Functional disorder of the gastrointestinal tract in children treatment. Manifestations of functional bowel disorder. The formation of the functions of the gastrointestinal tract

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Functional diseases of the digestive tract in children. Principles of rational therapy

Khavkin A.I., Belmer S.V., Volynets G.V., Zhikhareva N.S.

Functional disorders (FD) of the gastrointestinal tract occupy one of the leading places in the structure of the pathology of the digestive system. For example, recurrent abdominal pain in children is functional in 90-95% of children and only 5-10% are associated with an organic cause. In about 20% of cases, chronic diarrhea in children is also due to functional disorders.

In recent decades, if we focus on the number of publications on this issue, interest in functional disorders has been growing exponentially. A simple analysis of the number of publications on functional disorders displayed in the US National Library of Medicine database, well known as Medline, showed that from 1966 to 1999 the number of articles on this topic doubled every decade. At the same time, the increase in the number of publications related to childhood had the same trend, steadily occupying about one-fourth of the total number of articles.

Diagnosis of FN often causes significant difficulties for practitioners, leading to a large number of unnecessary examinations, and most importantly, to irrational therapy. In this case, one often has to deal not so much with ignorance of the problem as with its misunderstanding.

In terms of terminology, it is necessary to differentiate between functional disorders and dysfunctions, two consonant, but somewhat different concepts that are closely related to each other. Violation of the function of a particular organ can be associated with any reason, incl. and organic damage. Functional disorders, in this light, can be considered as a special case of an organ dysfunction that is not associated with its organic damage.

The main physiological processes (functions) occurring in the gastrointestinal tract are: secretion, digestion, absorption, motility, microflora activity and immune system activity. Accordingly, violations of these functions are: violations of secretion, digestion (maldigestion), absorption (malabsorption), motility (dyskinesia), the state of microflora (dysbiosis, dysbacteriosis), immune system activity. All of the listed dysfunctions are interconnected through a change in the composition of the internal environment, and if at the beginning of the disease only one function may be impaired, then as the disease progresses, the others are also violated. Thus, the patient, as a rule, violated all the functions of the gastrointestinal tract, although the degree of these violations is different.

When it comes to functional disorders as a nosological unit, motor function disorders are usually meant, however, it is quite legitimate to talk about other functional disorders, for example, those associated with secretion disorders.

According to modern concepts, FN is a diverse combination of gastrointestinal symptoms without structural or biochemical disorders (D.A. Drossman, 1994).

The causes of functional disorders lie outside the organ, the function of which is impaired, and are associated with a violation of the regulation of this organ. The most studied are the mechanisms of nervous regulation disorders caused either by autonomic dysfunctions, often associated with psycho-emotional and stress factors, or by an organic lesion of the central nervous system and secondary autonomic dystonia. Humoral disorders have been studied to a lesser extent, but are quite obvious in situations where, against the background of a disease of one organ, dysfunction of neighboring ones develops: for example, biliary tract dyskinesia in duodenal ulcer. Motility disorders have been well studied in a number of endocrine diseases, in particular, in disorders of the thyroid gland.

In 1999, the Committee on Childhood Functional Gastrointestinal Disorders, Multinational Working Teams to Develop Criteria for Functional Disorders, University of Montreal, Quebec, Canada) created a classification of functional disorders in children.

This classification, built according to clinical criteria, depending on the prevailing symptoms:

• vomiting disorders: regurgitation, ruminapia, and cyclic vomiting
• Abdominal pain disorders: functional dyspepsia, irritable bowel syndrome, functional abdominal pain, abdominal migraine, and aerophagia
• defecation disorders: children's dyschezia (painful defecation), functional constipation, functional stool retention, functional encopresis.

The authors themselves recognize the imperfection of this classification, explaining this by insufficient knowledge in the field of functional disorders of the gastrointestinal tract in children, and emphasize the need for further study of the problem.

Clinical variants of functional disorders

Gastroesophageal reflux

From the point of view of general pathology, reflux, as such, is the movement of liquid contents in any communicating hollow organs in the opposite, antiphysiological direction. This can occur both as a result of functional insufficiency of the valves and / or sphincters of hollow organs, and in connection with a change in the pressure gradient in them.

Gastroesophageal reflux (GER) refers to the involuntary leakage or reflux of stomach or gastrointestinal contents into the esophagus. Basically, this is a normal phenomenon observed in humans, in which pathological changes in the surrounding organs do not develop.

In addition to physiological GER, long-term exposure to acidic gastric contents in the esophagus can cause pathological GER, which is seen in GERD. GER was first described by Quinke in 1879. And, despite such a long period of study of this pathological condition, the problem remains not fully resolved and quite relevant. First of all, this is due to the wide range of complications that GER causes. Among them: reflux esophagitis, ulcers and strictures of the esophagus, bronchial asthma, chronic pneumonia, pulmonary fibrosis and many others.

There are a number of structures that provide an antireflux mechanism: the phrenic-esophageal ligament, the mucous "rosette" (Gubarev's fold), the legs of the diaphragm, the acute angle of the esophagus into the stomach (His angle), the length of the abdominal part of the esophagus. However, it has been proven that the main role in the mechanism of closing the cardia belongs to the lower esophageal sphincter (LES), the insufficiency of which can be absolute or relative. LES or cardiac muscle thickening is not, strictly speaking, an anatomically autonomous sphincter. At the same time, LES is a muscular thickening formed by the muscles of the esophagus, has a special innervation, blood supply, and specific autonomous motor activity, which allows us to interpret LES as a separate morphofunctional formation. NPS acquires the greatest severity by 1-3 years of age.

In addition, the antireflux mechanisms of protection of the esophagus from aggressive gastric contents include the alkalizing effect of saliva and the "clearance of the esophagus", i.e. the ability to self-cleanse through propulsive contractions. This phenomenon is based on primary (autonomous) and secondary peristalsis, caused by swallowing movements. Of no small importance among the antireflux mechanisms is the so-called "tissue resistance" of the mucous membrane. There are several components of tissue resistance of the esophagus: preepithelial (mucus layer, unmixed water layer, bicarbonate ion layer); epithelial structural (cell membranes, intercellular connecting complexes); epithelial functional (epithelial transport of Na + /H + , Na + -dependent transport of Cl - /HLO -3 ; intracellular and extracellular buffer systems; cell proliferation and differentiation); postepithelial (blood flow, acid-base balance of the tissue).

GER is a common physiological phenomenon in children during the first three months of life and is often accompanied by habitual regurgitation or vomiting. In addition to the underdevelopment of the distal esophagus, reflux in newborns is based on such reasons as a small volume of the stomach and its spherical shape, and slow emptying. In general, physiological reflux has no clinical consequences and resolves spontaneously when an effective antireflux barrier is gradually established with the introduction of solid food. In older children, factors such as an increase in the volume of gastric contents (rich food, excessive secretion of hydrochloric acid, pylorospasm and gastrostasis), a horizontal or inclined position of the body, an increase in intragastric pressure (when wearing a tight belt and using gas-forming drugs) can lead to retrograde reflux of food. drinks). Violation of antireflux mechanisms and mechanisms of tissue resistance lead to a wide range of pathological conditions mentioned earlier and require appropriate correction.

Failure of the antireflux mechanism can be primary or secondary. Secondary failure may be due to hiatal hernia, pylorospasm and/or pyloric stenosis, gastric secretion stimulants, scleroderma, gastrointestinal pseudo-obstruction, etc.

The pressure of the lower esophageal sphincter also decreases under the influence of gastrointestinal hormones (glucagon, somatostatin, cholecystokinin, secretin, vasoactive intestinal peptide, enkephalins), a number of medications, foods, alcohol, chocolate, fats, spices, nicotine.

The basis of the primary failure of the antireflux mechanisms in young children, as a rule, is a violation of the regulation of the activity of the esophagus by the autonomic nervous system. Vegetative dysfunction, most often, is due to cerebral hypoxia, which develops during unfavorable pregnancies and childbirth.

An original hypothesis about the reasons for the implementation of persistent GER was put forward. This phenomenon is considered from the point of view of evolutionary physiology and GER is identified with such a phylogenetically ancient adaptive mechanism as rumination. Damage to dumping mechanisms due to birth trauma leads to the appearance of functions that are not characteristic of a person as a biological species and are of a pathological nature. A relationship has been established between catalytic injuries of the spine and spinal cord, more often in the cervical region, and functional disorders of the digestive tract. When examining the cervical spine, such patients often reveal dislocation of the vertebral bodies at various levels, a delay in the ossification of the tubercle of the anterior arch of the 1st cervical vertebra, early dystrophic changes in the form of osteoporosis and platyspondylia, less often - deformities. In young children, secondary trauma to the cervical spine can occur if the massage is performed incorrectly. These changes are usually combined with various forms of functional disorders of the digestive tract and are manifested by esophageal dyskinesia, insufficiency of the lower esophageal sphincter, cardiospasms, inflection of the stomach, pyloroduodenospasms, duodenospasms, dyskinesia of the small intestine and colon. In 2/3 of patients, combined forms of functional disorders are revealed: various types of small intestine dyskinesia with GER and persistent pylorospasm.

Clinically, this can manifest itself with the following symptoms: increased excitability of the child, profuse salivation, severe regurgitation, intense intestinal colic.

The clinical picture of GER in children is characterized by persistent vomiting, regurgitation, belching, hiccups, morning cough. In the future, such symptoms as heartburn, chest pain, dysphagia join. As a rule, symptoms such as heartburn, pain behind the sternum, in the neck and back are already observed with inflammatory changes in the mucosa of the esophagus, i.e. with reflux esophagitis.

functional dyspepsia

In 1991, Tally defined non-ulcerative (functional) dyspepsia. A symptom complex that includes pain or a feeling of fullness in the epigastric region, associated or not associated with eating or exercise, early satiety, bloating, nausea, heartburn, belching, regurgitation, intolerance to fatty foods, etc., in which the process of a thorough examination of the patient fails to identify any organic disease.

This definition has now been revised. Diseases accompanied by heartburn are now considered in the context of GERD.

According to the clinical picture, 3 variants are distinguished in PD:

1. Ulcerative (localized pain in the epigastrium, hungry pain, or after sleep, passing after eating and (or) antacids. Remissions and relapses may be observed;
2. Dyskinetic (early satiety, feeling of heaviness after eating, nausea, vomiting, intolerance to fatty foods, upper abdominal discomfort, aggravated by eating);
3. Nonspecific (a variety of complaints that are difficult to classify).

It should be noted that the division is rather arbitrary, since complaints are rarely stable (according to Johannessen T. et al., only 10% of patients have stable symptoms). When assessing the intensity of symptoms, patients more often note that the symptoms are not intense, with the exception of pain in the ulcer-like type.

In accordance with the Rome II diagnostic criteria, FD is characterized by 3 pathogmonic signs:

1. Persistent or recurrent dyspepsia (pain or discomfort localized in the upper abdomen along the midline), the duration of which is at least 12 weeks. for the last 12 months;
2. No evidence of organic disease as evidenced by careful history taking, upper GI endoscopic examination, and abdominal ultrasonography;
3. No evidence that dyspepsia is relieved by defecation or is associated with changes in stool frequency or shape (conditions with these symptoms are referred to as IBS).

In domestic practice, if a patient treats with such a symptom complex, then the doctor will most often diagnose "chronic gastritis / gastroduodenitis". In foreign gastroenterology, this term is used not by clinicians, but mainly by morphologists. Abuse by clinicians of the diagnosis of "chronic gastritis" has turned it, figuratively speaking, into the "most frequent misdiagnosis" of our century (Stadelman O., 1981). Numerous studies conducted in recent years have repeatedly proven the absence of any connection between gastric changes in the gastric mucosa and the presence of dyspeptic complaints in patients.

Speaking about the etiopathogenesis of non-ulcer dyspepsia at the present time, most authors assign a significant place to the violation of the motility of the upper gastrointestinal tract, against the background of changes in the myoelectric activity of these sections of the gastrointestinal tract, and the associated delay in gastric emptying and numerous GER and DGR. X Lin et al. note that a change in gastric myoelectric activity occurs after a meal.

Disorders of gastroduodenal motility identified in patients with non-ulcer dyspepsia include: gastroparesis, impaired antroduodenal coordination, weakening of postprandial motility of the antrum, impaired distribution of food inside the stomach (disorders of gastric relaxation; disturbances in accommodation of food in the fundus of the stomach), impaired cyclic activity of the stomach in the interdigestive period: gastric dysrhythmias, DGR.

With a normal evacuation function of the stomach, the causes of dyspeptic complaints may be the increased sensitivity of the receptor apparatus of the stomach wall to stretching (the so-called visceral hypersensitivity), associated either with a true increase in the sensitivity of the mechanoreceptors of the stomach wall or with an increased tone of its fundus. A number of studies have shown that epigastric pain in patients with ND occurs with a significantly lower increase in intragastric pressure compared to healthy individuals.

Previously, it was assumed that NRP plays a significant role in the etiopathogenesis of non-ulcer dyspepsia, it has now been established that this microorganism does not cause non-ulcer dyspepsia. But there are works that show that the eradication of NRP leads to an improvement in the condition of patients with non-ulcer dyspepsia.

The leading role of the peptic factor in the pathogenesis of non-ulcer dyspepsia has not been confirmed. Studies have shown that there are no significant differences in the level of hydrochloric acid secretion in patients with non-ulcer dyspepsia and healthy people. However, the effectiveness of such patients taking antisecretory drugs (proton pump inhibitors and histamine H2 receptor blockers) has been noted. It can be assumed that the pathogenetic role in these cases is played not by hypersecretion of hydrochloric acid, but by an increase in the contact time of acidic contents with the mucous membrane of the stomach and duodenum, as well as hypersensitivity of its chemoreceptors with the formation of an inadequate response.

In patients with non-ulcer dyspepsia, there was no greater prevalence of smoking, drinking alcohol, tea and coffee, taking NSAIDs compared with patients suffering from other gastroenterological diseases.

It should be noted that not only changes in the gastrointestinal tract lead to the development of non-ulcer dyspepsia. These patients are significantly more prone to depression, and have a negative perception of major life events. This indicates that psychological factors play a minor role in the pathogenesis of non-ulcer dyspepsia. Therefore, in the treatment of non-ulcer dyspepsia, both physical and mental factors must be taken into account.

Interesting work continues to study the pathogenesis of non-ulcer dyspepsia. Kaneko H. et al. found in their study that the concentration of Immimoreactive-somatostatin in the gastric mucosa in patients with ulcer-like type of non-ulcer dyspepsia is significantly higher than in other groups of non-ulcer dyspepsia, as well as in comparison with patients with peptic ulcer and the control group. Also in this group, the concentration of substance P was increased in comparison with the group of patients with peptic ulcer.

Minocha A et al. conducted a study to study the effect of gas formation on the formation of symptoms in HP+ and HP- patients with non-ulcer dyspepsia.

Interesting data were obtained by Matter SE et al. They found that patients with non-ulcer dyspepsia, who have an increased number of mast cells in the antrum of the stomach, respond well to therapy with H 1 antagonists, in contrast to standard anti-ulcer therapy.

Functional abdominal pain

This disease is very common, so according to H.G. Reim et al. in children with abdominal pain in 90% of cases there is no organic disease. Transient episodes of abdominal pain occur in children in 12% of cases. Of these, only 10% manage to find the organic basis of these abdominalgias.

The clinical picture is dominated by complaints of abdominal pain, which is more often localized in the umbilical region, but can also occur in other regions of the abdomen. Intensity, nature of pain, frequency of attacks are very variable. Concomitant symptoms are loss of appetite, nausea, vomiting, diarrhea, headaches, and constipation are rare. In these patients, as well as in patients with IBS and FD, there is increased anxiety and psycho-emotional disorders. From the whole clinical picture, characteristic symptoms can be distinguished, based on which a diagnosis of Functional abdominal pain (FAB) can be made.

1. Frequently recurring or continuous abdominal pain for at least 6 months.
2. Partial or complete lack of association between pain and physiological events (i.e., eating, defecation, or menstruation).
3. Some loss of daily activities.
4. Absence of organic causes of pain and insufficient evidence for the diagnosis of other functional gastroenterological diseases.

For FAB, sensory abnormalities are very characteristic, characterized by visceral hypersensitivity, i.e. a change in the sensitivity of the receptor apparatus to various stimuli and a decrease in the pain threshold. Both central and peripheral pain receptors are involved in the implementation of pain sensations.

Psychosocial factors and social disadaptation play a very important role in the development of functional disorders and in the occurrence of chronic abdominal disease.

Regardless of the nature of the pain, a feature of the pain syndrome in functional disorders is the occurrence of pain in the morning or afternoon when the patient is active and subsides during sleep, rest, vacation.

In children of the first year of life, the diagnosis of functional abdominal pain is not made, and a condition with similar symptoms is called Infantile colic, i.e. unpleasant, often causing discomfort, feeling of fullness or squeezing in the abdominal cavity in children of the first year of life.

Clinically, children's colic occurs, as in adults - abdominal pains that are spastic in nature, but unlike adults in a child, this is expressed by prolonged crying, anxiety, and twisting of the legs.

Abdominal migraine

Abdominal pain with abdominal migraine is most common in children and young men, however, it is often detected in adults. The pain is intense, diffuse, but can sometimes be localized in the navel, accompanied by nausea, vomiting, diarrhea, blanching and cold extremities. Vegetative concomitant manifestations can vary from mild, moderately pronounced to bright vegetative crises. The duration of pain ranges from half an hour to several hours or even several days. Various combinations with migraine cephalgia are possible: the simultaneous appearance of abdominal and cephalgic pain, their alternation, the dominance of one of the forms with their simultaneous presence. When diagnosing, the following factors should be taken into account: the relationship of abdominal pain with migraine headache, provoking and accompanying factors characteristic of migraine, young age, family history, therapeutic effect of anti-migraine drugs, an increase in the velocity of linear blood flow in the abdominal aorta during dopplerography (especially during paroxysm).

irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional intestinal disorder manifested by abdominal pain and/or defecation disorders and/or flatulence. IBS is one of the most common diseases in gastroenterological practice: 40-70% of patients who visit a gastroenterologist have IBS. It can manifest itself at any age, incl. in children. The ratio of girls and boys is 2-4:1.

The following are symptoms that can be used to diagnose IBS (Rome 1999)

• Stool frequency less than 3 times a week.
• Stool frequency more than 3 times a day.
• Hard or bean-shaped stool.
• Liquefied or watery stools.
• Straining during the act of defecation.
• Imperative urge to defecate (inability to delay bowel movements).
• Feeling of incomplete emptying of the bowels.
• Isolation of mucus during the act of defecation.
• Feeling of fullness, bloating or transfusion in the abdomen.

Pain syndrome is characterized by a variety of manifestations: from diffuse dull pain to acute, spasmodic; from persistent to paroxysmal abdominal pain. Duration of painful episodes - from several minutes to several hours. In addition to the main "diagnostic" criteria, the patient may experience the following symptoms: increased urination, dysuria, nocturia, dysmenorrhea, fatigue, headache, back pain. Changes in the mental sphere in the form of anxiety and depressive disorders occur in 40-70% of patients with irritable bowel syndrome.

In 1999, diagnostic criteria for irritable bowel syndrome were developed in Rome: the presence of abdominal discomfort or pain for 12 optionally consecutive weeks in the last 12 months, in combination with two of the following three signs:

• stopping after the act of defecation; and/or
• associated with changes in stool frequency; and/or
• associated with changes in the shape of stool.

The pathogenetic mechanisms of IBS have been studied for many years. The motor-evacuation function of the intestine in patients with irritable bowel syndrome has been studied by many researchers, since in the clinical picture of the disease, violations of this particular function come to the fore. At least two types of motor activity of the distal colon have been identified: segmental contractions that occur asynchronously in neighboring segments of the intestine, and peristaltic contractions. Most of the data obtained relates only to segmental motor activity. This is due to two circumstances. Peristaltic activity occurs rarely, only once or twice a day in healthy volunteers. Segmental contractions, which are the most common type of colonic motor activity, delay the passage of intestinal contents towards the anus rather than move it forward.

However, it was not possible to identify motor disorders specific to IBS; the observed changes were recorded in patients with organic bowel diseases and correlated poorly with the symptoms of IBS.

Patients with IBS have a significantly reduced resistance to balloon distension of the colon. On this basis, it has been suggested that altered receptor sensitivity may be the cause of pain during bowel distension in patients with IBS. It has also been shown that patients with IBS have increased sensitivity to colon distension and increased pain sensitivity.

In IBS, there was a diffuse nature of the disturbance in the perception of pain throughout the intestine. The severity of the syndrome of visceral hyperalgesia correlated well with the symptoms of IBS.

Among patients with IBS who turn to doctors, all researchers note a high frequency of deviations from the norm in mental status and exacerbation of the disease in various stressful situations.

Patients with signs of IBS and who are under dispensary observation have a certain type of personality, which is characterized by impulsive behavior, neurotic state, anxiety, suspiciousness and TA. Depression and anxiety most often characterize these patients. Violation of the neuropsychic status manifests itself in a wide variety of symptoms. Among them: fatigue, weakness, headaches, anorexia, paresthesia, insomnia, increased irritability, palpitations, dizziness, sweating, a feeling of lack of air, chest pain, frequent urination.

According to other scientists, intestinal disorders and changes in mental status in patients with IBS are not causally related and coexist in a large percentage of cases only among patients who turn to doctors.

It has been established that persons with a neurotic personality type focus more on intestinal symptoms, which is the reason for seeking medical help. Even a favorable prognosis for IBS in these patients causes a feeling of internal dissatisfaction, exacerbates neurotic disorders, which, in turn, can exacerbate irritable bowel syndrome. A number of researchers have shown that patients with IBS, but with a stable nervous system, as a rule, do not seek medical help, or seek treatment in the presence of concomitant pathology.

Thus, at present, the question of the role of stress in the etiopathogenesis of IBS cannot be unambiguously resolved and requires further study.

Constipation is caused by a violation of the processes of formation and promotion of feces throughout the intestine. Constipation is a chronic delay in bowel movements for more than 36 hours, accompanied by difficulty in the act of defecation, a feeling of incomplete emptying, discharge of a small (

One of the most common causes of constipation is dysfunction and uncoordinated work of the muscular structures of the pelvic floor and rectum. In these cases, there is a lack or incomplete relaxation of the posterior or anterior levators, the puborectal muscle. Disorders of intestinal motility lead to constipation, more often an increase in non-propulsive and segmenting movements and a decrease in propulsive activity with an increase in sphincter tone - "drying" of the fecal column, a discrepancy between the capacity of the TC and the volume of intestinal contents. The occurrence of changes in the structure of the intestine and nearby organs may interfere with normal progress. Also, the cause of functional constipation can be the inhibition of the defecation reflex observed in shy children (conditioned reflex constipation). They occur most often with the beginning of the child's visit to preschool institutions, with the development of anal fissures and with the accompanying act of defecation with pain syndrome - "fear of the pot." Also, constipation can occur with late getting out of bed, morning rush, studying in different shifts, poor sanitary conditions, a sense of false shame. In neuropathic children with prolonged stool retention, defecation causes pleasure.

Chronic functional diarrhea

The division of diarrhea into acute and chronic is arbitrary, but diarrhea lasting at least 2 weeks is generally considered chronic. Diarrhea is a clinical manifestation of malabsorption of water and electrolytes in the intestine.

In young children, diarrhea is considered to be more than 15 g/kg/day of stool. By three years of age, stool volume approaches that of adults, in which case diarrhea is considered to be more than 200 g/day. In terms of defining functional diarrhea, there is another opinion. So, according to A.A. Sheptulina with the functional nature of the disease, the volume of intestinal contents does not increase - the mass of feces in an adult does not exceed 200 g / day. The nature of the stool changes: liquid, more often mushy, with a frequency of 2-4 times a day, more often in the morning. Accompanied by increased gas formation, the urge to defecate is often imperative.

Functional diarrhea in the volume of chronic diarrhea occupies a significant place. In about 80% of cases, chronic diarrhea in children is based on functional disorders. According to I. Magyar, in 6 out of 10 cases, diarrhea is functional. More often, functional diarrhea is a clinical variant of IBS, but if other diagnostic criteria are absent, then chronic functional diarrhea is considered as an independent disease. The etiology and pathogenesis of functional diarrhea are not fully understood, but it has been established that in such patients there is an increase in propulsive intestinal motility, which leads to a decrease in the transit time of intestinal contents. An additional role may be played by malabsorption of short-chain fatty acids as a result of the rapid transit of contents through the small intestine, followed by impaired absorption of water and electrolytes in the colon.

Dysfunctions of the biliary tract

Due to the close anatomical and functional proximity of the digestive organs and the peculiarities of the reactivity of the growing organism in gastroenterological patients, as a rule, the stomach, duodenum, biliary tract and intestines are involved in the pathological process. Therefore, it is quite natural to include in the classification of functional disorders of the motility of the digestive organs and dysfunctions of the biliary tract.

Classification of functional disorders of the biliary tract:

• primary dyskinesias, causing a violation of the outflow of bile and / or pancreatic secretion into the duodenum in the absence of organic obstructions;
• gallbladder dysfunction;
• dysfunction of the sphincter of Oddi;
• secondary dyskinesia of the biliary tract, combined with organic changes in the gallbladder and sphincter of Oddi.

In domestic practice, this condition is described by the term "biliary dyskinesia". Dysfunctions of the biliary tract are accompanied by a violation of the processes of digestion and absorption, the development of excessive bacterial growth in the intestine, as well as a violation of the motor function of the gastrointestinal tract.

Diagnostics

Diagnosis of functional diseases of the gastrointestinal tract is based on their definition and involves a thorough examination of the patient in order to exclude organic lesions of the gastrointestinal tract. For this purpose, a thorough collection of complaints, anamnesis, general clinical laboratory tests, biochemical blood tests is carried out. It is necessary to carry out appropriate ultrasound, endoscopic and x-ray studies to exclude peptic ulcer, tumors of the gastrointestinal tract, chronic inflammatory bowel disease, chronic pancreatitis, cholelithiasis.

Among the instrumental methods for diagnosing GER, the most informative are 24-hour pH-metry and functional diagnostic tests (esophageal manometry). 24-hour monitoring of esophageal pH makes it possible to identify the total number of reflux episodes per day and their duration (normal esophageal pH is 5.5-7.0, in case of reflux less than 4). GERD is diagnosed only if the total number of GER episodes during the day is more than 50 or the total duration of the decrease in pH in the esophagus to 4 or less exceeds 1 hour. the appearance of pain, heartburn, etc. e) allows you to assess the role of the presence and severity of pathological reflux in the occurrence of certain symptoms. If necessary, patients undergo scintigraphy.

With all functional disorders of the gastrointestinal tract, the psycho-emotional status of the patient plays an important role, therefore, when diagnosing such diseases, it is necessary to consult a psychoneurologist.

It is imperative to pay attention to the presence of "alarm symptoms" or so-called "red flags" in patients with FN gastrointestinal tract, which include fever, unmotivated weight loss, dysphagia, vomiting with blood (hematemesis) or black tarry stools (melena), the appearance of scarlet blood in the feces (hematochezia), anemia, leukocytosis, an increase in ESR. The detection of any of these symptoms makes the diagnosis of a functional disorder unlikely and requires a thorough diagnostic search to rule out a serious organic disease.

Since for an accurate diagnosis of FN of the gastrointestinal tract, the patient needs to conduct a lot of invasive studies (FEGDS, pH-metry, colonoscopy, cholepistography, pyelography, etc.), it is therefore very important to conduct a thorough history taking of the patient, identify symptoms and then conduct the necessary studies .

Treatment

In the treatment of all the above conditions, an important role is played by the normalization of the diet, the protective psycho-emotional regime, explanatory conversations with the patient and his parents. The choice of drugs is a difficult task for a gastroenterologist with functional diseases of the gastrointestinal tract.

Children with FN of the gastrointestinal tract are treated in accordance with the principles of step therapy ("step-up / down treatment"). Essence, so-called. "step-by-step" therapy consists in increasing therapeutic activity as funds from the therapeutic arsenal are spent. Upon reaching stabilization or remission of the pathological process, a similar tactic is carried out to reduce therapeutic activity.

The classical scheme for the treatment of functional disorders of the gastrointestinal tract includes the use of biological products, antispasmodics, antidepressants.

In recent years, the problem of intestinal microecology has attracted great attention not only from pediatricians, but also from doctors of other specialties (gastroenterologists, neonatologists, infectious disease specialists, bacteriologists). It is known that the microecological system of an organism, both an adult and a child, is a very complex phylogenetically formed, dynamic complex, which includes associations of microorganisms that are diverse in quantitative and qualitative composition and products of their biochemical activity (metabolites) under certain environmental conditions. The state of dynamic equilibrium between the host organism, its inhabiting microorganisms and the environment is commonly called "eubiosis", in which human health is at an optimal level.

There are many reasons due to which there is a change in the ratio of the normal microflora of the digestive tract. These changes can be either short-term - dysbacterial reactions, or persistent - dysbacteriosis. Dysbiosis is a state of the ecosystem in which the functioning of all its constituent parts - the human body, its microflora and the environment, as well as the mechanisms of their interaction, is disrupted, which leads to the occurrence of a disease. Intestinal dysbacteriosis (DK) is understood as qualitative and quantitative changes in the human normal flora characteristic of a given biotype, which entail pronounced clinical reactions of the macroorganism or are the result of any pathological processes in the body. DC should be considered as a symptom complex, but not as a disease. It is clear that DC is always secondary and mediated by the underlying disease. This explains the absence of such a diagnosis as "dysbiosis" or "intestinal dysbacteriosis" in the International Classifier of Human Diseases (ICD-10), adopted in our country, as well as throughout the world.

During intrauterine development, the gastrointestinal tract of the fetus is sterile. During childbirth, the newborn colonizes the gastrointestinal tract through the mouth, passing through the mother's birth canal. E. coli bacteria and streptococci can be found in the gastrointestinal tract a few hours after birth, and they spread from the mouth to the anus. Various strains of bifidobacteria and bacteroids appear in the gastrointestinal tract 10 days after birth. Babies born by caesarean section have significantly lower levels of lactobacilli than those born naturally. Only in children who are breastfed (breast milk), bifidobacteria predominate in the intestinal microflora, which is associated with a lower risk of developing gastrointestinal infectious diseases.

With artificial feeding, the child does not form the predominance of any group of microorganisms. The composition of the intestinal flora of a child after 2 years is slightly different from that of an adult: more than 400 species of bacteria, most of which are anaerobes that are difficult to cultivate. All bacteria enter the gastrointestinal tract by the oral route. The density of bacteria in the stomach, jejunum, ileum and colon, respectively, is 1000.10,000.100,000 and 1000,000,000 per 1 ml of intestinal contents.

Factors affecting the diversity and density of microflora in various parts of the gastrointestinal tract primarily include motility (normal structure of the intestine, its neuromuscular apparatus, the absence of diverticula of the small intestine, defects in the ileocecal valve, strictures, adhesions, etc.) of the intestine and the absence of possible influences on this process, implemented by functional disorders (slowing down the passage of chyme through the large intestine) or diseases (gastroduodenitis, diabetes mellitus, scleroderma, Crohn's disease, ulcerative necrotic colitis, etc.). This allows us to consider a violation of the intestinal microflora as a consequence of the "irritable bowel syndrome" - a syndrome of functional and motor-evacuation disorders of the gastrointestinal tract with / without changes in the intestinal biocenosis. Other regulatory factors are: the pH of the environment, the content of oxygen in it, the normal enzyme composition of the intestine (pancreas, liver), a sufficient level of secretory IgA and iron. The diet of a child older than a year, a teenager, an adult does not matter as much as in the neonatal period and in the first year of life.

Currently, biologically active substances used to improve the functioning of the digestive tract, regulate the microbiocenosis of the gastrointestinal tract, prevent and treat certain specific infectious diseases are divided into dietary supplements, functional nutrition, probiotics, prebiotics, synbiotics, bacteriophages and biotherapeutic agents. According to the literature, the first three groups are combined into one - probiotics. The use of probiotics and prebiotics leads to the same result - an increase in the number of lactic acid bacteria, natural inhabitants of the intestine (Table 1). Thus, these drugs should be given primarily to infants, the elderly, and those who are hospitalized.

Probiotics are live microorganisms: lactic acid bacteria, more often bifidus or lactobacilli, sometimes yeast, which, as the term "probiotic" implies, belong to the normal inhabitants of the intestines of a healthy person.

Probiotic preparations based on these microorganisms are widely used as nutritional supplements, as well as in yogurt and other dairy products. Microorganisms that make up probiotics are not pathogenic, non-toxic, contained in sufficient quantities, remain viable when passing through the gastrointestinal tract and during storage. Probiotics are generally not considered drugs and are seen as beneficial to human health.

Probiotics can be included in food as dietary supplements in the form of lyophilized powders containing bifidobacteria, lactobacilli and their combinations, used without a doctor's prescription to restore intestinal microbiocenosis, to maintain good health, therefore, permission for the production and use of probiotics as dietary supplements from state structures controlling the creation of drugs (in the USA - the Food and Drug Administration (PDA), and in Russia - the Pharmacological Committee and the Committee for Medical and Immunobiological Preparations of the Ministry of Health of the Russian Federation) are not required.

Prebiotics. Prebiotics are partially or wholly non-digestible food ingredients that promote health by selectively stimulating the growth and/or metabolic activity of one or more groups of bacteria found in the colon. For a food component to be classified as a prebiotic, it must not be hydrolyzed by human digestive enzymes, must not be absorbed in the upper digestive tract, but must be a selective substrate for the growth and/or metabolic activation of one species or a specific group of microorganisms inhabiting the large intestine, leading to to normalize their ratio. Food ingredients that meet these requirements are low molecular weight carbohydrates. The properties of prebiotics are most pronounced in fructose-oligosaccharides (FOS), inulin, galacto-oligosaccharides (GOS), lactulose, lactitol. Prebiotics are found in dairy products, corn flakes, cereals, bread, onions, field chicory, garlic, beans, peas, artichokes, asparagus, bananas and many other foods. On the vital activity of the human intestinal microflora, on average, up to 10% of the energy received and 20% of the volume of food taken are spent.

Several studies conducted on adult volunteers have proven a pronounced stimulatory effect of oligosaccharides, especially those containing fructose, on the growth of bifidus and lactobacilli in the large intestine. Inulin is a polysaccharide found in the tubers and roots of dahlias, artichokes, and dandelions. It is a fructose, since its hydrolysis produces fructose. It was shown that inulin, in addition to stimulating the growth and activity of bifidobacteria and lactobacilli, increases calcium absorption in the large intestine, i.e. reduces the risk of osteoporosis, affects lipid metabolism, reducing the risk of atherosclerotic changes in the cardiovascular system and possibly preventing the development of type II diabetes, there is preliminary evidence of its anticarcinogenic effect. Oligosaccarides, including M-acetylglucosamine, glucose, galactose, fucose oligomers or other glycoproteins, which make up a significant proportion of breast milk, are specific factors for the growth of bifidobacteria.

Lactulose (Duphalac) is a synthetic disaccharide that is not found in nature, in which each galactose molecule is linked (3-1,4-bond with a fructose molecule. Lactulose enters the large intestine unchanged (only about 0.25-2.0% absorbed unchanged in the small intestine) and serves as a nutrient substrate for saccharolytic bacteria.Lactulose has been used in pediatrics for more than 40 years to stimulate the growth of lactobacilli in infants.

In the process of bacterial decomposition of lactupose into short-chain fatty acids (lactic, acetic, propionic, butyric), the pH of the contents of the large intestine decreases. Due to this, the osmotic pressure increases, leading to fluid retention in the intestinal lumen and an increase in its peristalsis. The use of lactulose (Duphalac) as a source of carbohydrates and energy leads to an increase in the bacterial mass, and is accompanied by the active utilization of ammonia and amino acid nitrogen. These changes are ultimately responsible for the preventive and therapeutic effects of lactupose: in constipation, portosystemic encephalopathy, enteritis (Salmonella enteritidis, Yersinia, Shigella), diabetes mellitus and other possible indications.

So far, the properties of such prebiotics as mannose-, maltose-, xylose- and glucose-oligosaccharides have been little studied.

The mixture of probiotics and prebiotics is combined into a group of synbiotics that have a beneficial effect on the health of the host organism, improving the survival and establishment in the intestine of live bacterial supplements and selectively stimulating the growth and activation of the metabolism of indigenous lactobacilli and bifidobacteria.

The use of prokinetics in the treatment of functional disorders takes place, but their effectiveness is not very high and they cannot be used as monotherapy.

Since ancient times, intestinal disorders have been treated with enterosorbents. In this case, charcoal and soot were used. The enterosorption method is based on the binding and removal of various microorganisms, toxins, antigens, chemicals, etc. from the gastrointestinal tract. The adsorption properties of sorbents are due to the presence in them of a developed porous system with an active surface capable of retaining gases, vapors, liquids or substances in solution. The mechanisms of therapeutic action of enterosorption are associated with direct and indirect effects:

As enterosorbents, porous carbon adsorbents are mainly used, in particular, activated carbons of various origins obtained from carbon-rich vegetable or mineral raw materials. The main medical requirements for enterosorbents are:

• non-toxicity;
• atraumatic for mucous membranes;
• good evacuation from the intestine;
• high sorption capacity;
• convenient pharmaceutical form;
• the absence of negative organoleptic properties of the sorbent (which is especially important in pediatric practice);
• beneficial effect on the processes of secretion and intestinal biocenosis.

Enterosorbents created on the basis of a natural polymer of plant origin lignin meet all the above requirements. It was developed back in 1943 under the name "licked" in Germany by G. Scholler and L. Mesler. It has also been successfully used as an antidiarrheal agent, and administered to young children by enema. In 1971, "medical lignin" was created in Leningrad, which was later renamed polyphepan. One of the negative properties of the drug is that it has the greatest adsorption activity in the form of a wet powder, which is a favorable environment for the reproduction of microorganisms. Therefore, the drug is quite often rejected by the control laboratories of the Ministry of Health of the Russian Federation, and the release of the drug in the form of dry granules leads to a significant decrease in its adsorption capacity.

As noted earlier, one of the leading pathological mechanisms in functional bowel diseases is excessive contraction of the smooth muscles of the intestinal wall and associated abdominal pain. Therefore, in the treatment of these conditions, it is rational to use drugs with antispasmodic activity.

Numerous clinical studies have proven the effectiveness and good tolerability of myotropic antispasmodics in functional bowel diseases. However, this pharmacological group is heterogeneous, and when choosing a drug, its mechanism of action should be taken into account, since abdominal pain is very often combined with other clinical symptoms, primarily flatulence, constipation and diarrhea.

The active ingredient in Duspatalin is mebeverine hydrochloride, a methoxybenzamine derivative. A feature of the drug Duspatalin is that smooth muscle contractions are not completely suppressed by mebeverine, which indicates the preservation of normal peristalsis after suppression of hypermotility. Indeed, there is no known dose of mebeverine that would completely inhibit peristaltic movements, i.e. would cause hypotension. Experimental studies show that mebeverine has two effects. First, the drug has an antispastic effect, reducing the permeability of smooth muscle cells to Na+. Second, it indirectly reduces K+ efflux and therefore does not cause hypotension.

The main clinical advantage of Duspatalin is that it is indicated for patients with irritable bowel syndrome and abdominal pain of functional origin, which is accompanied by both constipation and diarrhea, since the drug has a normalizing effect on bowel function.

If necessary, antidiarrheal, laxative drugs are included in the treatment of functional disorders of the intestine, but in all cases these drugs cannot be used as monotherapy.

The role of Helicobacter pylori (HP) in the pathogenesis of chronic abdominal pain is discussed. Studies have shown that HP infection does not play a significant role, but some authors present data on some decrease in pain intensity after HP erradication. It is recommended to examine patients with abdominal pain only if there is a suspicion of structural changes in the organs.

The use of prokinetics in the treatment of functional disorders takes place, but their effectiveness is not very high and they cannot be used as monotherapy. The most widely used prokinetics are in the treatment of GER. Among prokinetics, the most effective antireflux drugs currently used in pediatric practice are dopamine receptor blockers - prokinetics, both central (at the level of the chemoreceptor zone of the brain) and peripheral. These include metoclopramide and domperidone. The pharmacological action of these drugs is to increase the anthropoloric motility, which leads to accelerated evacuation of the contents of the stomach and an increase in the tone of the lower esophageal sphincter. However, when prescribing cerucal, especially in young children at a dose of 0.1 mg/kg 3-4 times a day, we observed extapyramide reactions. More preferable in childhood is a dopamine receptor antagonist - domperidone Motilium. This drug has a pronounced antireflux effect. In addition, when using it, extrapyramidal reactions in children are practically not noted. A positive effect of domperidone in constipation in children was also found: it leads to the normalization of the defecation process. Motilium is administered at a dose of 0.25 mg/kg (as a suspension and tablets) 3-4 times a day 30-60 minutes before meals and at bedtime. It cannot be combined with antacids, since its absorption requires an acidic environment and with anticholinergic drugs that neutralize the effect of motilium.

Considering that practically, in all of the above diseases, the psycho-emotional status of the patient plays an important role, it is necessary, after consulting a psychoneurologist, to resolve the issue of prescribing psychotropic drugs (antidepressants).

Often, in patients with FN of the gastrointestinal tract, as noted above, not only motor dysfunction is observed, but also a violation of digestion. In this regard, it is legitimate to use enzymatic preparations in therapy for such diseases. There are many enzymes currently on the pharmaceutical market. The following are the requirements for modern enzyme preparations:

• non-toxicity;
• good tolerance;
• no adverse reactions;
• optimum action at pH 5-7.5;
• resistance to the action of HCl, pepsins, proteases;
• the content of a sufficient amount of active digestive enzymes;
• long shelf life.

All enzymes on the market can be divided into the following groups:

• extracts of the gastric mucosa (pepsin): abomin, acidinpepsin, pepsidil, pepsin;
• pancreatic enzymes (amylase, lipase, trypsin): creon, pancreatin, pancitrate, mezim-forte, trienzyme, pangrol, prolipase, pankurmen;
• enzymes containing pancreatin, bile components, hemicellulase: digestal, festal, cotazim-forte, panstal, enzistal;
• combined enzymes: combicin (pancreatin + rice fungus extract), panzinorm-forte (lipase + amylase + trypsin + chymotrypsin + cholic acid + amino acid hydrochlorides), pancreoflat (pancreatin + dimethicone);
• enzymes containing lactase: tilactase, lactase.

Pancreatic enzymes are used to correct pancreatic insufficiency, which is often observed in FN of the gastrointestinal tract. The summary table shows the composition of these drugs.

Such preparations as KREON®, Pancitrate, Pangrol belong to the "therapeutic" group of enzymes and are characterized by a high concentration of enzymes, the ability to replace the exocrine function of the pancreas, and what is very important, the rapid onset of the therapeutic effect. However, it should be noted that long-term use of high doses of Pangrol, Pancytrate enzymes, unlike Creon, is dangerous for the development of structures in the ascending section and ileocecal region of the colon.

Conclusion

In conclusion, I would like to note that the study of the problem of functional disorders of the gastrointestinal tract in children has now raised more questions than it has answered. Thus, the classification of FN of the gastrointestinal tract in children that meets all the requirements has not yet been developed. Due to the lack of knowledge of the mechanisms of etiopathogenesis, there is no pathogenetic therapy for these diseases. The selection of symptomatic therapy is a complex "creative" process of a gastroenterologist and pediatrician. There is a rather confusing variety of concepts that are often synonymous to refer to complaints that are often encountered in clinical practice and are associated with dysfunctions of the digestive tract. In this regard, it becomes extremely desirable to have a unified definition of the various designations of this pathology. The significant prevalence of functional diseases of the gastrointestinal tract in children gives rise to the need to determine some provisions that are of paramount importance for the practitioner:

• identification of risk groups for each nosological form;
• systematic preventive measures, including dietary nutrition;
• timely and correct interpretation of the first clinical signs;
• sparing, that is, extremely reasonable, choice of diagnostic methods that provide the most complete information.

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A complex system of regulation of the functions of the gastrointestinal tract determines such a variety of functional disorders. At newborns there is a particular predisposition to functional impairment. Firstly, the neonatal period is a critical period in which the formation of the functions of the gastrointestinal tract occurs: the transition to independent nutrition is carried out, during the first month of life the amount of food increases dramatically, the formation of intestinal biocenosis occurs, etc. Secondly, a number of diseases of the neonatal period and iatrogenic interventions that do not directly affect the gastrointestinal tract can affect its functions. Therefore, children in the neonatal period can be considered as a group of increased risk of functional disorders.

The formation of the functions of the gastrointestinal tract:

Adrenergic, cholinergic and nitrergic neurons appear in the fetus in the esophagus from 5 weeks of gestation, in the anal canal - by 12 weeks. Contacts between muscles and nerves are formed from 10 to 26 weeks. In premature infants, there is a peculiarity in the distribution of NSC neurons, which can lead to changes in motor skills. Thus, in premature infants up to 32 weeks of gestation, a difference in the density of NSC neurons in the small intestine is revealed: on the mesenteric wall, the density of neurons is higher, and on the opposite wall, lower. These features, along with others, lead to peculiar changes in the motility of the gastrointestinal tract. It is known that in adults and older children, during the pause between meals, motor activity has a certain cyclic sequence. The manometry method allows you to select 3 phases in each cycle. Cycles repeat every 60-90 minutes. The first phase is the phase of relative rest, the second phase is the phase of irregular contractions, and finally the third phase is the complex of regular contractions (the migrating motor complex) moving distally. The presence of the third phase is necessary to cleanse the intestines from the remnants of undigested food, bacteria, etc. The absence of this phase dramatically increases the risk of intestinal infections. In premature babies, during the period of pauses between feedings, the motility of the duodenum and small intestine differs significantly from full-term ones. Phase 3 (MMC) of “hungry motility” is not formed, the duration of contraction clusters of the 2nd phase in the duodenum is shorter, the motility of the stomach and duodenum 12 is uncoordinated: the percentage of coordinated contractions in premature babies is 5%, in full-term babies - 31%, in adults people - 60% (coordination is necessary for effective gastric emptying). The advancement of the wave of coordinated contractions in full-term and preterm infants is carried out at a speed approximately 2 times lower than in adults, without a significant difference between full-term and premature ones.

Own hormones intestines are found in the fetus at 6-16 weeks of gestation. During pregnancy, their spectrum and concentrations change. Perhaps these changes play one of the key roles in the development of the functions of the gastrointestinal tract. In premature babies, the concentration of pancreatic polypeptide, motilin and neurotensin is lower. It is possible that these features play an adaptive role (increasing the digestive function with a decrease in motor skills), but at the same time, they do not allow a premature baby to respond quickly and adequately to a change in the volume of feeding. Unlike full-term babies, preterm babies do not change their gut hormone profile in response to feeding. However, on average, after 2.5 days of regular milk feeding, reactions to food intake similar to full-term babies appear. Moreover, to obtain this effect, very small amounts of milk are sufficient, which confirms the correctness of the method of "minimal enteral (or trophic) nutrition." On the other hand, there is no increase in the production of these hormones on total parenteral nutrition.

In a full-term newborn, the number of neurons that produce substance P and VIP in the circular muscles of the colon is reduced compared to adults with a comparable level of these hormones in the blood, but by 3 weeks of age, the number of neurons that produce substance P increases from 1-6% to 18- 26%, and the number of neurons producing VIP - from 22-33% to 52-62% of the total number of neurons.

The concentration of intestinal hormones in newborns is similar to their concentration in adults during fasting, and the concentration of gastrin and VIP is even higher. A high level of VIP may be associated with low sphincter tone. At the same time, the reaction to gastrin (also found in high concentration in the blood) and motilin in newborns is reduced. Probably, there are some features of the regulation of the functions of receptors for these substances.

Functional maturation of NSC continues up to 12-18 months of life.

Functional disorders of the gastrointestinal tract - a combination of gastrointestinal symptoms without structural or biochemical disorders of the gastrointestinal tract.

The reason lies outside the organ, the reaction of which is disturbed, and is associated with a disorder of nervous and humoral regulation.

Classification:

• RF manifested by vomiting
• RF manifested by abdominal pain
• FR defecation
• RF of the biliary tract
• combined risk factors

Causes of RF in young children:

• anatomical and functional immaturity of the digestive organs
• uncoordinated work of various organs
• dysregulation due to immaturity of the intestinal nervous system
• unformed intestinal biocenosis

FR of the stomach:

• rumination
• functional vomiting
• aerophagia
• functional dyspepsia

Important signs of GI FR in young children:

• symptoms are associated with normal development
• arise due to insufficient adaptation in response to external or internal stimuli
• observed in 50-90% of children under 3 months
• not related to the nature of feeding

Syndrome of vomiting and regurgitation in young children:

regurgitation- passive involuntary throwing of food into the mouth and out.

Vomit- a reflex act with automatic contraction of the muscles of the stomach, esophagus, diaphragm and anterior abdominal wall, in which the contents of the stomach are thrown out.

Rumination- esophageal vomiting, characterized by the reverse flow of food from the esophagus into the mouth during feeding

It is due to the peculiarities of the structure of the upper gastrointestinal tract: weakness of the cardiac sphincter with a well-developed pyloric sphincter, the horizontal location of the stomach and the shape in the form of a "bag", high pressure in the abdominal cavity, the horizontal position of the child himself and a relatively large amount of food.

This is the norm for children of the first 3 months of life, it is a condition at a certain stage of life, and not a disease.

Functional vomiting is based on:

• impaired coordination of swallowing and peristalsis of the esophagus
• low salivation
• insufficient peristalsis of the stomach and intestines
• delayed evacuation from the stomach
• increased postprandial gastric distension
• pylorospasm

In most cases, this is the result of the immaturity of the neurovegetative, intramural and hormonal systems for regulating the motor function of the stomach. At a later age, functional vomiting is a manifestation of neurotic reactions, and occurs in emotional, excitable children in response to various unwanted manipulations: punishment, force-feeding. Often combined with anorexia, selectivity in food, stubbornness. functional vomiting is not accompanied by nausea, abdominal pain, intestinal dysfunction. Easily tolerated, feeling good.

Diagnostic criteria for regurgitation:

• 2 or more r / d
• for 3 or more weeks
• no vomiting, impurities, apnea, aspiration, dysphagia
• normal development, good appetite and general condition

Treatment:

• feeding children when spitting up: sitting, the child at an angle of 45-60 degrees, holding him in a horizontal position for 10-30 seconds, before feeding, taking rice water ("HiPP"), diluted in expressed milk, for children older than 2 months 1 tsp. 5% rice porridge before each feeding
• special mixtures with a thickener (NaN-antireflux, Enfamil A.R., Nutrilon A.R.)

Thickeners: potato or rice starch (has nutritional value, slows down motility), locust bean gum (has no nutritional value, has a prebiotic effect, increases stool volume and intestinal motility)

Rules for taking the mixture: prescribed at the end of each feeding, a dose of 30.0 is sufficient, given in a separate bottle with an enlarged hole in the nipple, can be replaced as the main one for artificially fed children

In parallel, sedatives and antispasmodics are prescribed

With insufficient effectiveness of the diet and sedatives, prokinetics are prescribed:

dopamine receptor blockers - cerucal 1 mg / kg, domperidone 1-2 mg / kg 3 times a day 30 minutes before meals, serotonin receptor antagonists cisapride 0.8 mg / kg.

Aerophagia- swallowing a large amount of air, accompanied by bursting in the epigastric region and belching.

Occurs more often during feedings in hyperexcitable, eagerly suckling children from 2-3 weeks of age in the absence or 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 during artificial feeding, when the nipple is not completely filled with milk, with general hypotension.

Bulging in the epigastrium and boxed sound on percussion above it. After 10-15 minutes regurgitation of unchanged milk with a loud sound of outgoing air. May be accompanied by hiccups.

An x-ray shows an excessively large gas bubble in the stomach.

Treatment: normalization of feeding technique, sedatives for excitable children and consultation of a psychotherapist.

functional dyspepsia

- a symptom complex, including pain and discomfort in the epigastrium. Occurs in older children.

The reasons:

• alimentary - irregular meals, abrupt changes in nutrition, overeating, etc.
• psycho-emotional - fear, anxiety, dissatisfaction, etc.
• Violation of the daily rhythm of gastric secretion, excessive stimulation of the production of gastrointestinal hormones, leading to the secretion of hydrochloric acid
• violation of the motor function of the upper gastrointestinal tract due to gastroparesis, impaired antroduodenal coordination, weakening of postprandial motility of the antrum, impaired distribution of food inside the stomach, impaired cyclic activity of the stomach in the interdigestive period, duodenogastric reflux.

Clinic:

• ulcer-like - pain in the epigastrium on an empty stomach, relieved by food, sometimes night pains
• dyskinetic - a feeling of heaviness, fullness after eating or out of touch with food, rapid satiety, nausea, belching, loss of appetite
• non-specific - complaints of pain or discomfort of a changing, indistinct nature, rarely recurring, there is no connection with food.

Diagnosis is only by exclusion of diseases with a similar clinic (chronic gastritis, ulcer, giardiasis, chronic diseases of the liver and biliary tract). To do this, use FEGDS, a study on Helicobacter, abdominal ultrasound, fluoroscopy with barium, 24-hour monitoring of intragastric pH, to study motor function - electrogastrography, rarely scintigraphy. A diary is kept for 2 weeks (time of intake, type of food, nature and frequency of stools, emotional factors, pathological symptoms).

Roman criteria:

• persistent or recurrent dyspepsia for at least 12 weeks in the last 12 months
• lack of evidence of organic disease, confirmed by careful history taking, endoscopy, ultrasound
• lack of association of symptoms with defecation, with a change in the frequency and nature of the stool

Treatment: normalization of lifestyle, diet and diet

In the ulcer-like variant, H2-histamine blockers are prescribed famotidine 2 mg/kg 2 times a day, PPI omeprazole 0.5-1 mg/kg/day for 10-14 days

With a dyskenitic variant of prokinetics, motillium 1 mg / kg / day or cisapride 0.5-0.8 mg / kg 3 times a day 30 minutes before meals for 2-3 weeks

With a non-specific variant, a psychotherapist.

If Helicobacter is detected - eradication

Functional disorders of the small and large intestines:

Intestinal colic.

Occurs as a result of:

• excessive gas formation, gases stretch the intestinal wall, causing pain
• digestive and motility disorders - food retention in the stomach and intestines, constipation and excessive fermentation
• visceral hypersensitivity, ie. increased perception of pain due to immaturity of the enteric nervous system

Symptoms:

• appear in 1-6 months, more often in the first three
• episodes of crying more often 2 weeks after birth (rule of 3 - crying more than 3 hours a day, more than 3 days a week, at least one week)
• extremely harsh uncontrollable cry, sudden onset, for no apparent reason, not soothed by conventional means
• signs of colic: red face, clenched fists, tucked-in legs, tense swollen abdomen
• normal weight gain, good general condition
• calm between episodes of colic

Treatment:

• correction of mother's nutrition (exclude cucumbers, grapes, beans, corn, milk)
• in case of fermentopathy, exclude adapted mixtures based on hydrolyzate; in case of lactose deficiency, lactose-free mixtures (enfamil, lactofre, NAN lactase-free)
• Applies NAN-comfort blend
• correction of intestinal microflora (pro- and prebiotics)
• adsorbents (smecta)
• enzymes (creon)
• defoamers (espumizan, disflatil)
• myotropic antispasmodics (no-shpa)
• carminative herbs - mint, fennel fruit

Functional constipation

- violation of bowel function, expressed in an increase in the intervals between acts of defecation, compared with the individual physiological norm or systematic insufficiency of bowel movement.

The reasons:

• violation of nervous and endocrine regulation - vegetodystonia, violation of spinal innervation, psycho-emotional factors
• suppression of the urge to defecate
• intestinal infections transferred at an early age (development of hypoganglionosis)
• nutritional factors - lack of dietary fiber (30-40 g / d), violation of the diet
• endocrine pathology - hypothyroidism, hyperparathyroidism, adrenal insufficiency
• weakening of the muscles of the anterior abdominal wall, diaphragm, pelvic floor with hernias, exhaustion, physical inactivity
• anorectal pathology - hemorrhoids, anal fissures
• side effects of medications

Two mechanisms of formation: a decrease in propulsive activity and a slowdown in transit throughout the intestine (hypotonic constipation) and a violation of the movement of contents along the rectosigmoid section (hypertensive constipation). The stool thickens, causing pain and reflex delay. Expansion of the distal sections of the intestine, a decrease in receptor sensitivity, an even greater decrease in feces.

Clinic: the chair is compacted, fragmented or resembles "sheep". Sometimes dense first portions, then normal. After the first constipation, the stool periodically departs in a large volume, it can be liquefied. There may be pain in the lower abdomen or diffuse, disappear after defecation. Bloating, palpation of dense stool in the lower left quadrant. Hypo- and hypertonic it is not always possible to distinguish. When hypotonic, they are heavier and more persistent, with streaks and the formation of stones.

Diagnostic criteria, at least 2 criteria within 1 month in a child under 4 years of age

• 2 or less bowel movements per week
• at least 1 episode per week of fecal incontinence after toilet training
• long history of stool retention
• history of painful or difficult bowel movements
• the presence of a large amount of feces in the large intestine
• a history of large-diameter stools that "clogged" the toilet

The diagnosis is established by history and objective data. Objectively palpable dense fecal masses. Rectally, the rectum is filled with dense feces, the anal sphincter can be relaxed.

Additional studies to exclude organic pathology:

• digital rectal examination - the state of the ampoule, sphincter, anatomical disorders, blood behind the finger
• endoscopy - condition of the mucosa
• colonodynamic study - assessment of motor function

Differential diagnosis with Hirschsprung's disease, hypertrophy of the internal anal sphincter

Treatment: diet - for children up to a year, mixtures with prebiotics (NAN-comfort, nutrile comfort), with gum (Frisov, Nutrilon A.R), lactulose (Semper-bifidus), for older children fermented milk products enriched with bifidus and lactobacilli. Consumption of dietary fiber (coarse-fiber cereals, bread, bran).

Active lifestyle, sports, running. In case of inefficiency appoint:

• hypertension - anticholinergics (spasmomen, buscolan), antispasmodics (dicetel)
• hypotension - cholinomimetics (cisapride), anticholinosterase (prozerin)
• laxatives - lactulose (Duphalac 10 ml / day). Cleansing enemas with a delay of more than 3 days.

irritable bowel syndrome

- a complex of functional bowel disorders lasting over 3 months, the main clinical syndrome of which is abdominal pain, flatulence, constipation, diarrhea and their alternation

Etiology:

• intestinal motility disorder
• diet violation
• neurogenic disorders associated with external and internal nervous regulation
• violation of sensitivity (hyperreflexia as a result of muscle overstretching, impaired innervation, inflammation)
• violation of the connection "gut-brain" - psychological disorders.

Clinic:

• pain of varying intensity, relieved after defecation
• more than 3 r/d or less than 3 r/week
• hard or bean-shaped stools, thin or watery
• imperative urge to defecate
• feeling of incomplete emptying of the bowels
• feeling of fullness, fullness, bloating

Characterized by variability and variety of symptoms, lack of progression, normal weight and general appearance, increased complaints during stress, association with other functional disorders, pain occurs before defecation and disappears after it.

Diagnostic criteria:

abdominal discomfort or pain within 12 weeks in the last 12 months. In combination with two of the 3 signs:

Associated with changes in stool frequency

Associated with changes in stool shape

Are bought after the act of defecation

Investigations: HOW, b / x, fecal occult blood test, coprogram, irrigography, sigmocolonoscopy, stool culture for the causative agent of intestinal infections, eggworm, colonodynamic and electromyographic examination of the colon.

Treatment:- daily routine and diet (reducing carbohydrates, milk, smoked meats, soda). If it's not efficient.

The human intestine performs one of the important functions in the body. Through it, nutrients and water enter the blood. Problems associated with the violation of its functions, in the initial stages of diseases, as a rule, do not attract our attention. Gradually, the disease becomes chronic and makes itself felt by manifestations that are hard to miss. What could be the causes that caused a functional violation of the intestine, and how these diseases are diagnosed and treated, we will consider further.

What does pathology mean?

Functional bowel disorder contains several types of intestinal disorders. All of them are united by the main symptom: impaired motor function of the intestine. The disorders usually appear in the middle or lower parts of the digestive tract. They are not the result of neoplasms or biochemical disorders.

We list which pathologies belong here:

• Syndrome
• The same pathology with constipation.
• Irritable bowel syndrome with diarrhea.
• Chronic functional pain.
• Fecal incontinence.

The class of "diseases of the digestive system" includes a functional disorder of the intestine, in the ICD-10 pathology code K59 is assigned. Consider the most common types of functional disorders.

This disease refers to a functional disorder of the intestine (ICD-10 code K58). In this syndrome, there are no inflammatory processes and the following symptoms are observed:

• Colon motility disorder.
• Rumbling in the intestines.
• Flatulence.
• The chair changes - then diarrhea, then constipation.
• On examination, pain in the region of the caecum is characteristic.
• Pain in the chest.
• Headache.
• Cardiopalmus.

There may be several types of pain:

• Bursting.
• Pressing.
• Dull.
• Cramping.
• Intestinal colic.
• Migration pains.

It is worth noting that pain can be aggravated as a result of positive or negative emotions, in case of stress, as well as during physical exertion. Sometimes after eating. To reduce the pain syndrome can discharge gases, stool. As a rule, with pain at night with falling asleep, they disappear, but in the morning they can resume.

In this case, the following course of the disease is observed:

• After a bowel movement comes relief.
• Gases accumulate, there is a feeling of bloating.
• The stool changes its consistency.
• The frequency and process of defecation is disturbed.
• Possible mucus secretion.

If several symptoms persist for some time, the doctor makes a diagnosis of irritable bowel syndrome. A functional disorder of the intestine (ICD-10 identifies such a pathology) also includes constipation. Let us consider further the features of the course of this disorder.

Constipation - bowel dysfunction

According to such a functional disorder of the intestine, according to the ICD-10 code, it is under the number K59.0. With constipation, transit slows down and dehydration of feces increases, coprostasis is formed. Constipation has the following symptoms:

• Bowel movements less than 3 times a week.
• Lack of feeling of complete emptying of the bowels.
• The act of defecation is difficult.
• The stool is hard, dry, fragmented.
• Spasms in the intestines.

Constipation with spasms, as a rule, in the intestines has no organic changes.

Constipation can be classified according to severity:

• Light. Chair 1 time in 7 days.
• Average. Chair 1 time in 10 days.
• Heavy. Chair less than 1 time in 10 days.

In the treatment of constipation, the following directions are used:

• integral therapy.
• rehabilitation measures.
• Preventive actions.

The disease is caused by insufficient mobility during the day, malnutrition, disorders in the nervous system.

Diarrhea

ICD-10 classifies this disease as a functional disorder of the large intestine according to the duration and degree of damage to the intestinal mucosa. A disease of an infectious nature refers to A00-A09, non-infectious - to K52.9.

This functional disorder is characterized by watery, loose, loose stools. Defecation occurs more than 3 times a day. There is no feeling of bowel movement. This disease is also associated with impaired intestinal motility. It can be divided according to severity:

• Light. Chair 5-6 times a day.
• Average. Chair 6-8 times a day.
• Heavy. Chair more than 8 times a day.

It can turn into a chronic form, but be absent at night. Lasts for 2-4 weeks. The disease may recur. Often diarrhea is associated with the psycho-emotional state of the patient. In severe cases, the body loses a large amount of water, electrolytes, protein, and valuable substances. This can lead to death. It should also be borne in mind that diarrhea can be a symptom of a disease that is not associated with the gastrointestinal tract.

Common Causes of Functional Disorders

The main reasons can be divided into:

• External. Psycho-emotional problems.
• Internal. Problems are associated with weak intestinal motility.

There are several common causes of functional disorders of the intestine in adults:

• Prolonged use of antibiotics.
• Dysbacteriosis.
• Chronic fatigue.
• Stress.
• Poisoning.
• Infectious diseases.
• Urinary problems in women.
• Hormonal disruptions.
• Menstruation, pregnancy.
• Insufficient water intake.

Causes and symptoms of functional disorders in children

Due to the underdevelopment of the intestinal flora, functional disorders of the intestine in children are not uncommon. The reasons may be the following:

• The inability of the intestine to external conditions.
• Infectious diseases.
• Infection of the body with various bacteria.
• Violation of the psycho-emotional state.
• Heavy food.
• Allergic reaction.
• Insufficient blood supply to certain parts of the intestine.
• Intestinal obstruction.

It should be noted that in older children, the causes of manifestation of functional disorders are similar to those in adults. Small children and infants are much more difficult to tolerate intestinal diseases. In this case, you can not do just a diet, it is necessary to take medication and consult a doctor. Severe diarrhea can lead to the death of a child.

The following symptoms may be noted:

• The child becomes lethargic.
• Complains of pain in the abdomen.
• Irritability appears.
• Attention decreases.
• Flatulence.
• Increased stool or its absence.
• There is mucus or blood in the stools.
• The child complains of pain during defecation.
• Temperature rise is possible.

In children, functional disorders of the intestine can be infectious and non-infectious. Only a pediatrician can determine. If you notice any of the above symptoms, you should take your child to the doctor as soon as possible.

According to ICD-10, a functional disorder of the large intestine in a teenager is most often associated with a violation of the diet, stress, medication, intolerance to a number of products. Such disorders are more common than organic lesions of the intestine.

General symptoms

If a person has a functional bowel disorder, the symptoms may be as follows. They are characteristic of many of the above diseases:

• Pain in the abdominal region.
• Bloating. Involuntary passage of gases.
• No stool for several days.
• Diarrhea.
• Frequent belching.
• False urge to defecate.
• The consistency of the stool is liquid or solid and has mucus or blood.

The following symptoms are also possible, which confirm the intoxication of the body:

• Headache.
• Weakness.
• Cramps in the abdomen.
• Nausea.
• Strong sweating.

What should be done and which doctor should I contact for help?

What diagnosis is needed?

First of all, you need to go for an examination to a therapist who will determine which specialist you should contact. It can be:

• Gastroenterologist.
• Nutritionist.
• Proctologist.
• Psychotherapist.
• Neurologist.

To make a diagnosis, the following studies may be prescribed:

• General analysis of blood, urine, feces.
• Blood chemistry.
• Examination of feces for the presence of occult blood.
• Coprogram.
• Sigmoidoscopy.
• Colonofibroscopy.
• Irrigoscopy.
• X-ray examination.
• Biopsy of intestinal tissues.
• Ultrasound procedure.

Only after a complete examination, the doctor prescribes treatment.

We make a diagnosis

I would like to note that with an unspecified functional disorder of the intestine, the diagnosis is made on the basis of the fact that the patient has the following symptoms for 3 months:

• Abdominal pain or discomfort.
• Defecation is either too frequent or difficult.
• The consistency of the stool is either watery or hard.
• The defecation process is broken.
• There is no feeling of complete emptying of the intestines.
• There is mucus or blood in the stools.
• Flatulence.

Palpation during examination is important, there should be superficial and deep sliding. You should pay attention to the condition of the skin, to the increased sensitivity of individual areas. If we consider a blood test, as a rule, it does not have pathological abnormalities. An X-ray examination will show signs of colon dyskinesia and possible changes in the small intestine. Barium enema will show painful and uneven filling of the large intestine. Endoscopic examination will confirm swelling of the mucous membrane, an increase in the secretory activity of the glands. It is also necessary to exclude peptic ulcer of the stomach and 12 duodenal ulcer. The coprogram will show the presence of mucus and excessive fragmentation of the feces. Ultrasound reveals the pathology of the gallbladder, pancreas, pelvic organs, osteochondrosis of the lumbar spine and atherosclerotic lesions of the abdominal aorta. After examining the feces on a bacteriological analysis, an infectious disease is excluded.

If there are postoperative sutures, it is necessary to consider adhesive disease and functional pathology of the intestine.

What treatments are available?

In order for the treatment to be as effective as possible, if a functional bowel disorder is diagnosed, it is necessary to perform a set of measures:

1. Establish a work and rest schedule.
2. Use psychotherapy methods.
3. Follow the dietitian's recommendations.
4. Take medications.
5. Apply physical therapy.

Now a little more about each of them.

A few rules for the treatment of intestinal diseases:

• Take regular walks outdoors.
• Do exercises. Especially if the job is sedentary.
• Avoid stressful situations.
• Learn to relax and meditate.
• Take a warm bath regularly.
• Do not resort to snacking on junk food.
• Eat foods that are probiotics and contain lactic acid bacteria.
• With diarrhea, limit the consumption of fresh fruits and vegetables.
• Perform abdominal massage.

Methods of psychotherapy help to cure functional disorders of the intestine, which are associated with stressful conditions. So, it is possible to use the following types of psychotherapy in the treatment:

• Hypnosis.
• Methods of behavioral psychotherapy.
• Abdominal autogenic training.

It should be remembered that with constipation, first of all, it is necessary to relax the psyche, and not the intestines.

• Food should be varied.
• Drinking should be plentiful, at least 1.5-2 liters per day.
• Do not eat foods that are poorly tolerated.
• Do not eat food that is cold or very hot.
• Do not eat vegetables and fruits raw and in large quantities.
• Do not abuse products with essential oils, products made from whole milk and containing refractory fats.

Treatment of functional bowel disorders includes the use of the following drugs:

• Antispasmodics: "Buscopan", "Spazmomen", "Dicetep", "No-shpa".
• Serotonergic drugs: "Ondansetron", "Buspirone".
• Carminatives: Simethicone, Espumizan.
• Sorbents: "Mukofalk", "Activated carbon".
• Antidiarrheal drugs: Linex, Smecta, Loperamide.
• Prebiotics: "Lactobacterin", "Bifidumbacterin".
• Antidepressants: Tazepam, Relanium, Phenazepam.
• Antipsychotics: "Eglonil".
• Antibiotics: Cefix, Rifaximin.
• Laxatives for constipation: Bisacodyl, Senalex, Lactulose.

The attending physician should prescribe medicines, taking into account the characteristics of the body and the course of the disease.

Physiotherapy procedures

Each patient is prescribed physiotherapy individually, depending on the functional disorders of the intestine. They may include:

• Baths with carbon dioxide bischofite.
• Treatment with interference currents.
• Application of diadynamic currents.
• Reflexology and acupuncture.
• Therapeutic and physical culture complex.
• Electrophoresis with magnesium sulfate.
• Bowel massage.
• Cryomassage.
• Ozone therapy.
• Swimming.
• Yoga.
• Laser therapy.
• autogenic exercises.
• Warm compresses.

Good results were noted with the use of mineral waters in the treatment of the gastrointestinal tract. It is worth noting that after undergoing physiotherapy procedures, medication is sometimes not required. The work of the intestines is getting better. But all procedures are possible only after a full examination and under the supervision of a doctor.

Prevention of functional disorders of the intestine

Any disease is easier to prevent than to cure. There are rules for the prevention of intestinal diseases that everyone should know. Let's list them:

1. Food should be varied.
2. It is better to eat fractionally, in small portions 5-6 times a day.
3. The menu should include whole grain bread, cereals, bananas, onions, bran, containing a large amount of fiber.
4. Eliminate gas-producing foods from your diet if you have a tendency to flatulence.
5. Use natural laxative products: plums, lactic acid products, bran.
6. To live an active lifestyle.
7. Controlling your own leads to diseases of the digestive system.
8. To refuse from bad habits.

By following these simple rules, you can avoid such a disease as a functional bowel disorder.

Traditionally, disorders that occur in any system of the human body are divided into organic and functional. Organic pathology is associated with damage to the structure of the organ, the severity of which can vary widely from a gross developmental anomaly to minimal enzymopathy. If organic pathology is excluded, then we can talk about functional disorders (FN). Functional disorders are symptoms of physical ailments caused not by diseases of the organs, but by violations of their functions.

Functional disorders of the gastrointestinal tract (FN GIT) are one of the most common problems, especially among children in the first months of life. According to various authors, FN of the gastrointestinal tract is accompanied by 55% to 75% of infants in this age group.

According to D. A. Drossman (1994), functional digestive disorders are "a diverse combination of gastrointestinal symptoms without structural or biochemical disorders" of the function of the organ itself.

Given this definition, the diagnosis of PE depends on the level of our knowledge and the capabilities of research methods that allow us to identify certain structural (anatomical) disorders in a child and thereby exclude their functional nature.

In accordance with the Rome III criteria, proposed by the Committee for the Study of Functional Disorders in Children and the International Working Group on the Development of Criteria for Functional Disorders (2006), GI FN in infants and children in the second year of life include:

• G1. regurgitation syndrome;
• G2. rumination syndrome;
• G3. Syndrome of cyclic vomiting;
• G4. Infantile intestinal colic;
• G5. Syndrome of functional diarrhea;
• G6. Soreness and difficulty in defecation (dyschesia);
• G7. Functional constipation.

Of the presented syndromes, the most common conditions are regurgitation (23.1% of cases), infantile intestinal colic (20.5% of cases) and functional constipation (17.6% of cases). Most often, these syndromes are observed in various combinations, less often - as one isolated syndrome.

In the clinical work carried out under the guidance of Professor E.M. Bulatova, devoted to the study of the frequency of occurrence and causes of the development of digestive FD in infants during the first months of life, the same trend was noted. At an outpatient appointment with a pediatrician, parents often complained that their child was spitting up (57% of cases), worried, kicking his legs, he had bloating, cramping pain, screaming, that is, episodes of intestinal colic (49% of cases) . Somewhat less frequently, there were complaints of loose stools (31% of cases) and difficulty in defecation (34% of cases). It should be noted that the majority of infants with difficult defecation suffered from infantile dyschezia syndrome (26%) and constipation in only 8% of cases. The presence of two or more syndromes of FN of digestion was recorded in 62% of cases.

At the heart of the development of FN of the gastrointestinal tract, a number of reasons can be distinguished, both on the part of the child and on the part of the mother. Reasons for a child include:

• transferred ante- and perinatal chronic hypoxia;
• morphological and (or) functional immaturity of the gastrointestinal tract;
• a later start in the development of the autonomic, immune and enzyme systems of the digestive tube, especially those enzymes that are responsible for the hydrolysis of proteins, lipids, disaccharides;
• age-appropriate nutrition;
• violation of feeding technique;
• force feeding;
• lack or excess of drinking, etc.

On the part of the mother, the main reasons for the development of FN of the gastrointestinal tract in a child are:

• increased level of anxiety;
• hormonal changes in the body of a nursing woman;
• asocial living conditions;
• serious violations of the regime of the day and nutrition.

It was noted that FN of the gastrointestinal tract is much more common in first-born children, long-awaited children, as well as in children of elderly parents.

The reasons underlying the development of functional disorders of the gastrointestinal tract affect the motor, secretory and absorption capacity of the digestive tube and negatively affect the formation of intestinal microbiocenosis and the immune response.

Changes in the microbial balance are characterized by the induction of the growth of opportunistic proteolytic microbiota, the production of pathological metabolites (isoforms of short-chain fatty acids (SCFA)) and toxic gases (methane, ammonia, sulfur-containing gases), as well as the development of visceral hyperalgesia in the baby, which is manifested by severe anxiety, crying and cry. This condition is due to the nociceptive system still formed antenatally and the low activity of the antinociceptive system, which begins to function actively after the third month of the baby's postnatal life.

Excessive bacterial growth of opportunistic proteolytic microbiota stimulates the synthesis of neurotransmitters and gastrointestinal hormones (motilin, serotonin, melatonin), which change the motility of the digestive tube in a hypo- or hyperkinetic type, causing spasm not only of the pyloric sphincter and sphincter of Oddi, but also of the anal sphincter, as well as development of flatulence, intestinal colic and defecation disorders.

Adhesion of opportunistic flora is accompanied by the development of an inflammatory reaction of the intestinal mucosa, the marker of which is a high level of calprotectin protein in the coprofiltrate. With infantile intestinal colic, necrotizing enterocolitis, its level increases sharply compared to the age norm.

The connection between inflammation and the kinetics of the intestine is carried out at the level of interaction between the immune and nervous systems of the intestine, and this connection is bidirectional. Lymphocytes of the intestinal lamina propria possess a number of neuropeptide receptors. When immune cells release active molecules and inflammatory mediators (prostaglandins, cytokines) during inflammation, then enteric neurons express receptors for these immune mediators (cytokines, histamine), receptors activated by proteases (protease-activated receptors, PARs), etc. It was found that Toll-like receptors that recognize lipopolysaccharides of gram-negative bacteria are present not only in the submucosal and muscular plexus of the gastrointestinal tract, but also in the neurons of the dorsal horns of the spinal cord. Thus, enteric neurons can respond both to inflammatory stimuli and be directly activated by bacterial and viral components, participating in the interaction of the organism with the microbiota.

The scientific work of Finnish authors, carried out under the guidance of A. Lyra (2010), demonstrates the aberrant formation of intestinal microbiota in functional digestive disorders, for example, microbiocenosis in irritable bowel syndrome is characterized by a reduced level Lactobacillus spp., increasing the titer Cl. difficile and Clostridium XIV cluster, abundant growth of aerobes: Staphylococcus, Klebsiella, E. coli and instability of microbiocenosis during its dynamic assessment.

In a clinical study by Professor E. M. Bulatova, devoted to the study of the species composition of bifidobacteria in infants who are on different types of feeding, the author showed that the species diversity of bifidobacteria can be considered as one of the criteria for the normal motor function of the intestine. It was noted that in children of the first months of life without physical activity (regardless of the type of feeding), the species composition of bifidobacteria is significantly more often represented by three or more species (70.6% vs. 35% of cases), with the dominance of infant bifidobacteria species ( B. bifidum and B. longum, bv. infantis). The species composition of bifidobacteria in infants with FN of the gastrointestinal tract was mainly represented by an adult species of bifidobacteria - B. adolescentis(p< 0,014) .

FN of digestion that arose in the first months of a baby's life, without timely and proper treatment, can persist throughout the entire period of early childhood, be accompanied by a significant change in health, and also have long-term negative consequences.

In children with persistent regurgitation syndrome (score from 3 to 5 points), there is a lag in physical development, diseases of the upper respiratory tract (otitis media, chronic or recurrent stridor, laryngospasm, chronic sinusitis, laryngitis, stenosis of the larynx), iron deficiency anemia. At the age of 2-3 years, these children have a higher incidence of respiratory diseases, restless sleep and increased excitability. By school age, they often develop reflux esophagitis.

B. D. Gold (2006) and S. R. Orenstein (2006) noted that children suffering from pathological regurgitation in the first two years of life constitute a risk group for the development of chronic gastroduodenitis associated with Helicobacter pylori, the formation of gastroesophageal reflux disease, as well as Barrett's esophagus and / or esophageal adenocarcinoma at an older age.

The works of P. Rautava, L. Lehtonen (1995) and M. Wake (2006) show that infants who have experienced intestinal colic in the first months of life suffer from sleep disturbance in the next 2-3 years of life, which manifests itself in difficulty falling asleep and frequent night awakenings. At school age, these children are much more likely than in the general population to show bouts of anger, irritation, bad mood during meals; have a decrease in general and verbal IQ, borderline hyperactivity, and behavioral disorders. In addition, they are more likely to have allergic diseases and abdominal pain, which in 35% of cases are functional in nature, and 65% require inpatient treatment.

The consequences of untreated functional constipation are often tragic. Irregular, infrequent bowel movements underlie the syndrome of chronic intoxication, sensitization of the body and can serve as a predictor of colorectal carcinoma.

To prevent such serious complications, children with FN of the gastrointestinal tract need to be provided with timely assistance and in full.

Treatment of FN of the gastrointestinal tract includes explanatory work with parents and their psychological support; use of positional (postural) therapy; therapeutic massage, exercises, music, aroma and aeroionotherapy; if necessary, the appointment of drug pathogenetic and post-syndromic therapy and, of course, diet therapy.

The main task of diet therapy in FN is to coordinate the motor activity of the gastrointestinal tract and normalize the intestinal microbiocenosis.

This problem can be solved by introducing functional foods into the child's diet.

According to modern views, functional products are called products that, due to their enrichment with vitamins, vitamin-like compounds, minerals, pro- and (or) prebiotics, as well as other valuable nutrients, acquire new properties - a beneficial effect on various functions of the body, improving not only the state of health human, but also preventing the development of various diseases.

For the first time, functional nutrition was discussed in Japan in the 1980s. Subsequently, this trend has become widespread in other developed countries. It is noted that 60% of all functional foods, especially those enriched with pro- or prebiotics, are aimed at improving the intestines and the immune system.

The latest research on the study of the biochemical and immunological composition of breast milk, as well as longitudinal observations of the health of children who received breast milk, allow us to consider it a product of functional nutrition.

Taking into account the existing knowledge, manufacturers of baby food for children deprived of breast milk produce adapted milk formulas, and for children older than 4-6 months - complementary foods that can be classified as functional foods, since the introduction of vitamins, vitamin-like and mineral compounds, polyunsaturated fatty acids, namely docosahexaenoic and arachidonic acids, as well as pro- and prebiotics, give them functional properties.

Pro- and prebiotics are well studied and widely used in both children and adults for the prevention of conditions and diseases such as allergies, irritable bowel syndrome, metabolic syndrome, chronic inflammatory bowel disease, low bone mineral density, chemically induced bowel tumors.

Probiotics are pathogen-free live microorganisms that, when consumed in adequate amounts, have a direct beneficial effect on the health or physiology of the host. Of all the studied and commercially produced probiotics, the vast majority belong to bifidobacteria and lactobacilli.

The essence of the “prebiotic concept”, which was first introduced by G. R. Gibson and M. B. Roberftoid (1995), is aimed at changing the intestinal microbiota under the influence of food by selectively stimulating one or more types of potentially beneficial groups of bacteria (bifidobacteria and lactobacilli) and reducing the number of pathogenic species microorganisms or their metabolites, which significantly improves the health of the patient.

As prebiotics in the nutrition of infants and young children, inulin and oligofructose are used, which are often combined under the term "fructooligosaccharides" (FOS), or "fructans".

Inulin is a polysaccharide found in many plants (chicory root, onion, leek, garlic, Jerusalem artichoke, bananas), has a linear structure, with a wide spread along the chain length, and consists of fructosyl units linked by β-(2 -1) -glycosidic bond.

Inulin, used to fortify baby food, is commercially obtained from chicory roots by extraction in a diffuser. This process does not change the molecular structure and composition of natural inulin.

To obtain oligofructose, "standard" inulin is subjected to partial hydrolysis and purification. Partially hydrolyzed inulin consists of 2-8 monomers that have a glucose molecule at the end - this is a short-chain fructooligosaccharide (scFOS). Long-chain inulin is formed from "standard" inulin. Two ways of its formation are possible: the first is enzymatic chain elongation (fructosidase enzyme) by adding sucrose monomers - “elongated” FOS, the second is the physical separation of scFOS from chicory inulin - long-chain fructooligosaccharide (dlFOS) (22 monomers with a glucose molecule at the end of the chain).

The physiological effects of dlFOS and ccFOS are different. The first is subjected to bacterial hydrolysis in the distal colon, the second - in the proximal, as a result, the combination of these components provides a prebiotic effect throughout the entire colon. In addition, in the process of bacterial hydrolysis, fatty acid metabolites of different composition are synthesized. Fermentation of dlFOS produces mainly butyrate, while fermentation of ccFOS yields lactate and propionate.

Fructans are typical prebiotics, therefore they are practically not cleaved by α-glycosidases of the intestine, and in an unchanged form they reach the large intestine, where they serve as a substrate for the saccharolytic microbiota, without affecting the growth of other groups of bacteria (fusobacteria, bacteroids, etc.) and suppressing the growth of potentially pathogenic bacteria : Clostridium perfringens, Clostridium enterococci. That is, fructans, contributing to an increase in the number of bifidobacteria and lactobacilli in the large intestine, apparently, are one of the reasons for the adequate formation of the immune response and the body's resistance to intestinal pathogens.

The prebiotic effect of FOS is confirmed by the work of E. Menne (2000), who showed that after stopping the intake of the active ingredient (scFOS/dlFOS), the number of bifidobacteria begins to decrease and the composition of the microflora gradually returns to its original state, observed before the start of the experiment. It is noted that the maximum prebiotic effect of fructans is observed for dosages from 5 to 15 g per day. The regulatory effect of fructans has been determined: people with an initially low level of bifidobacteria are characterized by a clear increase in their number under the action of FOS compared to people with an initially higher level of bifidobacteria.

The positive effect of prebiotics on the elimination of functional digestive disorders in children has been established in a number of studies. The first work on the normalization of the microbiota and the motor function of the digestive tract concerned adapted milk formulas enriched with galacto- and fructooligosaccharides.

In recent years, it has been proven that the addition of inulin and oligo-fructose to the composition of milk formulas and complementary foods has a beneficial effect on the spectrum of intestinal microbiota and improves digestion.

In a multicenter study conducted in 7 cities of Russia, 156 children aged 1 to 4 months took part. The main group included 94 children who received an adapted milk formula with inulin, the comparison group included 62 children who received a standard milk formula. In the children of the main group, while taking the product enriched with inulin, a significant increase in the number of bifidobacteria and lactobacilli and a tendency to a decrease in the level of both Escherichia coli with mild enzymatic properties and lactose-negative Escherichia coli were found.

In a study performed at the Department of Baby Nutrition of the Research Institute of Nutrition of the Russian Academy of Medical Sciences, it was shown that the daily intake of porridge with oligofructose (0.4 g per serving) by children in the second half of the year of life has a positive effect on the state of the intestinal microbiota and the normalization of stool.

An example of complementary foods enriched with prebiotics of plant origin - inulin and oligofructose - is the cereals of the transnational company Heinz, the entire line of cereals - low-allergenic, dairy-free, dairy, dainty, Lubopyshki - contains prebiotics.

In addition, the prebiotic is included in the monocomponent prune puree, and a special line of dessert purees with prebiotic and calcium has been created. The amount of prebiotic added to complementary foods varies widely. This allows you to individually select a complementary food product and achieve good results in the prevention and treatment of functional disorders in young children. The study of products containing prebiotics is ongoing.

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N. M. Bogdanova, Candidate of Medical Sciences