DIGESTIVE SYSTEM

The anatomic and physiological features of the

digestive system
Digestive organs of the child have a number of morphological and physiological
features. These features are most pronounced in infants whose digestive system is adapted
primarily for the assimilation of breast milk, digestion of which requires the least amount
of enzymes.

ORAL

Newborns and infants mouth is relatively small. Lips neonatal thick on the inner surface of
a transverse ridges. Circular muscle of the mouth well developed. Cheeks in infants and
young children are rounded and convex due to the presence between the skin and a well
developed circular muscle of the buccal fat body (fatty lumps Bichat), which subsequently,
from the age of 4, gradually atrophies. Hard palate is flat, its mucous membrane forms a
mild transverse folds, poor glands. Soft palate is relatively short, is almost
horizontal. Velum does not apply to the rear wall of the pharynx, allowing the child to
breath during sucking. With the emergence of primary teeth is a significant increase in the
size of the alveolar processes of jaws and a set of hard palate as it rises. Language neonatal
short, wide, fat and sedentary, the mucosa can be seen well-marked papillae. Language is
the entire oral cavity: with a closed mouth touches with the cheeks and hard palate,
protruding between the jaws on the eve of his mouth.

Oral mucosa in children, especially young children, thin and easily vulnerable, it is
necessary to take into account when processing the oral cavity. The mucous membrane of
the bottom of the mouth forms a prominent fold, covered with a large number of
villi. Protrusion in the form of ridge is present on the mucosa of the cheek in the gap
between the upper and lower jaws. In addition, the transverse folds (ridges) are solid and
the sky, vali-koobraznye thickening - on the gums. All these formations provide the sealing
of the mouth in the process of sucking. In the mucosa of the hard palate in the midline in
newborns are nodules Bona - yellowish education - retention cysts of salivary glands,
disappearing by the end of the first month of life.

Oral mucosa in children the first 3-4 months of life is relatively dry, due to insufficient
development of the salivary glands and lack of saliva. Salivary glands (parotid,
submandibular, sublingual, small cancer of the oral mucosa) in the newborn is
characterized by low secretory activity and produce a very small amount of thick viscous
saliva, needed for bonding and sealing lips of the mouth during sucking. Functional activity
of the salivary glands begins to increase at the age of 1,5-2 months; in 3-4-month-old
children often derives saliva from the mouth due to the immaturity of the regulation of
salivation and swallowing of saliva (physiological salivation). The most intense growth and
development of the salivary glands occurs between the ages of 4 months and 2 years. By 7
years of a child produced the same amount of saliva as an adult. The reaction of saliva in
infants more often neutral or slightly acid. From the first days of life in their saliva contains
a-amylase and other enzymes needed for decomposition of starch and glycogen. Newborn
concentration of amylase in saliva is low during the first year of life, its content and activity
increase significantly, reaching a peak in 2-7 years.

Pharynx and larynx

Throat newborn has the shape of the crater, its lower edge is projected on the level of the
intervertebral disk between the P M | and C IV. By adolescence, he descends to the level of
C vl-C V | |. Larynx in infants also have funnel-shaped form and is different than in adults.
Entrance into the larynx is located high above nizhnezadnim edge of the velum and
connected to the oral cavity. Food moves along the sides of the serving of the larynx, so the
child can breathe and swallow at the same time, without interrupting the sucking.

Sucking and swallowing

Sucking and swallowing - congenital unconditioned reflexes. In healthy and mature

newborns, they are already formed at the time of birth. When a child sucking his lips tightly
grasp nipple. Jaws are squeezing it, and communication between the oral cavity and the
outside air is terminated. In the mouth of the child creates a negative pressure, which
contributes to lowering of the mandible with the tongue down and back. Then, in the
rarefied space of the oral cavity enters breast milk. All elements of the masticatory
apparatus adapted to process newborn sucking chest: gum membrane, expressed palatine
transverse folds and body fat in the cheeks. Gadgets mouth to newborn sucking also serves
as a physiological infant retrogna-ment, which later turns into ortognatiyu. In the process
of sucking child produces rhythmic movements of the lower jaw from front to back. Lack
articular tubercle facilitates sagittal movement of the mandible of the Child.

ESOPHAGEAL

Esophagus - muscular tube fusiform, the inside is lined with mucous membrane. By the
birth of the esophagus is formed, the length of a newborn is 10-12 cm, at age 5 - 16 cm, and
in 15 years - 19 cm The relationship between esophageal length and body length remained
relatively constant and is approximately 1:5. The width of the esophagus in a newborn - 5-
8 mm, in 1 year - 10-12 mm, to 3.6 years - 13-15 mm to 15 years - 18-19 mm. Dimensions
of the esophagus should be considered in fiber-esophagogastroduodenoscopy (FEGDS),
duodenal sounding and gastric lavage.

Anatomical narrowing of the esophagus in infants and children in the first year of life are
mild and are formed with age. The wall of the esophagus in a newborn thin, muscular
sheath weakly developed, it rapidly grows to 12-15 years. The mucous membrane of the
esophagus in infants is poor glands. Longitudinal folds appear at the age of 2-2,5 years.Sub-
mucous membrane well developed, rich in blood vessels.

Beyond the act of swallowing the transition of the pharynx to the esophagus
closed. Peristalsis of the esophagus occurs when swallowing movements.

STOMACH

Stomach of a newborn is in the form of a cylinder, bull horns or a fishing rod and sits high
(inlet of the stomach at the level of T VIII-T IX, a hole doorman - at T x1-T x | 1). With the growth
and development of the child stomach drops and the age of 7 years of its inlet (in the
vertical position of the body) is projected between T X | X1 and T |, and the output -
between xk and T L,. Infants stomach is flat, but as soon as the child begins to walk, it
gradually assumes a more upright position.

Cardiac portion, bottom and pyloric stomach in the newborn department are mild, porter
wide. Input part of the stomach are often located above the diaphragm, the angle between
the abdominal part of the esophagus and the adjacent wall of the bottom of the stomach is
not enough pronounced cardiac muscle membrane of the stomach is also poorly
developed. Valve Gubareva (fold mucosa, jutting out into the cavity of the esophagus and
prevents the casting of food) is almost not expressed (growing to 8.9 months of life),
cardiac sphincter is functionally defective, whereas the pyloric division of the stomach is
functionally well developed at birth of the child. These features determine the possibility of
casting the contents of the stomach into the esophagus and the development of peptic
lesions to the mucous membrane. In addition, the tendency of children in the first year of
life to the sry-givaniyu and vomiting associated with the absence of dense obhvatyvaniya
esophageal foot aperture, and the violation of innervation with increased intra-gastric
pressure. Regurgitation also contributes to swallowing air when sucking (pneumophagia)
for improper feeding technique, short bridle tongue, greedily sucking up too quickly
allocation of milk from the breast of the mother.

In the first weeks of life stomach is in an oblique frontal plane, the front is fully covered
with the left lobe of the liver, and therefore the bottom of the stomach in a prone position is
below the antral-pyloric division, so to prevent aspiration after feeding children should be
given to exalted status. By the end of the first year of life extended stomach, and in the
period from 7 to 11 years, takes the form similar to the adult form. By 8 years of complete
formation of its cardiac part.

Anatomic newborn stomach capacity is 30-35 cm 3, to 14 th day of life, she grows up to 90

cm 3. The physiological capacity of less than anatomical, and on the first day of life is only
7.10 ml; K4 day after the start of enteral feeding, it increases to 40-50 ml, and the 10-th day
- up to 80 ml. In the subsequent capacity of the stomach monthly increases of 25 ml and the
end of the first year of life is 250-300 ml, and sentenced to 3 years - 400-600 ml. The
intensive increase capacity of the stomach starts after 7 years and 10.12 years of 1300-
1500 ml.

Muscle membrane of the stomach in the newborn is weak, it reaches its maximum
thickness of only 15-20 years. The mucous membrane of the stomach in the newborn thick,
folds higher. During the first 3 months of life mucosal surface increases to 3 times, which
helps to digest milk. For 15 years the surface of the gastric mucosa increased 10
times. With age, an increasing number of gastric pits, which opened holes in the gastric
glands. Gastric cancer in the birth of morphologically and functionally are underdeveloped,
their relative number (per 1 kg body weight) in newborn infants in 2.5 times less than in
adults, but increases rapidly the start of enteral nutrition.

The secretory apparatus of the stomach in children the first year of life are
underdeveloped, the functional capacity of the low. Gastric juice infant contains the same
components as the gastric juice adult: hydrochloric acid, himozin (clot milk), pepsin (cleave
proteins at albumozy and peptones) and lipase (breaks down neutral fats into fatty acids
and glycerol).

For children of the first weeks of life characterized by very low concentration of
hydrochloric acid in gastric juice and its low total acidity. It increases significantly after the
introduction of complementary foods, ie, the transition from lacquer-totrofnogo supply to
normal. At the same time lowering the pH of gastric juice increases the activity of carbonic
anhydrase, which is involved in the formation of hydrogen ions. The children of the first 2
months of life the pH value is mainly determined by hydrogen ions, lactic acid, and
subsequently - a salt.

The synthesis of proteolytic enzymes principal cells begins in the antenatal period, but
their content and functional activity in neonates are low and gradually increased with age.
The leading role in the hydrolysis of proteins in infants is fetal pepsin, which has a higher
proteolytic activity. Infants marked by wide fluctuations in activity proteolytic enzymes,
depending on the nature of feeding (artificial - indicators of activity above). In children the
first year of life (unlike adults) have noted the high activity of gastric lipase, which provides
the hydrolysis of fat in the absence of bile acids in the neutral medium.

Low concentrations of hydrochloric acid and pepsin in the stomach in neonates and infants
identify a reduced protective function of gastric juice, but at the same time contribute to
the preservation of Ig, which comes with mother's milk.

In the first months of life and motor function of the stomach is reduced, sluggish peristalsis,
the gas bubble is increased. Frequency of peristaltic contractions in the smallest babies,
then actively growing and after 3 years to stabilize. By 2 years of structural and
physiological features of the stomach correspond to those of an adult. Infants may improve
muscle tone of the stomach in the pyloric division, the maximum expression of which is
pilorospazme. In older age sometimes observed kardiospazm. Frequency of peristaltic
contractions in the smallest babies, then actively growing and after 3 years to stabilize.

COLON

The intestine begins at the pyloric stomach and ends with the rectum. There are small and
large bowel. Small intestine is divided into the duodenum, lean and iliac; colon - on the
blind, colon (ascending, transverse, descending, sigmoid) and rectum. The relative length of
the small intestine in a newborn large: for 1 kg of body weight accounts for 1 m, and in
adults - only 10 cm

Duodenum

Duodenum newborn has a ring-shaped form (bends are formed later), its beginning and
end are located at Children older than 5 months the upper part of the duodenum at the
level of T X ([; down side is gradually lowered to 12 years to a level L | M-L | V. In infants
duodenum is very agile, but for 7 years around appears adipose tissue, which captures the
intestine, reducing its mobility.

In the upper part of the duodenum occurring alkalization acidic gastric chyme, preparation
for the action of enzymes, which come from the pancreas and are formed in the intestine,
and mixing with bile. The folds of the mucous membrane of the duodenum in infants is
lower than in older children, duodenal cancer are small, branched weaker than in
adults.Duodenum has a regulating effect on the entire digestive system by hormones,
endocrine cells of its allocated mucosa.

Small Intestine

Jejunum is approximately 2 / 5, and iliac 3 / 5 length of the small intestine (without the
duodenum). Ileum ends ileocecal valve (valve Bauhin). In young children celebrate the
relative weakness of the ileocecal valve, and therefore the contents of the cecum, the most
rich bacterial flora, may throw in the ileum, causing a high incidence of inflammatory
lesions of the terminal division.

The small intestine in children is a more volatile situation, depending on the degree of its
filling, posture, tone the intestines and muscles anterior abdominal wall. Compared with
older intestinal loops are more compact (due to the relatively large size of the liver and
hypoplasia of the pelvis). After 1 year of life, with the development of the pelvis, the
location of loops of small intestine becomes more permanent.

In the small intestine of an infant contains a relatively large number of gases, the volume of
which gradually decreases until the complete disappearance of 7 years (adults in normal
gas in the small intestine is not).
The mucosa is thin, richly vascularized and has increased permeability, especially in
children the first year of life. Intestinal cancer in children larger than that of adults. Their
number increases considerably during the first year of life. In general histological structure
of the mucous membrane is similar to that seen in adults to 5.7 years. Babies in the
thickness of the mucosa present single and group lymphoid follicles. Initially, they are
scattered throughout the gut, and subsequently grouped mainly in the ileum in a group of
lymph follicles (peyerovyh plaques). Lymphatic vessels are numerous, have a wider lumen
than in adults. Lymph flowing from the small intestine, does not pass through the liver, and
food intake directly into the blood.

Muscular sheath, particularly the longitudinal layer, the newborn is poorly

developed. Mesentery in infants and young children is short, significant increases in length
during the first year of life.

In the small intestine there are basic steps the complex process of splitting and absorption
of nutrients under the joint action of intestinal juice, bile and pancreatic
secretions.Cleavage of food substances by enzymes takes place both in the cavity of the
small intestine (abdominal digestion), and directly on the surface of the mucosa (Near-wall
or membrane, digestion, which dominates in infancy during the period of milk feeding).

The secretory apparatus of the small intestine to the birth of a whole is formed. Even
newborns in the intestinal juice can be defined the same enzymes as that of adults
(enterokinase, alkaline phosphatase, lipase, amylase, mal-pelvis, nuclease), but their lower
and increases with age. The peculiarities of protein digestion in infants should include a
high development of pinocytosis epitheliocytes gut mucosa, resulting in milk proteins in
children during the first weeks of life may pass into the blood in maloizmenennykh form,
which can lead to the emergence of AT to the proteins of cow's milk. In children over the
age of proteins undergo hydrolysis with formation of amino acids.

From the first days of life all divisions of the small intestine have a sufficiently high
hydrolytic activity. Disaharidazy in the intestines even appearing in the prenatal
period. Maltase activity is high enough for the birth and remains so in adults, later
increases activity saccharases. In the first year of life, there is a direct correlation between
the age of the child and the activity of Maltase and saccharases. Lactase activity increases
rapidly in the last weeks of gestation and after birth increase the activity decreases. High, it
remains for the duration of breastfeeding, to 4-5 years is a substantial declines, it is the
smallest in adults. It should be noted that the p-lactose human milk is absorbed more
slowly than the oc-lactose cow's milk, and partially into the colon, that promotes the
formation of Gram-positive intestinal microflora in children who are breastfed.

Because of the low activity of lipase is particularly hard is the process of digestion of fats.

Fermentation in the intestines of infants complements zymolysis food. Rotting in the

intestines of healthy children during the first months of life for it.
Absorption is closely related to parietal digestion and depends on the structure and
function of cells of the surface layer of mucous membrane of the small intestine.

The colon

The colon in the newborn has an average length of 63 cm by the end of the first year of life,
it shall be extended to 83 cm, and subsequently, its length is approximately equal to the
growth of the child. The birth of large intestine does not complete its development. In the
newborn there is no stuffing processes (appearing on the 2 nd year of life), tapes colon
barely identified, haustrum colon missing (they appear after 6 months). Ribbons colon,
haustrum and packing processes are completely formed by 6-7 years.

The cecum in newborns has a conical or funnel shape, its width dominates over the
length. It is situated high (in the neonate directly under the liver) and in the right iliac fossa
down to the mid-teens. The higher the cecum, the more fully developed ascending
colon. Ileocecal valve in newborns has the form of small folds. Ileocecal orifice ring-shaped
or triangular, yawning. In children over the year it becomes a slit. Appendix in the newborn
has a conical shape, the entrance to his wide open (the valve is formed in the first year of
life). Appendix has a high mobility because of the long mesentery and can be placed in any
part of the abdomen, including lumbar. After the birth in the appendix appearing lymphoid
follicles, receiving the maximum development for 10-14 years.

Colon surrounds the loop of the small intestine. Rising part of a newborn is very short (2-
9 cm) and increases after the colon will take its final position. Lateral portion of the colon in
a newborn is usually oblique position (left of curve lies above right) and only 2 years is
horizontal position. mesentery of transverse colon in a newborn is short (up to 2 cm)
within 1.5 years of its width increases up to 5-8,5 cm, so gut acquires the ability to easily
move around while filling the stomach and small intestine. The descending part of the
colon in a newborn has a smaller diameter than other parts of the colon. She weakly mobile
and rarely has the mesentery.

Sigmoid colon in a newborn relatively long (12-29 cm) and mobile. Up to 5 years, it is
high in the abdominal cavity due to hypoplasia of the pelvis, and then sinks into it. Motility
due to a long mesentery. To 7 years of bowel loses its mobility as a result of shortening and
accumulation of mesenteric adipose tissue around it. The colon provides the resorption of
water and the evacuation-reservoir function. It ends with digested food intake, split the
remaining substances (as under the influence of enzymes originating from the small
intestine and the bacteria inhabiting the colon), is formed stool.

The mucosa of the colon in children is characterized by several features: deepened crypts,
the epithelium of a flat above the rate of its proliferation. Secretion of the colon under
normal conditions slightly, but it increases sharply with the mechanical stimulation of the
mucosa.
Rectum

Rectum in the newborn has a cylindrical shape, has an ampoule (its formation occurs in the
first period of childhood) and bends (formed simultaneously with the sacral and tail curves
of the spine), the folds of her are not expressed. The children of the first months of life, the
rectum is relatively long and poorly fixed because fatty tissue is not developed. The final
position of the rectum is for 2 years. Newborn muscle membrane is poorly developed. With
well-developed submucosa and mucosa of weak fixation on the submucosa, as well as the
insufficient development of the sphincter of the anus in infants, it is often a loss. Rectum in
children is located in the dorsal compared with adults, at a distance of 20 mm from the
coccyx.

Functional features of intestinal

Motor function of the intestines (motility) consists of a pendulum-like motions, resulting in

the small intestine, through which the contents are mixed, and bowel movements that
promote chyme toward the large intestine. For the colon and is characterized anastaltic
motion, thickening and forming cal.

Motor activity in young children more active, which contributes to frequent bowel
movement. Infants duration of passage of chyme through the intestines is from 4 to 18 h,
and the older children - about one day. High motor activity of intestine in combination with
insufficient fixation loops determines its propensity to create intussusception.

Defecation

During the first hours of life is discharge of meconium (feces original) - sticky mass of dark
green color with a pH of about 6,0. Myoko-tion consists of desquamated epithelium, mucus,
remnants of amniotic fluid, bile pigments, etc. In the 2-3rd day of life to meconium mixed
with feces, and from the 5 th day of cal takes characteristic of a newborn look. In children,
the first month of life defecation usually takes place after each feeding - 5-7 times a day,
children from the 2 nd month of life - 3-6 times in 1 year - 1-2 times. When mixed and
artificial feeding defecation more rare.

Cal for children who are breastfed, mushy, yellow color, acid reaction and the sour smell,
with artificial feeding stool has a thicker consistency (zamazkoobrazny), lighter, sometimes
with a grayish hue, neutral or alkaline reaction, a sharp odor. The golden-yellow color of
feces in the first months of life due to the presence of bilirubin, greenish - dehydrobilirubin.

Infants defecation reflex action occurs without the participation of faith. Since the end of
the first year of life a healthy baby gradually learns to ensure that defecation is an arbitrary
act.

The microflora of the gastrointestinal tract

The microflora of the digestive tract is involved in digestion, prevents the development of
pathogenic flora in the intestine synthesizes some vitamins, is involved in the inactivation
of physiologically active substances and enzymes that affect the renewal rate of
enterocytes, enterohepatic circulation of bile acids, etc.

Colon fetus and the newborn is sterile during the first 10-20 h (aseptic phase). Then begins
settling intestinal microorganisms (second phase), and the third phase - stabilization
microflora - lasts at least 2 weeks. Formation of microbial gut microflora begins with the
first days of life, the 7-9-th days in healthy term infants bacterial flora usually consists
mainly of Bifidobacterium bifidum, Lactobacillus acidophilus. When breastfeeding
among intestinal microflora dominated by B. bifidum, when artificial feeding in almost
equal amounts present L. acidophilus, B. bifidum and enterococci. Switch to food that is
typical for adults, accompanied by a change in the composition of intestinal microflora.

Pancreas

Pancreas - parenchymal organ of external and internal secretion - the newborn has a small
size: its mass is about 2-3 g, and length - 4-5 cm By 6 months of the mass of cancer is
doubled to 1 year increased by 4 times, and to 10 years - 10 times.

In the newborn pancreas is located deep in the abdomen at the level of T x, ie higher than in
adults. Due to the weak fixation to the rear wall of the abdominal cavity of a newborn, she
is more mobile. In infants and older ages, the pancreas is on the level of L ". The most
intense iron increases in the first 3 years and puberty.

By birth and the first months of life, the pancreas is differentiated enough, richly
vascularized connective tissue and poor. At an early age the surface of the pancreas is
smooth, but appears to 10.12 years roughness caused by release of the borders of the
lobes. Fractions and lobules of the pancreas in children is smaller in size and in
numbers. Endocrine part of the pancreas to the birth of more developed than eccrine.

Pancreatic juice contains enzymes that ensure the hydrolysis of proteins, fats and
carbohydrates, as well as bicarbonate, creating a need for them to activate alkaline
environment. Newborn allocated a small amount of pancreatic juice after stimulation,
amylase and bicarbonate capacity are low. Amylase from birth to 1 year increased by
several times. When you go to the usual food, in which more than half of the caloric
requirement is covered by carbohydrates, amylase increases rapidly and reaches a
maximum value of 6.9 years. The activity of pancreatic lipase in neonates is low, which
determines the important role of lipase salivary glands, gastric juice and breast milk lipases
in hydrolysis of fat. The activity of lipase duodenal content increases towards the end of the
first year of life, reaching adult levels by 12 years. Proteolytic activity of the secretion of the
pancreas in children during the first months of life is high enough, it reaches a maximum at
the age of 4-6 years.
Significant effect on the activity of the pancreas has a kind-feeding: when artificial feeding
activity of enzymes in the duodenal juice is 4-5 times higher than in the natural.

LIVER

Liver at the time of birth is one of the largest bodies and has 1/3-1/2 of the abdomen, its
lower edge substantially supported from the hypochondrium and the right proportion can
even touch the iliac crest. Newborn weight of the liver is more than 4% of body weight and
adults - 2%. In postnatal liver continues to grow, but slower than the mass of the body: the
initial mass of the liver doubled to 8.10 months, and tripled for 2-3 years.

Due to the different rates of increase in the liver and body weight in children from 1 to 3
years of life beyond the edge of the liver from the right hypochondrium and easily
detectable by 1-3 cm below the costal arch to sredneklyuchichnoy line. Since 7 years the
lower edge of the liver from the edge of the arc comes out in a calm situation is not
palpated, the median line does not exceed the upper third of the distance from the navel to
the xiphoid process.

The formation of the lobes of the liver begins in the fetus, but by the time of birth of the
liver lobules delimited clearly. Their final differentiation is completed in the postnatal
period. Lobed structure is revealed only at the end of the first year of life.

The branches of the hepatic veins are located in compact groups and not intermingled with
the branches of the portal vein. Liver healthy, resulting in rapid increases in infections and
intoxications, disorders of blood circulation. Fibrous capsule of the liver is thin.

About 5% of the liver in infants accounted for hematopoietic cells, subsequently their
number is rapidly declining.

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

Liver

Education bile begins in the intrauterine period, but choleresis early retarded. With age,
increasing the ability of the gall bladder to concentrate bile. The concentration of bile acids
in hepatic bile in children the first year of life is high, especially in the first days after birth,
resulting in frequent development of obstructive cholestasis (accumulation of bile
syndrome) in neonates. By the 4.10-year concentration of bile acids decreases and
increases again in adults.

For the neonatal period is characterized by immaturity all phases pechenoch-but-enteric

circulation of bile acids: lack of capture of hepatitis-totsitami, excretion through the tubular
membrane, the current slowdown in bile, disholiya by reducing the synthesis of secondary
bile acids in the intestine and their low level of reabsorption in the intestine .Children
produce more atypical, less hydrophobic and less toxic fatty acids than in
adults. Accumulation of fatty acids in intrahepatic bile duct causes increased permeability
of intercellular connections and the high content of components of bile in the blood. Bile is
a child of the first months of life contains less cholesterol and salt, which determines the
rarity of stone formation.

Newborn fatty acids are connected mainly with tau rinom (for adults - with glycine).
Taurinovye conjugates were more soluble in water and less toxic. Relatively higher content
in the bile taurocholic acid, is bactericidal, determines the rarity of bacterial inflammation
of the biliary tract in children the first year of life.

Liver enzyme systems that provide adequate metabolism of various substances, the birth of
immature. Artificial feeding encourages earlier of their development, but leads to their
imbalance.

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

Children in the liver is much more actively transaminirova-tion of amino acids: the birth of
the activity of aminotransferases in the blood of the child is 2 times higher than in maternal
blood. At the same time, the processes pereaminirova-tion immature, and the number of
essential acids for children than for adults. Thus, there are 8 adults, children under 5-7
years old need further in histidine, and the children of the first 4 weeks of life - even in the
cysteine.

Mochevinoobrazovatelnaya liver function is formed by 3-4 months of life, before the

children note the high urinary excretion of ammonia at low concentrations of urea.

Children of the first year of life resistant to ketoacidosis, although get-rich fat food, and
those aged 2-12 years, by contrast, tend to him.

Newborn cholesterol and its esters in the blood is much lower than that of the
mother. After the start of breastfeeds during the 3-4 months mark hypercholesterolemia.
In the next 5 years the concentration of cholesterol in children is lower than in adults.

Babies in the first days of life note the lack of activity glyukuroniltransferazy, with the
participation of which occur conjugation of bilirubin with glucuronic acid and the
formation of water-soluble "direct" bilirubin. Shortness of excretion of bilirubin - the main
cause of physiological neonatal jaundice.

The liver performs barrier function, neutralizes endogenous and exogenous noxious
substances, including toxins coming from the intestine and is involved in the metabolism of
drugs. Young children neutralized liver function is not sufficiently developed.
Gall bladder in newborns is usually hidden by the liver, its shape may be different. Its size
increases with age, and to 10.12 years in length increases by about 2 times. The rate of
cystic bile in infants 6 times less than in adults.

Method of investigation of the digestive

Inquiries

When questions need to pay particular attention to the complaints. abdominal pain

In early childhood abdominal pain manifested common concern, crying, children "suchat
legs. In older children, the equivalent of early pain may be a feeling of satiation during the
meal and repletion. In the presence of abdominal pain should clarify their response.

Localization of (pre-school children if they have abdominal pain, usually indicate the area
of the navel).

The irradiation (holding beyond the projection of the affected organ).

Character (cramping, dull, aching, pulling, sharp - "stabbing", etc.).

Frequency (alternating periods of pain and well-being).

Seasonality (occurrence or worsening pain in the spring and autumn).

With the quality and quantity of food intake.

Time of occurrence (during meals, early - after 30-60 minutes after eating, late - after 1,5-
3 hours after eating, starving - in 6-7 hours after eating and disappearing after meals, at
night, resulting in an interval between 23 h and 3 h morning and disappearing after
meals). Medications, which method reduces pain.

Nausea and vomiting

Nausea - unpleasant sensation in the epigastric region, accompanied by weakness,

dizziness sometimes until the faint state, pale skin, salivation.

Vomiting - the eruption of stomach contents out. Variety of vomiting in young children -
vomiting, which occurs without an abdominal strain. In gathering medical history should
clarify the nature of the vomiting, the time it occurred (on an empty stomach in the
morning, immediately after eating, after 1,5-2 hours after eating, at the height of pain),
frequency, determine whether it brings relief. Ascertain the volume of vomit, the smell of
their , color, texture, presence of food residue and various impurities.
Belching and heartburn

Belching - exit gas from the stomach into the mouth, sometimes with chyme. It should
identify the triggers of its factors (obesity, physical exercise, consumption of certain foods),
the frequency.

Heartburn - a burning sensation behind the breastbone and in the epigastric region. Note
the frequency of its occurrence (occasionally, several times a day), connection with the
admission of certain foods (spicy, sour, oily, rough), medicines, body position.

Changes in appetite

Changes in appetite (feeling the need, the meal) - its decline, the lack of gain / distortion
(eating inedible materials - chalk, lime, ash, etc.), a feeling of satiation. On the appetite of
infants judged by the duration of suckling and how the child takes the mother's breast.

Constipation and diarrhea

Constipation - lack of bowel movements more than 36 hours Diarrhea - frequent bowel
movements with the changing nature of the chair (from watery to mushy).

Swallowing difficulties

Violation of swallowing (dysphagia) may result in difficulty in swallowing, fear of

swallowing food, pain or discomfort during the passage of food from the esophagus,
regurgitation (regurgitation), aspiration of food.

Other complaints

Thirst - subjective feeling of the need to drink water. Attention is drawn to the presence of
dry mouth, change in taste in the mouth, raspira-tion and heaviness in the stomach, the
feeling of transfusion and rumbling in the stomach.

It is also possible complaints related to chronic intoxication - fatigue, reduced performance,

muscle weakness, various neurotic disorders (irritability, sleep disturbance, tearfulness,
etc.).

Medical history

In the history of the disease find out the initial signs of the disease, its duration, frequency
of periods of exacerbations, duration of remission, the dependence on the change of the
nutrition and living conditions, previous diseases and treatments, etc. Take into account
data from previous clinical and laboratory-tion and instrumental studies and the effect of
the older treatments.
Anamnesis LIFE

The history of a patient's life reveals the risk factors and possible causes of his gastro-
intestinal diseases. Pay attention to during pregnancy and childbirth from the mother
transferred the disease, especially the DCI, the presence of dyspeptic disorders with birth,
feeding and nutrition in the subsequent, allergic history, intolerance to certain
products.Family history reveals a possible hereditary predisposition to diseases of the
digestive tract.

INSPECTION

General examination

Assess the overall condition of the child, its position (with abdominal pain patients usually
lie on your side or back, pressing her hands to the painful area, bending your knees), the
degree of physical development. Observe color of skin and mucous membranes (whiteness,
yellowness, subikterichnost) , the presence of rash, hemorrhage, scratching, peeling,
telangiectasia, striae, scars, increased venous network on the anterior abdominal wall (
"head of Medusa") and the side surfaces of the abdomen.

Dental examination

Inspection of the oral cavity should be made at the end of the study, because it can cause a
negative reaction in the child. It includes inspection of the lips, tongue, oral mucosa, teeth,
throat and pharynx, as well as the definition of breath. First, pay attention to the color of
the lips, their moisture content, the presence of cracks, rash (herpes), ulcers in the corners
of the mouth (angular cheilitis). Then examine the oral cavity and pharynx. A healthy
child's mucous membrane of the mouth and throat is uniformly pink, teeth - white, moist
tongue, pink and clean. Tonsils normally do not go because of the palatine arches, halitosis
is absent.

Look for the rash, the AFL (round-shaped erosions yellowish or whitish color), leukoplakia
(sites epidermidalization mucosa of the cheeks), the spots Belsky, Filatov, Koplik (with
measles), changes in the gums (gingivitis), the defeat of tongue (glossitis), infiltrates or
ulcers in the corners of the mouth ( "I shall go").

Inspection of the abdomen

Inspection of the abdomen carried out in both the horizontal and the vertical position of
the patient, paying attention to the shape, symmetry and size. Normally the stomach is
rounded symmetrical form. In prone position the stomach is slightly below the chest in
older children and infants and young children a few rises above the chest. The shape and
size of the stomach are dependent on the type of physique of the patient (with asthenic
type of stomach is usually small in size giperstenicheskom sometimes very large). Assess
the degree of active participation of the abdominal muscles in breathing. To this end, the
patient asked to "inflate belly", and then draw it into themselves. With stimulation of the
ventral sparing the patient breathing appropriate area.

Palpation

Palpation of the abdomen produced two of the patient: the horizontal and vertical (can
detect hernia, tumors, prolapse and other changes in the internal organs, which are not
palpated in the prone position). The relaxation of the muscles of the abdominal wall
provides diaphragmatic breathing palpation, low headboard and bend the legs at the knee
joints or distraction of the child from the doctor's actions.

Surface Palpation

The surface palpation abdomen conducted from the left inguinal region in symmetrical
areas of the left and right, climbing up to the epigastrium, or counterclockwise. When the
superficial palpation pay attention to the following.

Morbidity (the region of the projection indicates the presence of a pathological process in
the appropriate body).

Resistance (low voltage) of the muscles of the abdominal wall, indicating the possible
involvement in the inflammatory process of the peritoneum. It should check symptom
SHCHetkina-Bljumberga (a sharp increase in pain from the sudden removal of the stomach
palpating fingers.)

The state of "weakness" the anterior abdominal wall (white line abdominal aponeurosis
in the epigastrium, umbilical ring, outside opening the inguinal canal), the degree of
discrepancy recti, the presence of ruptures (defined as a protrusion of various sizes in the
area of the navel, or near the outer opening the inguinal canal appear or increase in size
with straining or cough shock), the size of hernial rings.

Significant increase in abdominal organs (liver, spleen) or the presence of a large tumor.

The projection of the abdominal cavity on the anterior abdominal wall as follows (Figure 2-
16).

Fig. 2 -16. The projection of the abdominal cavity on the anterior abdominal wall. 1 - right
hypochondrium; 2 - epigastrium (epigastric) region, 3 - left hypochondrium, 4 - right side region, 5 -
umbilical region;

6 - The left lateral region;

7 - Right on the hip fins, 8 - pubis, 9 - left hip region. (From: Propedeutics childhood diseases / under.
Red. AA Baranov, M., 1998.)
 Left hypochondrium: fore-stomach, the tail of the pancreas, spleen, left flexure, the upper
pole of left kidney.

Epigastric region: the stomach, duodenum, the body of the pancreas, the left share a liver.

Right hypochondrium: the right proportion of the liver, gallbladder, right flexure, the
upper pole of right kidney.

Left and right side areas: respectively, descending and ascending colon, the lower poles of
left and right kidney, part of the loops of the small intestine.

Umbilical region: a loop of small intestine, transverse colon, the lower horizontal part of
the duodenum, a large curvature of the stomach, head of the pancreas, the gate of the
kidneys, ureters.

Left iliac region: sigmoid colon, left ureter.

Suprapubic region: a loop of small intestine, bladder.

Right iliac region: cecum, terminal ileum, appendix, right ureter.

Deep palpation

Deep methodical sliding palpation gives an indication of some properties of the abdominal
cavity. At the same time determine the localization and extent of palpable body, its shape,
diameter (in cm), consistency (soft, firm), the nature of the surface (normally smooth, it is
possible

tuberosity), mobility and displaceability (& norms of various departments of intestinal

motile), as well as pain and "rumble" (normally absent). In healthy children in the vast
majority of cases to test the sigmoid, blind and transverse colon, ascending and descending
sections of the colon palpable impermanent.

Sigmoid colon detectable in the left iliac region in a smooth, moderately thick, not
humming, sluggish and rarely peristaltiruyu-schego strand diameter of 2.3 cm in
lengthening the mesentery itself or sigmoid colon (dolihosigma) intestine can palpate far
medial or lateral than usual --

The cecum is in the form of a smooth myagkoelasticheskogo cylinder diameter of 3-4 cm

it is somewhat extended downwards (pear-shaped expansion), which ends blindly. Gut
urchit with pressure.
 In the right iliac region can sometimes be palpated terminal ileum in the form of a
cylinder myagkoelasticheskoy consistency diameter 1-1,5 cm, well peristaltiruyuschego
and humming with palpation.

Ascending and descending sections of the colon are located longitudinally, respectively, in
the right and left lateral abdominal region, are mobile and moderately dense, painless
cylinders with a diameter of 2 cm

The transverse colon is palpated in the umbilical region in the form of a cylinder, curved
arcuately downwards, moderately dense, with a diameter of about 2.5 cm, not urchit.

The small intestine is usually not palpable, as is located deep in the abdominal cavity and
is very mobile.

In patients with thin abdominal wall deep palpation of the umbilical region provides an
opportunity to see an increase in mesenteric (mesenteric) lymph nodes.

Large curvature of the stomach and pyloric Front poorly accessible to palpation, and
other divisions of the stomach and not palpable. To determine the lower boundary of the
stomach is more commonly used method for identifying noise splashing. Normally, the
older children the lower boundary of the stomach is above the umbilicus by 2-4 cm

The pancreas is palpated very rare, so the diagnostic importance of pain points and zones
on the anterior abdominal wall. The head of the pancreas is projected in the zone
Chauffard, which has the shape of a right triangle, located in the upper right quadrant of the
umbilical region. One vertex of the triangle lies on the navel, one of the legs is the median
line, and the hypotenuse is the inner third of the lines connecting the umbilicus to the right
edge and forming an arc from the median line of the angle of 45 . The tail of the pancreas is
projected at Mayo-Robson, which is on the bisector of the upper left quadrant of the
abdomen, 1 / 3 the distance from the edge of the costal arch.

Palpation of the liver. Prior to palpation percussion pre-determine the localization of the
lower edge of the liver. On the right mid-clavicular line in infants is usually the edge of the
liver from the costal region of 1-2 cm, and in children older than 5-7 years is located at the
edge of the arc. On palpation of the lower edge of the liver determines its texture, shape,
tenderness (in the norm is painless, slightly tapered, myagkoelastichny).

Gall bladder normally not available palpation. The projection of the gall bladder to the
anterior abdominal wall corresponds to the intersection of the outside edge of the right
rectus abdominis muscle from the costal arch (the point of the gall bladder). On the
pathology of the gall bladder shown by the following symptoms.

-- Symptom Kera (the appearance of a sharp pain at the point of the gall bladder at a height
of inspiration in normal palpation of the gall bladder).
-- Symptom exemplary Murphy (strong and sharp pain at the moment of inspiration when
submerged fingers of physicians in the projection of the gall bladder).

-- Symptom Grekova-Ortner (pain in the right hypochondrium with effleurage edge of the
right hand with equal force alternately on both rib arcs).

-- Symptom Musso (frenikus-symptom) - pain at the point of the surface location of the
right phrenic nerve, identified by simultaneously pressing the fingertips in between the
legs of both sternoclavicular-mastoid muscle on the medial ends of clavicles.

Palpation of the spleen is carried out in the patient's condition on his back and right
side. Slightly bent fingers of his right hand have roughly opposite the X edge 3-4 cm below
the left costal arch parallel to it. At the patient's breath spleen, if enlarged, is out of the edge
rib arc encounters palpating fingers and "slip" with them. Normally the spleen is not
palpable because of its front edge does not reach approximately 3-4 cm to the edge of the
costal arch. Spleen can probe during its enlargement (splenomegaly) is not less than 1,5-2
times. On palpation of the spleen evaluate its shape, texture, surface condition, mobility,
tenderness.

Percussion

Percussion Belly

Percussion hold down the abdomen from the navel to the prone position and standing, and-
1 to the sides of the same in both directions. The norm on both sides of the border

transition timpanicheskogo sound stupid passes along the anterior axillary lines. More
medial location of such boundary indicates the cluster of free fluid in the abdominal cavity
(ascites). When passing the patient in the upright position the liquid moves to the lower
part of the abdominal cavity. Therefore, in the lateral abdominal region will be determined
* tambourines and percussion for the vertical lines in the direction; down in the bottom
half of the abdomen reveals the region with a blunt sound hori-g a horizontal upper
boundary.

In patients with marked ascites at any position on all of the abdomen revealed a dull
perkutRrny sound. In these cases, given the size of the stomach, its shape depending on the
status of the patient, changes in the skin anterior abdominal wall and umbilicus. Along with
the percussion to detect ascites also use the method of fluctuation (fluctuation).

Determination of liver

Determining the size of the liver conducted with the help of percussion. In children older
than 5-7 years to determine the size of the liver by the method of MG Kurlov: on the right
mid-clavicular line - 9 cm, the median line - 8 cm, the left costal arch - 7 cm
Determining the size of the spleen percussion

Under normal size spleen over it is determined not stupid, and moderately dull percussion
sound with timpanicheskim shade. First, define the upper and lower boundaries of the
spleen in the middle axillary line (in the upper limit of normal splenic dullness is located on
the edge of the IX, and its lower boundary - at the XI rib). The distance between the points
obtained (the width of splenic dullness), an average of 4 cm Defining the anterior and
posterior borders of splenic dullness by percussion exercise with respect to X edge from
the edge of the left costal arch to the spine and the left posterior axillary line forward
before dulling the sound. The distance between these points corresponds to the long-niku
spleen (average 6-8 cm in adults).

Auscultation

Auscultation of the abdomen reveals normal recurring sounds of peristalsis in the form of
rumbling and transfusion fluid.

INVESTIGATION OF COLON

Investigation of the rectum is usually performed in Bozeman's position the patient (in a
serious condition - in a prone position on the left side of her stomach reduced to the legs or
in a supine position with bent knees and a few-apart feet), preferably after a bowel
movement. First, inspect the anus and surrounding skin of the buttocks, perineum and
sacrococcygeal area, and then hold finger study, which determine the tone of the sphincter
of the rectum, the smoothness of the surface mucosa, palpable adrectal fiber. In the
presence of tumor entities determine their localization (front, rear or side walls of
intestines), shape, size, surface texture, consistency, smeshaemost, the presence of
fluctuations, soreness. After palpation inspect the glove, drawing attention to the color of
stool and the presence of pathological contaminants (blood, mucus, pus).

INSTRUMENTAL STUDIES

Instrumental methods of investigation include x-ray and ultrasound (ultrasound) study,

radiological methods. Most informative for evaluation of gastrointestinal endoscopic
techniques: FEGDS, laparoscopy, rektoromano and colonoscopy.

FUNCTIONAL METHODS

Functional methods of investigation include the secret-and acid-forming functions of the

pancreas (tubeless and probe methods, in-tragastralnuyu pH-meters). Important role in
assessing the functional status of organs of the digestive system occupy the biochemical
studies of serum (bilirubin, transaminases, total protein and protein fractions, coagulation
factors, glycemic curves, cholesterol, total lipids and their fractions, etc.).
Semiotics of lesions of the gastrointestinal tract
Change appetite

Loss of appetite occurs in many diseases of the digestive tract, including in gastritis, peptic
ulcer, chronic liver disease, pancreatitis, etc. Lack of appetite (anorexia) may develop in
pathology of gastrointestinal, psychiatric disorders, as well as being the result of improper
feeding or food.

Electoral appetite (aversion to certain products) can be formed with intolerance of any
food ingredients (proteins, fats, carbohydrates). For example, intolerance to disaccharides,
lactose, sucrose, fructose, and others - a child may refuse to dairy products, fruit and
sweets. In patients with liver and yellow-chevyvodyaschey system observed aversion to
greasy food. In peptic ulcer appetite may be reduced because of the fear of the appearance
of pain, increasing after meals. Children who have high acidity, usually refuse to acute or
salty foods.

Increased appetite (polyphagia) can be in healthy children during periods of rapid growth,
puberty, after recovering from illness, accompanied by a decrease in appetite, as well as in
patients with chronic pancreatitis, malabsorption syndrome (due to malabsorption of food
in the small intestine). Increased appetite up to high degrees (Bu Limia) occurs in children
suffering from diabetes, central nervous system pathology in patients receiving
glucocorticoids, anabolic steroids, etc.

Change saturability

Rapid saturability observed in patients with chronic gastritis, diseases of the liver and
biliary tract. Feeling of constant hunger is typical for patients with hunger disease, celiac
disease, a syndrome of "short bowel".

Thirst

Thirst occurs when dehydration due to diarrhea and / or vomiting, in patients with chronic
pancreatitis, diabetes, etc.

Increased salivation

Increased salivation in children older than 6 months sometimes arises when parasitic
invasions (eg, ascariasis), as well as diseases of the pancreas (due to compensatory gain
function of the salivary glands).

Unusual taste in mouth

Unusual taste in the mouth observed in some diseases of the digestive system: sour - when
gastroduodenitis, peptic ulcer, bitter or metallic - in diseases vague.

Swallowing difficulties

Swallowing difficulties (dysphagia) can occur for many reasons: the anatomical features of
the nasopharynx ( "palate", "hare lip"), or esophagus (atresia, stenosis), different acquired
diseases of the esophagus, impaired patency of the esophagus because of his passing-
PRINCIPLES FOR GOOD GOVERNANCE tumors, enlarged lymph nodes, thymus or thyroid
lesion of the muscles (myasthenia, dermatomyositis, ST, etc.), mental disorders and CNS
disorders, paralysis of muscles of the pharynx (eg, poliomyelitis, diphtheria polyneuritis,
etc.). One reason for swallowing difficulties in children may be kardiospazm caused by a
congenital defect of parasympathetic sites in the lower esophagus.

Belching and heartburn

Belching is possible in healthy infants when ingested air (pneumophagia), in older children
- with fast food, overeating. In pathological situations belching due to the high gassing due
to fermentation of food in its retention in the stomach.

Belching with rancid flavor is the result of processes of decay and characteristic of pyloric
stenosis, gastritis.

Belching with sharply sour, the hot taste occurs at high acidity (peptic ulcer, gastritis).

Belching with a trace of bitterness indicates abandonment of bile from the duodenum to
the stomach (hiatus gatekeeper, liver disease, biliary tract).

Heartburn is the result of irritation of the mucous membrane of the esophagus stomach
acid when it enters the esophagus, which is typical cardiochalasia. Heartburn watch with
esophagitis, gastroduodenitis, gastric ulcer or duodenal ulcer, hiatal hernia, overeating, etc.

Development of heartburn contribute to the state, accompanied by an increase in pressure

in the stomach and abdomen - ascites, flatulence.

Nausea and vomiting

Vomiting may be preceded by vomiting, or be an independent symptom. Nausea develops

in diseases of the digestive system (gastro-duodenitis, lesion and bile duct, etc.) and other
organs, and may be conditioned nature.

Vomiting - a conditioned reflex act that occurs during stimulation of the vomiting center
impulses coming from the vagus nerve of the various reflex zones (stomach, gall bladder,
liver and bile ducts, pancreas, appendix, ureters, pharynx, ventral, coronary arteries, etc.) ,
with direct toxic effects on the vomiting center and the development of various
pathological processes in the CNS. Vomiting in children occurs frequently, especially in the
age of 3 years, due to the presence of their specific anatomical and physiological
characteristics of FIR. By the nature of vomiting can make an assumption about its origins.

Vomiting central origin usually develops in the pathology of central nervous system,
arises at an altitude cerebral disorders (headache, increased blood pressure, blurred vision,
etc.) without prior nausea is not related to food, slim, does not improve the patient's
condition.

Vomiting reflex with lesions of different internal organs and usually occurs suddenly,
without preceding nausea and does not bring relief.

Gastric vomiting, typical of the stomach, usually occurs in 0,5-1,5 h after the meal, it is
preceded by nausea. Vomiting abundant, has a sour smell, brings temporary relief, the
patient (reduces nausea and pain).

-- Frequent and slim vomiting occurs in infants under pylori-spasm. It sometimes observed
visible to the eye peristalsis.

-- For pyloristenosis characterized by vomiting "fountain", vomit, abundant, with putrid

odor and remnants of food.

Bloody vomiting occurs when erosions and ulcers of the stomach and duodenal ulcers,
bleeding from varices of the esophagus and stomach. In moderate bleeding vomit are dark
brown ( "coffee ground") due to the presence of hydrochloric acid hematin (formed from
Hb under the influence of hydrochloric acid of gastric juice). When massive bleeding occurs
vomiting "mouth full" with blood clots, the source of such bleeding may be, in particular,
Vari-wiles veins of the esophagus or cardia of the stomach in portal hypertension.

When diverticula, achalasia, and narrowing of the lower esophagus vomiting usually
occurs immediately after a meal, the character is slim, vomit, composed of undigested food.

to

When intestinal obstruction vomit may have a different composition depending on the
level of obstruction: when the high occlusion vomit contain stomach contents mixed with
bile, with an average are brown, and fecal odor due anastaltic wave and hit the intestinal
contents of the stomach.

Vomit contain an admixture of bile in diseases zhelchevyvodya-ing ways and pancreas,

abnormalities of the duodenum.
 Atsetonemicheskaya vomiting, at which have a vomit smell of acetone occurs in young
children. It is usually accompanied by significant and repeated violations of water-
electrolyte metabolism and KSCHS.

Ruminatsiya (gum) - repeated rumination periodically swallowed and random burps food
- is not accompanied by nausea. Repeated ruminatsiya may be a manifestation of neurosis.

Abdominal pain

Abdominal pain arise as a pathology of the digestive system, as well as pathology of other
organs and systems. Must specify the time of pain, their intensity, location, irradiation, and
the frequency and seasonality.

Early pain that occurs during eating, are characteristic of esophagitis, immediately after a
meal - for gastritis. Late pain typical antral gastritis, duodenitis, gastroduodenitis or
duodenal ulcer (characterized by hunger and night pain).

The intensity of pain decreases after a meal with antral gastritis, gastroduodenitis and
duodenal ulcer. But after a while the pain again amplified (moyninga-movsky rhythm of
pain). Intense and prolonged stabbing pains in the right hypochondrium are characteristic
of liver and biliary tract in particular. Diverse in character of pain (dull aching or sharp
painful) are characteristic lesions of the pancreas, especially its tail and body. Intense pain
when there are lesions of the colon. The feeling of bursting open in the right
hypochondrium may be due diskineticheskih biliary tract disorders in hypotonic type.

Localization of pain and their irradiation to determine which body struck.

-- Pain in the epigastric region are typical for diseases of the stomach, in addition, there are
pathology of the pancreas, epigastric hernia, hiatal hernia, diseases of the esophagus.

-- Pain in right hypochondrium are characteristic of diseases of liver, gallbladder, bile duct,
pancreatic head, duodenum, liver angle of the colon.

-- Pain in the left hypochondrium observed in diseases of the stomach, the tail of the
pancreas, spleen, left flexure of the colon, the left lobe of the liver.

-- Pain in the field parumbilical observed when umbilical hernia, small bowel lesions,
mesenteric lymph nodes, omentum.

-- Pain in right iliac region typical for appendicitis, they also observed with lesions of the
colon or the final segment of the ileum and ileocecal angle, which is typical for Crohn's
disease.

-- Pain in the left iliac region often caused by lesion of sigmoid colon.
-- Pain in the pubic area occur in diseases of the urogenital system.

-- Pain in the groin area observed in inflammation of the appendix, diseases of the cecum,
terminal ileum, inguinal hernias. Pain in the left inguinal region are characteristic of
disease of sigmoid colon, and in diseases of the rectum pain is often localized in the
perineum.

-- Spilled abdominal pain occur in peritonitis, intestinal obstruction, adhesive disease, etc.

The irradiation of pain in his right shoulder, shoulder blade is for liver and biliary tract, in
both subcostal - with duodenitis; in diseases of the pancreas - in the back (spanning) or left
shoulder, with the defeat of the stomach - in the back. The feeling of pressure around the
navel, pulling pain , patients feel a burning sensation in diseases of the small
intestine.Analysis of various characteristics of abdominal pain suggests their genesis and
pathology, in which they developed (Table 2-10).

Identify the frequency and seasonality of abdominal pain is also important in the
recognition of pathology of the digestive system. Alternating periods of pain and well-
being, as well as the emergence and increasing pain in the spring-autumn period is often in
patients with peptic ulcer disease.

Jaundice

Yellowness of the skin and mucous membranes in newborns usually occurs when the
concentration of bilirubin in the blood more 68,4-85,5 mmol / l (4-5 mg%) and in children
over the year - at higher concentrations above 20,5-34, 5 mmol / L (1,2-2 mg%). On the
mechanism of development are three variants of jaundice (Table 2-11).

Newborn jaundice is a physiological conjugate, which develops on the 2 nd day of life,

reaches maximum expression at 4-5-th day and usually disappears by 7 th and 10 th
days.Preterm duration of physiological jaundice can be up to 4 weeks. Its development is
due to the immaturity of age glyukuroniltransferaznoy system of the liver. Due to the lack
of activity glkzhuroniltransferazy not all indirect bilirubin into a straight line that leads to
its accumulation in the blood. In addition, neonatal jaundice may be associated with
hereditary deficiency glkzhuroniltransferazy (syndrome Kriegler-Nayar), atresia biliary
ducts, fetal hepatitis and thickening of bile syndrome, and others (see "neonatal jaundice"
in Chapter 6, "Diseases of the newborn").

The nature of pain Characteristics of pain Diseases, syndromes

Spastic (arise as a result Acute, paroxysmal (sudden starts and often also Biliary colic, renal colic,
of spasm of smooth suddenly end), very intense, usually well localized, intestinal colic (irritable
muscles) with typical irradiation, weakened after taking bowel syndrome),
antispasmodics. May be accompanied by vomiting, stomach cramps (with
often bringing relief, fever (reflex origin) and the local peptic ulcer), etc.
strain of muscles of the abdominal wall

Distenzionnye (pain Stupid pulling low-intensity, usually spilled, without Flatulence, giposekretorny
from the stretching of clear localization and irradiation, often do not subside syndrome (gastritis with a
the walls of hollow after taking antispasmodics decrease in the secretory
organs and the tension and motor functions of the
of the ligamentous stomach)
apparatus)

Peritoneal Emerge gradually (for inflammation bodies) or acute Peritonitis that developed
(when they rupture), constant, steadily worsening as a result: inflammation
(at transition until unbearable pain. Pain accompanied by general of organs (cholecystitis,
signs of inflammation and toxicity (fever, leukocytosis, appendicitis), perforation
inflammation etc.), vomiting, restriction of respiratory movements of hollow organs (stomach
abdominal muscle tension of the abdominal wall, ulcer)
on parietal positive symptom SHCHetkina-Bljumberga and
weakening (disappearance) of peristalsis. Possible
acute vascular insufficiency
peritoneum)

Vascular (in spasm or Suddenly begin spilled, can be very intense, ever- Msentrique thrombosis,
thrombosis of the increasing (up to unbearable). When necrosis embolism of the arteries,
arteries, leading to develops organs peritonitis, peritoneal pain arise abdominal angina (spasm)
organ ischemia or
necrosis)

* According to AV Strutynskomu et al., 1997

Table 2-10. Clinical characteristics of abdominal pain of various origins *

Table 2-11. Features jaundice of various origin

Type jaundice Parenchymal Mechanical Hemolytic

The mechanism Arises as a result of Developed during obturation Due to the formation of a large
of development the defeat of the liver extra-hepatic bile-excretory tract number of indirect bilirubin,
parenchyma or common bile duct which has no time to
metabolism in the liver
Pathology, in Hepatitis various Atresia zhelchevy-ducting tracts, Hemolytic anemia, HDN,
which it etiology, cirrhosis, thickening of the gall stone hemoglobin, poisoning
develops cancer, etc. obstruction, compression of the haemolytic poisons
tumor, enlarged lymph nodes

Tint color Lemon or reddish Greenish or grayish-green Pale lemon

Chair Periodically Discolored Dark

discolored

Urine Dark in Dark

Yellow
Hyperbolic Direct, indirect Direct bilirubin Indirect bilirubin
rubinemiya bilirubin

Bilirubin in + + --
urine

Urobilin in urine + -- +

Sterkobilin in + -- +
feces

The children, mostly during the first 5 years of life, often observed 1 give exogenous
jaundice due to consumption of more elec-. STVA foods containing pigment (carrots,
pumpkins, oranges, tangerines, persimmons, etc.) or drugs. This option does not arise
sclera jaundice staining, does not change the color of feces, the concentration of bilirubin in
the blood is not increased.

Table 2-12. Clinical features of diarrhea *

Kind Clinical features

Enteral (inflammation of the
mucous membrane of the small
intestine)
"
Moderate quickening chair (up to 4-6 times a day), very abundant
feces, which contain the remains of undigested food. Typical
steatorrhea (fatty stool). Diarrhea is often accompanied by pain
around the navel
Koliticheskie (often with lesions of Very frequent stools (10-15 times per day) accompanied by tenesmus
the mucous membrane distal (painful urge to defecate). Excrements scarce, often mixed with
colon) mucus and blood

Stomach (with a decrease in
secretory function of the stomach,
accompanied by a violation of the
digestion of proteins and rapid
gastric emptying)
Moderate quickening chair (up to 4-6 times a day), feces, liquid, dark
color, with the remnants of undigested food, often with unpleasant
putrid smell (violation of the digestion of proteins), with
mucus. Diarrhea is often accompanied by feelings overflow and blunt
expander pain distenzionnogo nature of epigastric

Pancreatic (with a decrease in the
external function of the pancreas)
Moderate quickening chair. Excrements abundant (polifekaliya),
mushy or liquid, with mucus. Steatorrhea characteristic and
unpleasant putrid smell. Diarrhea is accompanied by pain in the
upper half of the abdomen, sometimes the nature of herpes zoster,
flatulence, often significant weight loss

PoA.V. Strutynskomu et al., 1997

Flatulence

Flatulence develops in dysbacteriosis intestine, enterocolitis, tse-liakii, disaccharidase

deficiency, malabsorption syndrome, complete or partial intestinal obstruction, intestinal
paresis.

Diarrhea

Diarrhea develops in hypercatharsis and accelerated progress of its contents, slowing of

intestinal absorption of fluid and increase its secretion in the intestinal lesions. Diarrhea
may occur in many infectious and noninfectious diseases of the digestive tract, while some
of their clinical characteristics have differential diagnostic value (Table 2-12).

In addition, diarrhea observed in diseases of other organs and systems. Known allergic
diarrhea, neurogenic, deficiency of certain enzymes in the intestine, endocrine diseases
(thyrotoxicosis, Addison's disease, diabetes), helminthic invasions, etc.

Constipation

Causes of constipation may be mechanical obstacles in the intestine, the accumulation of

feces in the extended or elongated segments of intestine, intestinal paresis, the weakening
of peristalsis, the violation of the act of defecation.

Spastic constipation develops as a result of spasm of smooth muscles of the intestinal

wall, can be due to diseases of the colon (colitis, irritable bowel syndrome), viscero-vis-
tseralnye reflexes in diseases of other organs (stomach ulcer, cholecystitis), diseases of the
colon that contribute to increased tone anal sphincter (anal fissures, etc.), psychogenic
factors. Patients are often abdominal pain, stool may take the form "sheep".

Atonic constipation as a result of lowering the tone of smooth muscle occur in

Malnutrition, hypodynamic, CNS pathology, treatment of antacid
preparations. Characteristic blunt, arching pain during bowel, flatulence.

When mechanical intestinal obstruction (with malformation, adhesive disease, tumors,

etc.) develop intoxication, deterioration of general condition, vigorous intestinal peristalsis.

The tendency of infants to constipation can be attributed to the relatively large length of
intestine.

Changes stool

Changes in stool are of great importance for the diagnosis of various diseases (Table 2-13).

Table 2-13. The nature of the chair, under certain conditions in infants

Condition Nature chair

Simple Liquid, mixed with herbs (mixture dehydrobilirubin) contains white lumps (calcium
indigestion soap), sour smell, are often frothy

Toxic dyspepsia A watery, light yellow, with a small amount of mucus

When Frugal, thick, dark, may be kroshkovidnym contain mucus

malnutrition
When Chair liquid, ohryano-yellow, with mucus and white lumps
kolienterite

Tarry stools (melena) - Allocation of the anus blood dark, watching with esophageal or
gastric bleeding.

Select the chair of red blood indicates bleeding from the terminal divisions of the colon.

Changing the shape of the abdomen

Uniform bulging stomach occurs in obesity, flatulence, ascites (often accompanied by

protrusion of the navel); uneven - with an increase in abdominal organs (liver, spleen, etc.)
or the presence of tumor sharp indrawing with increased tone of abdominal muscles
celebrate with peritonitis.
Marked venous network

Marked venous network in the anterior abdominal wall shows the development of
collateral circulation due to obstruction of blood flow in the portal vein (portal
hypertension) or the inferior vena cava.

Muscle tension anterior abdominal wall

Muscle tension anterior abdominal wall (muscle protecting) - VIS-tseromotorny reflex that
develops during inflammation of the parietal peritoneum (diffuse or local peritonitis), and
the visceral peritoneum or serous membranes bodies (appendicitis, cholecystitis, etc.).

Change of bowel noises

Lack of peristaltic noises ( "deathly silence") is characteristic of intestinal atony with

peritonitis, and their gain is at intussusception, intestinal obstruction. When mechanical
ileus peristaltic noises above the narrow intestine become more frequent and sonorous,
and when paralytic ileus intestinal noises disappear completely.

Changes detected by palpation intestine

Dense small intestine can be palpated in spastic conditions, dense colon - for
constipation. In atony colon detectable in the form of soft-walled cylinder with a limp. In
congenital megacolon (disease Hirsshprunga), it greatly increased and may occupy almost
the entire abdominal cavity.

Increased liver

The main reasons for the increase of the liver in children following.

Actually liver pathology (hepatitis, cirrhosis, steatosis, tumors).

The defeat of the intrahepatic biliary ducts.

Stagnation of blood as a result of circulatory disturbances in pravozheludoch-sound of

heart failure.

Diseases of the blood (leukemia, anemia, lymphogranulomatosis).

Many infectious diseases and helminth infestation.

Noncommunicable diseases.

Amyloidosis.
The increase in the liver is often accompanied by increases in the density of its lower
edge. In acute hepatitis and jet appears soreness of the lower edge of the liver. In the
tumor, echinococcosis, hepatic cirrhosis lower edge is uneven and thick. Dense, hard edge
of the liver, up to the rocky, watching with cirrhosis. The surface of the liver in this
rough. Dense liver characteristic of neoplastic processes. Smooth, smooth, myagkovataya
palpation liver with a rounded edge, sharply painful can be palpated in acute blood
stagnation (cardiovascular failure) involved in the inflammatory process of the
parenchyma and intrahepatic bile ducts.

A sharp increase in the size of the liver is characteristic of the initial stage of liver disease,
including Botkin's disease. In acute malnutrition, it can be reduced in size and not palpable.

When right-sided pleural effusion bottom edge of the liver is shifted downwards, with
flatulence, ascites - up (the size of the liver are not changed). Disappearance of liver
dullness observed when perforation of duodenal ulcer and stomach.

Splenomegaly

Pathological changes in the spleen are expressed in its increase or enhance its function, the
deposition of various substances, venous stasis of blood in portal hypertension.
Splenomegaly accompanies many diseases (infectious diseases, blood diseases, neoplastic
processes, splenic vein thrombosis, infarction of the spleen, the accumulation of disease,
autoimmune disease etc.).