the tendency of children of the first year of life to regurgitation and vomiting is associated with the absence of a tight grasp of the esophagus by the legs of the diaphragm, as well as impaired innervation with increased intragastric pressure. Swallowing air during sucking (aerophagia) also contributes to regurgitation with improper feeding technique, a short frenulum of the tongue, greedy sucking, too rapid release of milk from the mother's breast.

In the first weeks of life, the stomach is located in an oblique frontal plane, completely covered in front by the left lobe of the liver, and therefore the fundus of the stomach in the supine position is located below the antral-pyloric section, therefore, to prevent aspiration after feeding, children should be given an elevated position. By the end of the first year of life, the stomach lengthens, and in the period from 7 to 11 years, it acquires a shape similar to that of an adult. By the age of 8, the formation of its cardiac part is completed.

The anatomical capacity of the stomach of a newborn is 30-35 cm3, by the 14th day of life it increases to 90 cm3. Physiological capacity is less than anatomical, and on the first day of life is only 7-10 ml; by the 4th day after the start of enteral nutrition, it increases to 40-50 ml, and by the 10th day - up to 80 ml. Subsequently, the capacity of the stomach increases monthly by 25 ml and by the end of the first year of life is 250-300 ml, and by 3 years - 400-600 ml. An intensive increase in the capacity of the stomach begins after 7 years and by 10-12 years is 1300-1500 ml.

The muscular membrane of the stomach in a newborn is poorly developed, it reaches its maximum thickness only by the age of 15-20. The mucous membrane of the stomach in a newborn is thick, the folds are high. During the first 3 months of life, the surface of the mucous membrane increases by 3 times, which contributes to better digestion of milk. By the age of 15, the surface of the gastric mucosa increases 10 times. With age, the number of gastric pits increases, into which openings of the gastric glands open. By birth, the gastric glands are morphologically and functionally underdeveloped, their relative number (per 1 kg of body weight) in newborns is 2.5 times less than in adults, but rapidly increases with the onset of enteral nutrition.

The secretory apparatus of the stomach in children of the first year of life is underdeveloped, its functional abilities are low. The gastric juice of an infant contains the same components as the gastric juice of an adult: hydrochloric acid, chymosin (curdles milk), pepsins (break down proteins into albumoses and peptones) and lipase (breaks down neutral fats into fatty acids and glycerol).

Children in the first weeks of life are characterized by a very low concentration of hydrochloric acid in gastric juice and its low total acidity. It increases significantly after the introduction of complementary foods, i. when switching from lactotrophic nutrition to normal. In parallel with the decrease in the pH of gastric juice, the activity of carbonic anhydrase, which is involved in the formation of hydrogen ions, increases. In children of the first 2 months of life, the pH value is mainly determined by the hydrogen ions of lactic acid, and subsequently by hydrochloric acid.

The synthesis of proteolytic enzymes by the chief cells begins in the antenatal period, but their content and functional activity in newborns are low and gradually increase with age. The leading role in the hydrolysis of proteins in newborns is played by fetal pepsin, which has a higher proteolytic activity. In infants, significant fluctuations in the activity of proteolytic enzymes were noted depending on the nature of feeding (with artificial feeding, activity indicators are higher). In children of the first year of life (unlike adults), a high activity of gastric lipase is noted, which ensures the hydrolysis of fats in the absence of bile acids in a neutral environment.

Low concentrations of hydrochloric acid and pepsins in the stomach in newborns and infants determine the reduced protective function of gastric juice, but at the same time contribute to the preservation of Ig, which come with mother's milk.

In the first months of life, the motor function of the stomach is reduced, peristalsis is sluggish, and the gas bubble is enlarged. The frequency of peristaltic contractions in newborns is the lowest, then it actively increases and after 3 years it stabilizes. By the age of 2, the structural and physiological features of the stomach correspond to those of an adult. In infants, an increase in the tone of the muscles of the stomach in the pyloric region is possible, the maximum manifestation of which is pylorospasm. At an older age, cardiospasm is sometimes observed. The frequency of peristaltic contractions in newborns is the lowest, then it actively increases and after 3 years it stabilizes.

In infants, the stomach is horizontal, with the pyloric portion near the midline and the lesser curvature facing posteriorly. As the child begins to walk, the axis of the stomach becomes more vertical. By the age of 7-11, it is located in the same way as in adults. The capacity of the stomach in newborns 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 cardiac sphincter in infants is very poorly developed, and the pyloric one functions satisfactorily. This contributes to the regurgitation often observed at this age, especially when the stomach is distended due to swallowing air during sucking ("physiological aerophagy"). In the gastric mucosa of young children, there are fewer glands than in adults. And although some of them begin to function even in utero, 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 composition of gastric juice in children is the same as in adults (hydrochloric acid, lactic acid, pepsin, rennet, lipase, sodium chloride), but the acidity and enzyme activity are much lower, which not only affects digestion, but also determines a low barrier stomach function. This makes it absolutely necessary to carefully observe the sanitary and hygienic regime during feeding of children (breast toilet, clean hands, proper expression of milk, sterility of nipples and bottles). In recent years, it has been established that the bactericidal properties of gastric juice are provided by lysozyme produced by the cells of the superficial epithelium of the stomach.

The maturation of the secretory apparatus of the stomach occurs earlier and more intensively in formula-fed children, which is associated with the body's adaptation to more indigestible food. The functional state and enzymatic activity depend on many factors: the composition of the ingredients and their quantity, the child's emotional tone, his physical activity, and his general condition. It is well known that fats suppress gastric secretion, while proteins stimulate it. Depressed mood, fever, intoxication are accompanied by a sharp decrease in appetite, i.e., a decrease in the secretion of gastric juice. Absorption in the stomach is insignificant and mainly concerns substances such as salts, water, glucose, and only partially - protein breakdown products. Motility of the stomach in children of the first months of life is slowed down, peristalsis is sluggish, the gas bubble is enlarged. The timing of the evacuation of food from the stomach depends on the nature of feeding. So, women's milk lingers in the stomach for 2-3 hours, cow's - for a longer time (3-4 hours and even up to 5 hours, depending on the buffer properties of milk), which indicates the difficulties of digesting the latter and the need to switch to more rare feedings.

Child's intestines

The intestine starts from the pylorus and ends at the anus. Distinguish between small and large intestines. The small intestine is divided into duodenum, jejunum and ileum; large intestine - on the blind, colon (ascending, transverse, descending, sigmoid) and rectum. The relative length of the small intestine in a newborn is large: 1 m per 1 kg of body weight, while in adults it is only 10 cm.

In children, the intestines are relatively longer than in adults (in an infant, it exceeds the length of the body by 6 times, in adults, by 4 times), but its absolute length varies individually within wide limits. The caecum and appendix are mobile, the latter is often located atypically, thereby making it difficult to diagnose inflammation. The sigmoid colon is relatively longer than in adults, and in some children even forms loops, which contributes to the development of primary constipation. With age, these anatomical features disappear. Due to the weak fixation of the mucous and submucosal membranes of the rectum, it may prolapse with persistent constipation and tenesmus in debilitated children. The mesentery is longer and easily stretchable, and therefore torsion, intussusception, etc., easily occur. The omentum in children under 5 years of age is short, so the possibility of localizing peritonitis in a limited area of ​​​​the abdominal cavity is almost excluded. Of the histological features, it should be noted the good severity of the villi and the abundance of small lymphatic follicles.

All intestinal functions (digestive, absorption, barrier and motor) in children differ from those of adults. 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 intestinal tract is generally formed by the time of the birth of the child, and even in the smallest children, the same enzymes are determined in the intestinal juice as in adults (enterokinase, alkaline phosphatase, erepsin, lipase, amylase, maltase, lactase, nuclease), but significantly less active. Only mucus is secreted in the large intestine. Under the influence of intestinal enzymes, mainly the pancreas, there is a breakdown of proteins, fats and carbohydrates. The process of digestion of fats is especially intense 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 parietal under the influence of pancreatic juice amylase and 6 disaccharidases localized in the brush border of enterocytes. In healthy children, only a small part of the sugars is not subjected to enzymatic breakdown and is converted in the large intestine to lactic acid by bacterial decomposition (fermentation). The processes of putrefaction in the intestines of healthy infants do not occur. Hydrolysis products formed as a result of cavitary and parietal digestion are absorbed mainly in the small intestine: glucose and amino acids into the blood, glycerol and fatty acids into the lymph. In this case, both passive mechanisms (diffusion, osmosis) and active transport with the help of carrier substances play a role.

The structural features 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, microbes and other pathogenic factors. The constituent components of human milk are most easily absorbed, the protein and fats of which in newborns are partially absorbed unsplit.

The motor (motor) function of the intestines is carried out in children very energetically due to pendulum movements that mix food, and peristaltic, moving food to the exit. Active motility is reflected in the frequency of 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 to 3 days after birth, the baby excretes meconium (original feces) of a greenish-black color. It consists of bile, epithelial cells, mucus, enzymes, and swallowed amniotic fluid. The feces of healthy breastfed newborns have a mushy texture, a golden yellow color, and a sour smell. In older children, the chair is decorated, 1-2 times a day.

Child's duodenum

The duodenum of a newborn has an annular shape (bends are formed later), its beginning and end are located at the L level. In children older than 5 months, the upper part of the duodenum is at the level of T X | 1; the descending part gradually drops by the age of 12 to the level L IM L IV . In young children, the duodenum is very mobile, but by the age of 7, adipose tissue appears around it, which fixes the intestine, reducing 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. The folds of the mucous membrane of the duodenum in newborns are lower than in older children, the duodenal glands are small, less branched than in adults. The duodenum has a regulatory effect on the entire digestive system through hormones secreted by the endocrine cells of its mucous membrane.

The small intestine of a child

The jejunum occupies approximately 2/5, and the ileum 3/5 of the length of the small intestine (excluding the duodenum). The ileum ends with an ileocecal valve (Bauhinian valve). In young children, relative weakness of the ileocecal valve is noted, and therefore the contents of the caecum, the richest in bacterial flora, can be thrown into the ileum, causing a high incidence of inflammatory lesions of its terminal section.

The small intestine in children occupies an unstable position, depending on the degree of its filling, the position of the body, the tone of the intestines and the muscles of the anterior abdominal wall. Compared with adults, the intestinal loops lie more compactly (due to the relatively large size of the liver and the underdevelopment of the small pelvis). After 1 year of life, as the pelvis develops, the location of the loops of the small intestine becomes more constant.

The small intestine of an infant contains a relatively large amount of gases, the volume of which gradually decreases until it disappears completely by the age of 7 (in adults, gases are normally absent in the small intestine).

The mucous membrane is thin, richly vascularized and has increased permeability, especially in children of the first year of life. Intestinal glands in children are larger than in adults. Their number increases significantly during the first year of life. In general, the histological structure of the mucous membrane becomes similar to that in adults by the age of 5-7 years. In newborns, single and group lymphoid follicles are present in the thickness of the mucous membrane. Initially, they are scattered throughout the intestine, and later they are grouped mainly in the ileum in the form of group lymphatic follicles (Peyer's patches). Lymphatic vessels are numerous, have a wider lumen than in adults. Lymph flowing from the small intestine does not pass through the liver, and the products of absorption enter the blood directly.

The muscular coat, especially its longitudinal layer, is poorly developed in newborns. The mesentery in newborns and young children is short, increasing significantly in length during the first year of life.

In the small intestine, the main stages of the complex process of splitting and absorption of nutrients occur with the combined action of intestinal juice, bile and pancreatic secretions. The breakdown of nutrients with the help of enzymes occurs both in the cavity of the small intestine (abdominal digestion) and directly on the surface of its mucous membrane (parietal, or membrane, digestion, which dominates in infancy during the period of milk nutrition).

The secretory apparatus of the small intestine is generally formed by birth. Even in newborns, the same enzymes can be determined in the intestinal juice as in adults (enterokinase, alkaline phosphatase, lipase, amylase, maltase, nuclease), but their activity is lower and increases with age. The peculiarities of protein assimilation in young children include the high development of pinocytosis by epithelial cells of the intestinal mucosa, as a result of which milk proteins in children in the first weeks of life can pass into the blood in an unmodified form, which can lead to the appearance of AT to cow's milk proteins. In children older than a year, proteins undergo hydrolysis to form amino acids.

Already from the first days of a child's life, all parts of the small intestine have a fairly high hydrolytic activity. Disaccharidases in the intestine appear even in the prenatal period. Maltase activity is quite high at birth and remains so in adults; sucrase activity increases somewhat later. In the first year of life, a direct correlation is observed between the age of the child and the activity of maltase and sucrase. Lactase activity increases rapidly in the last weeks of gestation, and after birth, the increase in activity decreases. It remains high throughout the period of breastfeeding, by the age of 4-5 there is a significant decrease in it, it is the smallest in adults. It should be noted that human milk rlactose is absorbed more slowly than cow's milk oslactose, and partially enters the large intestine, which contributes to the formation of gram-positive intestinal microflora in breastfed children.

Due to the low activity of lipase, the process of digesting fats is especially intense.

Fermentation in the intestines of infants complements the enzymatic breakdown of food. There is no rotting in the intestines of healthy children in the first months of life.

Absorption is closely related to parietal digestion and depends on the structure and function of the cells of the surface layer of the small intestine mucosa.

Large intestine of a child

The large intestine in a newborn has an average length of 63 cm. By the end of the first year of life, it lengthens to 83 cm, and subsequently its length is approximately equal to the height of the child. By birth, the colon does not complete its development. The newborn does not have omental processes (they appear on the 2nd year of the child's life), the bands of the colon are barely visible, the haustras of the colon are absent (they appear after 6 months). Colon bands, haustra and omental processes are finally formed by the age of 6-7 years.

The caecum in newborns has a conical or funnel-shaped shape, its width prevails over its length. It is located high (in a newborn directly under the liver) and descends into the right iliac fossa by the middle of adolescence. The higher the caecum, the more underdeveloped the ascending colon. The ileocecal valve in newborns looks like small folds. The ileocecal opening is annular or triangular, gaping. In children older than a year, it becomes slit-like. The appendix in a newborn has a conical shape, the entrance to it is wide open (the valve is formed in the first year of life). The appendix has great mobility due to the long mesentery and can be placed in any part of the abdominal cavity, including retrocecally. After birth, lymphoid follicles appear in the appendix, reaching their maximum development by 10-14 years.

The colon surrounds the loops of the small intestine. The ascending part of the newborn is very short (2-9 cm) and increases after the colon takes its final position. The transverse part of the colon in a newborn usually has an oblique position (its left bend is located higher than the right one) and only by the age of 2 takes a horizontal position. The mesentery of the transverse part of the colon in a newborn is short (up to 2 cm), within 1.5 years its width increases to 5-8.5 cm, due to which the intestine becomes able to move easily when the stomach and small intestine are filled. The descending part of the colon in a newborn has a smaller diameter than other parts of the colon. It is weakly mobile and rarely has a mesentery.

The sigmoid colon in a newborn is relatively long (12-29 cm) and mobile. Up to 5 years, it is located high in the abdominal cavity due to underdevelopment of the small pelvis, and then descends into it. 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. The large intestine provides water resorption and evacuation-reservoir function. It completes the absorption of digested food, breaks down the remaining substances (both under the influence of enzymes coming from the small intestine and bacteria that inhabit the large intestine), and the formation of feces occurs.

The mucous membrane of the large intestine in children is characterized by a number of features: deepened crypts, flatter epithelium, higher rate of its proliferation. Juice secretion of the colon under normal conditions is insignificant; however, it sharply increases with mechanical irritation of the mucous membrane.

The rectum of a child

The rectum of a newborn has a cylindrical shape, does not have an ampulla (its formation occurs in the first period of childhood) and bends (they form simultaneously with the sacral and coccygeal bends of the spine), its folds are not expressed. In children of the first months of life, the rectum is relatively long and poorly fixed, since fatty tissue is not developed. The rectum occupies the final position by 2 years. In a newborn, the muscular membrane is poorly developed. Due to the well-developed submucosa and weak fixation of the mucous membrane relative to the submucosa, as well as the insufficient development of the anal sphincter in young children, prolapse often occurs. The anus in children is located more dorsally than in adults, at a distance of 20 mm from the coccyx.

Functional features of the intestines of the child

The motor function of the intestine (motor) consists of pendulum movements that occur in the small intestine, due to which its contents are mixed, and peristaltic movements that move the chyme towards the large intestine. The colon is also characterized by anti-peristaltic movements, thickening and forming feces.

Motor skills in young children are more active, which contributes to frequent bowel movements. In infants, the duration of the passage of food gruel through the intestines is from 4 to 18 hours, and in older children - about a day. High motor activity of the intestine, combined with insufficient fixation of its loops, determines the tendency to intussusception.

Defecation in children

During the first hours of life, meconium (original feces) is passed - a sticky mass of dark green color with a pH of about 6.0. Meconium consists of desquamated epithelium, mucus, remnants of amniotic fluid, bile pigments, etc. On the 2nd-3rd day of life, feces are mixed with meconium, and from the 5th day, feces take on the appearance characteristic of a newborn. In children of the first month of life, defecation usually occurs after each feeding - 5-7 times a day, in children from the 2nd month of life - 3-6 times, in 1 year - 12 times. With mixed and artificial feeding, defecation is more rare.

Cal in children who are breastfed, mushy, yellow in color, sour reaction and sour smell; with artificial feeding, the feces have a thicker consistency (putty-like), lighter, sometimes with a grayish tint, neutral or even alkaline reaction, more pungent odor. 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 infants, defecation occurs reflexively, without the participation of the will. From the end of the first year of life, a healthy child is gradually accustomed to the fact that defecation becomes an arbitrary act.

Pancreas

The pancreas, a parenchymal organ of external and internal secretion, is small in newborns: its mass is about 23 g, and its length is 4-5 cm. Already by 6 months, the mass of the gland doubles, by 1 year it increases by 4 times, and by 10 years - 10 times.

In a newborn, the pancreas is located deep in the abdominal cavity at the level of T x, i.e. higher than that of an adult. Due to weak fixation to the posterior wall of the abdominal cavity in a newborn, it is more mobile. In children of early and older age, the pancreas is at the level of L n . Iron grows most intensively in the first 3 years and in the puberty period.

By birth and in the first months of life, the pancreas is not sufficiently differentiated, abundantly vascularized and poor in connective tissue. 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. The lobes and lobules of the pancreas in children are smaller and few in number. The endocrine part of the pancreas is more developed at birth than the exocrine part.

Pancreatic juice contains enzymes that ensure the hydrolysis of proteins, fats and carbohydrates, as well as bicarbonates, which create the alkaline reaction of the environment necessary for their activation. In newborns, a small volume of pancreatic juice is secreted after stimulation, amylase activity and bicarbonate capacity are low. Amylase activity from birth to 1 year increases several times. When switching to a normal diet, in which more than half of the calorie requirement is covered by carbohydrates, amylase activity increases rapidly and reaches maximum values ​​by 6-9 years. The activity of pancreatic lipase in newborns is low, which determines the great role of salivary gland lipase, gastric juice and breast milk lipase in the hydrolysis of fat. The activity of duodenal content lipase increases by the end of the first year of life, reaching the level of an adult by the age of 12. The proteolytic activity of the secret of the pancreas in children during the first months of life is quite high, it reaches a maximum at the age of 4-6 years.

The type of feeding has a significant effect on the activity of the pancreas: with artificial feeding, the activity of enzymes in the duodenal juice is 4-5 times higher than with natural feeding.

In a newborn, the pancreas is small (length 5-6 cm, by the age of 10 it is three times larger), located deep in the abdominal cavity, at the level of the X thoracic vertebra, in subsequent age periods - at the level of the I lumbar vertebra. It is richly vascularized, intensive growth and differentiation of its structure continues up to 14 years. The capsule of the organ is less dense than in adults, consists of fine-fibred structures, and therefore, in children with inflammatory edema of the pancreas, its compression is rarely observed. The excretory ducts of the gland are wide, which provides good drainage. Close contact with the stomach, the root of the mesentery, the solar plexus and the common bile duct, with which the pancreas in most cases has a common outlet to the duodenum, often leads to a friendly reaction from the organs of this zone with a wide irradiation of pain.

The pancreas in children, as in adults, has external and intrasecretory functions. The exocrine function is to produce pancreatic juice. It contains albumins, globulins, trace elements and electrolytes, as well as a large set of enzymes necessary for digestion of food, including proteolytic (trypsin, chymopsin, elastase, etc.), lipolytic (lipase, phospholipase A and B, etc.) and amylolytic (alpha- and beta-amylase, maltase, lactase, etc.). The rhythm of pancreatic secretion is regulated by neuro-reflex and humoral mechanisms. Humoral regulation is carried out by secretin, which stimulates the separation of the liquid part of pancreatic juice and bicarbonates, and pancreozymin, which enhances the secretion of enzymes along with other hormones (cholecystokinin, hepatokinin, etc.) produced by the mucous membrane of the duodenum and jejunum under the influence of hydrochloric acid. The secretory activity of the gland reaches the level of adult secretion by the age of 5. The total volume of separated juice and its composition depend on the amount and nature of the food eaten. The intrasecretory function of the pancreas is carried out by the synthesis of hormones (insulin, glucagon, lipocaine) involved in the regulation of carbohydrate and fat metabolism.

Liver in children

The size of the liver in children

The liver at the time of birth is one of the largest organs and occupies 1/3-1/2 of the volume of the abdominal cavity, its lower edge protrudes significantly from under the hypochondrium, and the right lobe can even touch the iliac crest. In newborns, the mass of the liver is more than 4% of body weight, and in adults - 2%. In the postnatal period, the liver continues to grow, but more slowly than body weight: the initial mass of the liver doubles by 8-10 months and triples by 2-3 years.

Due to the different rate of increase in the mass of the liver and body in children from 1 to 3 years of age, the edge of the liver comes out from under the right hypochondrium and is easily palpated 1-3 cm below the costal arch along the midclavicular line. From the age of 7, the lower edge of the liver does not come out from under the costal arch and is not palpable in a calm position; in the midline does not go beyond the upper third of the distance from the umbilicus to the xiphoid process.

The formation of liver lobules begins in the fetus, but by the time of birth, the liver lobules are not clearly demarcated. Their final differentiation is completed in the postnatal period. The lobulated structure is revealed only by the end of the first year of life.

The branches of the hepatic veins are located in compact groups and do not intersperse with the branches of the portal vein. The liver is plethoric, as a result of which it rapidly increases with infections and intoxications, circulatory disorders. The fibrous capsule of the liver is thin.

About 5% of the volume of the liver in newborns is accounted for by hematopoietic cells, subsequently their number decreases rapidly.

In the composition of the liver, the newborn has more water, but less protein, fat and glycogen. By the age of 8, the morphological and histological structure of the liver becomes the same as in adults.

Functions of the liver in the child's body

The liver performs various and very important functions:

• produces bile, which is involved in intestinal digestion, stimulates the motor activity of the intestine and sanitizes its contents;
• stores nutrients, mainly excess glycogen;
• performs a barrier function, protecting the body from exogenous and endogenous pathogenic substances, toxins, poisons, and takes part in the metabolism of medicinal substances;
• participates in the metabolism and conversion of vitamins A, D, C, B12, K;
• during fetal development is a hematopoietic organ.

The formation of bile begins already in the prenatal period, but bile formation at an early age is slowed down. With age, the ability of the gallbladder to concentrate bile increases. The concentration of bile acids in the hepatic bile in children of the first year of life is high, especially in the first days after birth, which leads to the frequent development of subhepatic cholestasis (bile thickening syndrome) in newborns. By the age of 4-10, the concentration of bile acids decreases, and in adults it increases again.

The neonatal period is characterized by the immaturity of all stages of the hepato-intestinal circulation of bile acids: insufficiency of their uptake by hepatocytes, excretion through the tubular membrane, slowing of bile flow, dyscholia due to a decrease in the synthesis of secondary bile acids in the intestine and a low level of their reabsorption in the intestine. Children produce more atypical, less hydrophobic, and less toxic fatty acids than adults. The accumulation of fatty acids in the intrahepatic bile ducts causes an increased permeability of intercellular junctions and an increased content of bile components in the blood. The bile of a child in the first months of life contains less cholesterol and salts, which determines the rarity of stone formation.

In newborns, fatty acids combine mainly with taurine (in adults - with glycine). Taurine conjugates are more soluble in water and less toxic. A relatively higher content of taurocholic acid in bile, which has a bactericidal effect, determines the rarity of the development of bacterial inflammation of the biliary tract in children of the first year of life.

Enzymatic systems of the liver, which provide adequate metabolism of various substances, are not mature enough at birth. Artificial feeding stimulates their earlier development, but leads to their disproportion.

After birth, the child's albumin synthesis decreases, which leads to a decrease in the albumin-globulin ratio in the blood.

In children, transamination of amino acids occurs much more actively in the liver: at birth, the activity of aminotransferases in the child's blood is 2 times higher than in the mother's blood. At the same time, the processes of transamination are not mature enough, and the number of essential acids for children is greater than for adults. So, in adults there are 8 of them, children under 5-7 years old need additional histidine, and children in the first 4 weeks of life also need cysteine.

The urea-forming function of the liver is formed by the age of 3-4 months; before that, children have a high excretion of ammonia in the urine at a low concentration of urea.

Children of the first year of life are resistant to ketoacidosis, although they receive a diet rich in fat, and at the age of 2-12 years, on the contrary, they are prone to it.

In a newborn, the content of cholesterol and its esters in the blood is much lower than in the mother. After the start of breastfeeding for 3-4 months, hypercholesterolemia is noted. In the next 5 years, the concentration of cholesterol in children remains lower than in adults.

In newborns in the first days of life, insufficient activity of glucuronyl transferase is noted, with the participation of which conjugation of bilirubin with glucuronic acid occurs and the formation of water-soluble "direct" bilirubin. Difficulty in the excretion of bilirubin is the main cause of physiological jaundice in newborns.

The liver performs a barrier function, neutralizes endogenous and exogenous harmful substances, including toxins from the intestines, and takes part in the metabolism of medicinal substances. In young children, the neutralizing function of the liver is not sufficiently developed.

The functionality of the liver in young children is relatively low. Its enzymatic system is especially untenable in newborns. In particular, the metabolism of indirect bilirubin released during hemolysis of erythrocytes is incomplete, resulting in physiological jaundice.

Gallbladder in a child

The gallbladder in newborns is usually hidden by the liver, its shape can be different. Its dimensions increase with age, and by the age of 10-12 years, the length increases by about 2 times. The rate of excretion of gallbladder bile in newborns is 6 times less than in adults.

In newborns, the gallbladder is located deep in the thickness of the liver and has a spindle-shaped shape, its length is about 3 cm. It acquires a typical pear-shaped shape by 6-7 months and reaches the edge of the liver by 2 years.

The bile of children differs in composition from the bile of adults. It is poor in bile acids, cholesterol and salts, but rich in water, mucin, pigments, and in the neonatal period, in addition, urea. 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 also accelerates the separation of pancreatic juice. Bile emulsifies fats, dissolves fatty acids, improves peristalsis.

The intestinal microflora of a child

During fetal development, the intestines of the fetus are sterile. Its colonization by microorganisms occurs first during the passage of the mother's birth canal, then through the mouth when children come into contact with surrounding objects. The stomach and duodenum contain a meager bacterial flora. In the small and especially the large intestine, it becomes more diverse, the number of microbes increases; microbial flora depends mainly on the type of feeding of the child. When breastfeeding, the main flora is B. bifidum, the growth of which is promoted by (3-lactose of human milk. When complementary foods are introduced or the child is transferred to cow's milk feeding, gram-negative Escherichia coli, which is a conditionally pathogenic microorganism, predominates in the intestine. therefore, dyspepsia is more common in formula-fed children.According to modern concepts, the normal intestinal flora performs three main functions:

Creation of an immunological barrier;

Final digestion of food residues and digestive enzymes;

Synthesis of vitamins and enzymes.

The normal composition of the intestinal microflora (eubiosis) is easily disturbed under the influence of infection, improper diet, as well as the irrational use of antibacterial agents and other drugs, leading to a state of intestinal dysbacteriosis.

Historical data on the intestinal microflora

The study of the intestinal microflora began in 1886, when F. Escherich described Escherichia coli (Bacterium coli centipae). The term "dysbacteriosis" was first introduced by A. Nissle in 1916. Later, the positive role of the normal intestinal microflora in the human body was proved by I. I. Mechnikov (1914), A. G. Peretz (1955), A. F. Bilibin (1967), V. N. Krasnogolovets (1968), A. S. Bezrukova (1975), A. A. Vorobyov et al. (1977), I.N. Blokhina et al. (1978), V. G. Dorofeichuk et al. (1986), B. A. Shenderov et al. (1997).

Characteristics of the intestinal microflora in children

The microflora of the gastrointestinal tract takes part in digestion, prevents the development of pathogenic flora in the intestine, synthesizes a number of vitamins, participates in the inactivation of physiologically active substances and enzymes, affects the rate of renewal of enterocytes, enterohepatic circulation of bile acids, etc.

The intestines of the fetus and newborn are sterile during the first 10-20 hours (aseptic phase). Then the colonization of the intestine by microorganisms begins (second phase), and the third phase - stabilization of the microflora - lasts at least 2 weeks. The formation of intestinal microbial biocenosis begins from the first day of life, by the 7-9th day in healthy full-term children, the bacterial flora is usually represented mainly by Bifidobacterium bifldum, Lactobacillus acidophilus. With natural feeding, B. bifidum prevails among the intestinal microflora, with artificial feeding, L. acidophilus, B. bifidum and enterococci are present in almost equal amounts. The transition to a diet typical for adults is accompanied by a change in the composition of the intestinal microflora.

Intestinal microbiocenosis

The center of the human microecological system is the intestinal microbiocenosis, which is based on the normal (indigenous) microflora, which performs a number of important functions:

Indigenous microflora:

• participates in the formation of colonization resistance;
• produces bacteriocins - antibiotic-like substances that prevent the reproduction of putrefactive and pathogenic flora;
• normalizes intestinal peristalsis;
• participates in the processes of digestion, metabolism, detoxification of xenobiotics;
• possesses universal immunomodulatory properties.

Distinguish mucoid microflora(M-microflora) - microorganisms associated with the intestinal mucosa, and cavity microflora(P-microflora) - microorganisms localized mainly in the intestinal lumen.

All representatives of the microbial flora with which the macroorganism interacts are divided into four groups: obligate flora (the main intestinal microflora); facultative (conditionally pathogenic and saprophytic microorganisms); transient (random microorganisms incapable of prolonged stay in the macroorganism); pathogenic (causative agents of infectious diseases).

Obligate microflora intestines - bifidobacteria, lactobacilli, full-fledged E. coli, propionobacteria, peptostreptococci, enterococci.

Bifidobacteria in children, depending on age, range from 90% to 98% of all microorganisms. Morphologically, they are gram-positive, immobile rods with a club-shaped thickening at the ends and bifurcation at one or both poles, anaerobic, not forming spores. Bifidobacteria are divided into 11 species: B. bifidum, B. ado-lescentis, B. infantis, B. breve, B. hngum, B. pseudolongum, B. thermophilum, B. suis, B. asteroides, B. indu.

Dysbacteriosis is a violation of the ecological balance of microorganisms, characterized by a change in the quantitative ratio and qualitative composition of the indigenous microflora in the microbiocenosis.

Intestinal dysbacteriosis is a violation of the ratio between anaerobic and aerobic microflora towards a decrease in the number of bifidus and lactobacilli, normal E. coli and an increase in the number of microorganisms found in small numbers or usually absent in the intestine (opportunistic microorganisms).

Methodology for the study of the digestive system

The state of the digestive organs is judged by complaints, the results of questioning the mother and the data of objective research methods:

examination and observation in dynamics;

palpation;

percussion;

laboratory and instrumental indicators.

Complaints of the child

The most common of these are complaints of abdominal pain, loss of appetite, regurgitation or vomiting, and bowel dysfunction (diarrhea and constipation).

Questioning a child

A doctor-directed questioning of the mother allows you to clarify the time of onset of the disease, its relationship with the characteristics of nutrition and regimen, past diseases, and family-hereditary nature. Of particular importance is the detailed clarification of feeding issues.

Abdominal pain is a common symptom that reflects a variety of childhood pathologies. Pain that arose for the first time requires, first of all, the exclusion of surgical pathology of the abdominal cavity - appendicitis, intussusception, peritonitis. They can also be caused by acute infectious diseases (influenza, hepatitis, measles), viral and bacterial intestinal infections, inflammation of the urinary tract, pleuropneumonia, rheumatism, pericarditis, Shenlein-Genoch disease, periarteritis nodosa. Recurrent abdominal pain in older children are observed in diseases such as gastritis, duodenitis, cholecystitis, pancreatitis, peptic ulcer of the stomach and duodenum, ulcerative colitis. Functional disorders and helminthic invasion can also be accompanied by abdominal pain.

Reduced or prolonged loss of appetite (anorexia) in children is often the result of psychogenic factors (school overload, family conflict, neuroendocrine dysfunction during puberty), including improper feeding of the child (forced feeding). However, usually a decrease in appetite indicates a low secretion of the stomach and is accompanied by trophic and metabolic disorders.

Vomiting and regurgitation in newborns and infants may be due to pyloric stenosis or pylorospasm. In healthy children of this age, aerophagia leads to frequent regurgitation, which is observed in violation of the feeding technique, a short frenulum of the tongue, and a tight chest in the mother. In children 2-10 years old, suffering from neuro-arthritic diathesis, acetonemic vomiting may periodically occur due to acute reversible metabolic disorders. Emergence of vomiting in connection with damage of TsNS, infectious diseases, poisonings is possible.

Diarrhea in children of the first year of life often reflects intestinal dysfunction due to qualitative or quantitative feeding errors, regimen violations, overheating (simple dyspepsia) or is accompanied by an acute febrile illness (parenteral dyspepsia), but can also be a symptom of enterocolitis with intestinal infection.

Constipation - rare bowel movements occurring after 48 hours or more. They can be the result of both a functional disorder (dyskinesia) of the large intestine, and its organic damage (congenital narrowing, anal fissures, Hirschsprung's disease, chronic colitis) or inflammatory diseases of the stomach, liver and biliary tract. Nutritional (food intake, poor fiber) and infectious factors are of some importance. Sometimes constipation is associated with the habit of delaying the act of defecation and the resulting violation of the tone of the lower segment of the colon, and in infants with chronic malnutrition (pyloric stenosis). In children with sufficient weight gain, breastfed, stools are sometimes rare due to good digestion and a small amount of toxins in the intestines.

When examining the abdomen, pay attention to its size and shape. In healthy children of different ages, it slightly protrudes above the level of the chest, and subsequently flattens somewhat. An increase in the size of the abdomen can be due to a number of reasons:

• hypotension of the muscles of the abdominal wall and intestines, which is especially often observed in rickets and dystrophies;
• flatulence that develops with diarrhea of ​​various etiologies, persistent constipation, intestinal dysbacteriosis, pancreatitis, pancreatic cystic fibrosis;
• an increase in the size of the liver and spleen in chronic hepatitis, systemic blood diseases, circulatory failure and other pathologies;
• the presence of fluid in the abdominal cavity due to peritonitis, ascites;
• neoplasm of the abdominal cavity and retroperitoneal space.

The shape of the abdomen also has a diagnostic value: its uniform increase is observed with flatulence, hypotension of the muscles of the anterior abdominal wall and intestines ("frog" abdomen - with rickets, celiac disease), local bulging with hepatolienal syndrome of various etiologies, tumors of the abdominal cavity and retroperitoneal space. Retraction of the abdomen can be observed when the child is starving, pyloric stenosis, meningitis, diphtheria. On examination, it is possible to determine the condition of the navel in newborns, the expansion of the venous network in liver cirrhosis, the divergence of the muscles of the white line and hernial protrusions, and in malnourished children in the first months of life, intestinal motility, which increases with pyloric stenosis, intussusception and other pathological processes.

Palpation of the abdomen and abdominal organs of the child

Palpation of the abdomen and abdominal organs is best done in the position of the patient on his back with legs slightly bent, with a warm hand, starting from the navel, and it is necessary to try to distract the child's attention from this procedure. Superficial palpation is carried out with light tangential movements. It makes it possible to determine the condition of the skin of the abdomen, muscle tone and tension of the abdominal wall. With deep palpation, the presence of painful points, infiltrates is detected, the dimensions, consistency, nature of the surface of the lower edge of the liver and spleen are determined, an increase in mesenteric lymph nodes in tuberculosis, lymphogranulomatosis, reticulosis and other diseases, spastic or atonic state of the intestine, accumulation of feces.

Palpation is also possible in the vertical position of the child with a half-tilt forward and lowered arms. At the same time, the liver and spleen are well probed, free fluid in the abdominal cavity is determined. In older children, bimanual palpation of the abdominal organs is used.

Percussion of the child's abdomen

Examination of the child's abdomen

Lastly, the child's mouth and pharynx are examined. At the same time, attention is paid to the smell from the mouth, the condition of the mucous membranes of the cheeks and gums (the presence of aphthae, ulcers, bleeding, fungal overlays, Filatov-Koplik spots), teeth, tongue (macroglossia with myxedema), papillary raspberry - with scarlet fever, coated - with diseases of the gastrointestinal tract, "geographic" - with exudative-catarrhal diathesis, "varnished" - with hypovitaminosis B12).

The area of ​​the anus is examined in younger children in the position on the side, in the rest - in the knee-elbow position. On examination, the following are revealed: anal fissures, a decrease in the tone of the sphincter and its gaping with dysentery, prolapse of the rectum with persistent constipation or after an intestinal infection, irritation of the mucous membrane during pinworm invasion. A digital examination of the rectum and sigmoid colonoscopy can detect polyps, tumors, strictures, fecal stones, ulcers of the mucous membrane, etc.

Of great importance in assessing the state of the digestive system is a visual examination of the stool. In infants with intestinal enzyme dysfunction (simple dyspepsia), dyspeptic stools are often observed, which look like chopped eggs (liquid, greenish, mixed with white lumps and mucus, acid reaction). Very characteristic stool in colitis, dysentery. Bloody stool without admixture of feces against the background of an acutely developed severe general condition may be in children with intestinal intussusception. Discolored stool indicates a delay in the flow of bile into the intestine and is observed in children with hepatitis, blockage or atresia of the bile ducts. Along with determining the quantity, consistency, color, odor and pathological impurities visible to the eye, the characteristics of the stool are supplemented by microscopy (coprogram) data on the presence of leukocytes, erythrocytes, mucus in the feces, as well as helminth eggs, lamblia cysts. In addition, bacteriological and biochemical studies of feces are carried out.

Laboratory and instrumental research

These studies are similar to those conducted in adults. The most important is endoscopy, which is currently widely used, which allows visually assessing the condition of the mucous membranes of the stomach and intestines, making a targeted biopsy, detecting neoplasms, ulcers, erosions, congenital and acquired strictures, diverticula, etc. Endoscopic examinations of children of early and preschool age are carried out under general anesthesia. Ultrasound examination of parenchymal organs, radiography of the biliary tract and gastrointestinal tract (with barium), gastric and duodenal sounding, determination of enzymes, biochemical and immunological blood parameters, biochemical analysis of bile, rheohepatography, laparoscopy with targeted liver biopsy and subsequent morphological study of the biopsy are also used. .

Of particular importance are laboratory and instrumental research methods in the diagnosis of diseases of the pancreas, which, due to its location, is not amenable to direct methods of physical examination. The size and contours of the gland, the presence of stones in the excretory ducts, developmental anomalies are detected by relaxation duodenography, as well as retrograde cholangiopancreatography, echopancreatography. Violations of exocrine function observed in cystic fibrosis, post-traumatic cysts, biliary atresia, pancreatitis, are accompanied by a change in the level of the main enzymes that are determined in the blood serum (amylase, lipase, trypsin and its inhibitors), in saliva (isoamylase), urine and duodenal contents. An important indicator of insufficiency of exocrine pancreatic function is persistent steatorrhea. The intrasecretory activity of the pancreas can be judged on the basis of studying the nature of the glycemic curve.