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Lecture N 8

Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

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Page 1: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Lecture N 8

Page 2: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

oral cavity rather small has adaptations to the act of suction – the

big tongue, Buchat's fat-pads, duplicators of gun mucosa

mucous membrane of oral cavity is tender, thin, richly supplied with blood vessels, dry because of deficiency of saliva

development of salivary glands comes to the end by 3-4 months, since this moment the physiological hypersalivation is observed

larynx entrance is posed highly; therefore the child can breathe and suck concurrently

Page 3: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

The esophagus has tender thin mucous membrane, well supplied with blood vessels. Glandules of an esophagus in newborn are completely absent, muscular and elastic tissue are badly advanced. The entrance to an esophagus in newborn is posed highly – at a level of 3-4 cervical vertebras, in the adult at a level of 7th vertebra. The exit from an esophagus at any age is on the level of 10-11 thoracic vertebra

Bishoff’s formula: Length of esophagus = 1/5 lengths of body +

6,3 cm

Page 4: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

The stomach in infants is posed horizontally. The cardiac part of a stomach is undeveloped; therefore regurgitation is possible. Pyloric part is developed well, and in overdevelopment pylorospasm is observed.

Capacity of stomach in newborn is 30-35 ml, in one year - 250-300 ml, in 8 years -1000 ml. One-time volume of nutrition for breast child: V=30(n+1), n - number of months.

Mucous membrane is tender, rich of blood vessels, contains few digestive glandules. Low production of gastric juice and low acidity are marked. The muscular layer is undeveloped, and the gastric air bubble is enlarged.

By 2 years structural and functional peculiarities of stomach approximate to those in adults.

Page 5: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

The small intestine consists of duodenum, jejunum and ileum. In children under 5 years old:

Has rather big length and the big mobility, therefore invaginations are frequently possible

Contains a lot of gases Weak development of muscular and elastic fibers

of intestinal wall Mucous membrane is thin, dry, rich of blood

vessels Secretor insufficiency and high permeability

promote penetration into a blood of undigested components of nutrition, toxins and microorganisms, causing sensibilization

Immature of ileocecal valve promotes to entering of bacterial flora from colon

Page 6: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Colon is situated higher and has the length peer to body height of the child. Haustration under 6 months is absent.

Appendix has widely open entrance, hypermobility and can localize in any part of an abdominal cavity, but most often in retrocecal position

Mucous membrane of rectum is badly fixed, therefore rectal prolapse is possible.

In the first day after a birth Meconium – first-born feces appears. Meconium consists from amniotic water, slime, cholic pigments, epitelium. Settling of an intestine by a normal microflora begins with the first hours of life and usually comes to an end by 7-10 day, therefore transitional dysbacteriosis is observed.

Page 7: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

pancreas in the first months of life is insufficiently differentiated, posed deeply in abdominal cavity. Its surface is smooth. The lobular structure of a pancreas appears only by 12 years.

Page 8: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

The liver in children has rather big sizes, 4 % from mass of body in newborn, 2 % in adult.

The lower edge of liver is on 1-2 cm lower then the right hypochondrium in children under 3 years, and lower than the upper third of distance between xiphoid process and umbilicus under 7 years.

Parenchyma of a liver is poorly differentiated, the lobular structure is typical only by the end of the first year of life. The liver is sanguineous, easily enlarged in infectious diseases, intoxication, circulatory insufficiency.

Bile is rather poor of cholic acids, but has high bactericid properties because of prevalence of taurocholic acids on glycocholic in it.

Page 9: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

The liver deposits nutrients: glycogen, lipids and proteins.

Albumins, α- and β-globulins, ceruloplasnin, transferrin, thrombinogen, and fibrinogen are synthesized in a liver.

In children hemorrhagic syndrome in liver diseases develops more often.

 

Page 10: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Regions of Abdomen

Page 11: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

There are 9 areas of abdomen: right and left hypochondrium, epigastric area, right and left flanks, paraumbilical area, right and left iliac areas, suprapubic area.

Pain in right hypochondrium is characteristic of diseases of liver, billiary tracts, right kidney, in left hypochondrium – pathology of pancreas, spleen, left kidney, in epigastria - gastritis, esophagitis

Pain in paraumbilical area can be in helminthoses, higher of umbilicus right-side – in duodenitis, in the right iliac area – in appendicitis, proximal colitis, in the left iliac area – in distal colitis, pathology of sigmoid colon.

Pain in all parts of abdomen is typical of enteritis, meteorism, and circular pain – of pancreatitis.

Page 12: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Diffuse (in inflammatory processes of intestine and liver) and local (cholecystitis, gastric and duodenal ulcer)

Dull (diseases of liver, billiary dyskinesia, at colitis, gastroduodenitis) and acute (cholelithiasis, intestinal colic, and ulcer).

Irradiation in the left hypochondrium is characteristic of diseases of pancreas, irradiation of pain under scapula, in the right humerus – of diseases of billiary tracts.

Page 13: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Early pain arises first 30 minutes after meal, can be connected with diseases of stomach, esophagus.

Late pain – in 30 – 60 minutes after meal - is characteristic of diseases of duodenum.

Moininganoff’s rhythm of pain: night and hungry (on an empty stomach) pain which remits after food intake and renew in 30-40 minutes is characteristic of duodenal ulcer.

Pain after spicy, fat, fried meal is characteristic of billiary diseases.

Page 14: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Pain after physical exertion is connected with diseases of parenchymatous organs at stretching of their capsule – liver, pancreatic, spleen diseases.

The intensive periodic pain during peristaltic vave and allocation of bloody slime from rectum on type of crimson jelly is characteristic of invagination of intestine. After the ending of a peristaltic wave the child become quiet. The new peristaltic wave associates with the beginning of new attack of pain

Page 15: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Eructation: air eructation after meal in infants is connected with aerophagia and underdevelopment of cardiac part of stomach; acidic eructation is connected with reflux of acidic contents of stomach to esophagus and mouth. Foul-smelling eructation in children practically does not meet, since true achylia absent. Regurgitation in infants is variant of norm, occurs without strain of muscles of prelum abdominale.

Heartburn – feeling of burning behind the breastbone; is caused by regurgitation of acidic gastric contents to esophagus

Page 16: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Nausea arises at rising of intraduodenal pressure. It can manifest the general intoxication in infectious and parasitic diseases

Vomiting without nausea arises in rising of intracranial pressure, intoxication, sea-sickness. Intractable vomiting with smell of acetone - in ketonemia

In pathology of digestive system – gastritis, duodenitis, intestinal infections, food poisonings vomiting is always accompanies with nausea.

Page 17: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Pylorospasm is functional disease. The vomiting arises from first days of life, but it is not plentiful and observed not after each feeding, loss of body mass is insignificant.

Pylorostenosis is congenital pathology of pylorus which demands surgical treatment. Disease manifests on 2-3 week of life. The fountain vomiting after each feeding is characteristic, and the quantity of vomit mass can exceed quantity of the eaten food. Loss of body mass of has progressed. Visible peristalsis is marked; sometimes on abdominal wall contour of "sand-glass" is present. The upper part of this formation is overfull by food stomach; the lower part is overfull by gas intestine owing to deficiency of nutrition. In 90 % pylorus is possible to palpate.

Page 18: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

In simple dyspepsia which is connected with qualitative dietetic error in yang children, stool is watery with green, undigested agglomerates of food. In toxic dyspepsia stool is watery, light yellow, with slime.

Excrements in dysentery content slime, pus and blood. The defecation is accompanied by tenesmus – morbid call to stool. In salmonellosis faeces have green color, with slime. In cholera the white vomiting and white plentiful liquid stool, up to 100 times per day are observed.

Page 19: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Polyfecalia Polyfecalia in combination of presence of viscous

stool is characteristic of malabsorbtion syndrome. In chronic diseases of intestine – Crohn’s disease and nonspecific ulcerative colitis - excrements with blood and slime. Abdominal pain, rapid watery stool, especially at night, tenesmus are marked.

In bleeding from the upper parts of gastrointestinal tract the patient has melena – black faeces. In a case of bleeding from lower departments of large intestine – in excrements presents not changed blood. In anal fissure the blood has scarlet color, and not mixes with faeces.

Page 20: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Constipation – delay of stool more than 48 hours. If the stool is absent since a birth within several days, it is possible to think about congenital anomaly – megacolon, Hirschsprung’s disease, or about congenital hypothyroidism. In older children constipations can be connected with dolyhosigma, dolyhocolon.

Meteorism and rumbling arise owing to infringement of an adsorption of gases and liquid contents in a terminal department of an ileum and proximal departments of a large intestine. They are observed at a pancreatitis, colitis, dysbacteriosis.

Poor appetite and anorexia can be displays of intoxication. Anorexia of a psychogenic parentage, and also because of phobia of occurrence of pain is possible at gastroduodenitis, a peptic ulcer, constipations. Appetite is reduced at helminthic invasions, hypovitaminoses C and B, hypervitaminosis D.

Page 21: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Hemolytic jaundice is observed in hemolytic disease of newborns, congenital hemolytic anemia, some infectious diseases – malarias, leishmaniasis, influents of hemotoxins. A skin is citreous color. The liver is expanded less, than spleen. Faeces have usual color. In urine there is no bilirubin, but it is a lot of urobilin. Functional assays of a liver are not changed. The erythrocyte osmotic resistance is reduced, the high reticulocytosis is marked. The indirect bilirubin is increased.

Page 22: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Jondice Parenchymatous jaundice is

characteristic of diseases of liver – hepatitis, cirrhosis. The yellowness with a reddish shade is observed. Urine is dark because of bilirubin contained in it. The faeces periodically decolorized. The liver enlarged, morbid. Functional biochemical parameters of liver are increased. In a blood raises direct and indirect bilirubin.

Page 23: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Jaundice Mechanical jaundice is caused by a

obstruction of billiary tract. Skin has greenish shade. The dermal itch is marked. The liver enlarged. The direct bilirubin is increased. Urine is dark, contains bilirubin, the faeces are decolorized.

Page 24: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Paleness, shadows under eyes can be displays of the general intoxication

The jaundice can be exogenous, connected with superfluous entering of Carotinum. In this case sclera are light, and palms and soles are painted more brightly.

Page 25: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Kerr’s sign - morbidity at a superficial palpation in the field of a projection of a gallbladder - crossing of external edge of a straight abdominal muscle with the right costal arch.

Murphy sign - the big finger of the doctor’s hand is deeply shipped in the field of Kerr’s point, and other fingers fix a costal arch; at an inspiration the patient feels the pain.

Ortner’s sign - morbidity at a percussion by a rib of a palm on the right costal arch.

Mussy sign (frenicus-sign) – morbidity at pressing between legs of right sternocleidomastoid, arising in the field of pressing, in the right hypochondrium and irradiating to the right arm

Page 26: Anatomic and physiological features of digestive system in children. semiotics of gastrointestinal diseases

Dezharden’s point (pain point of head of pancreas) is on a line connecting umbilicus and right axillary cavity on 4-6 cm upper of umbilicus (depending on age).

Shoffar’s zone (zone of a projection of body of pancreas) is in upper right quadrant between its bisector and median line of abdomen, on 3-5 cm higher of umbilicus.

Mayo - Robson point (pain point of tail of pancreas) is on bisector of left upper quadrant of abdomen, on 1/3 of dystance lower the costal arch.