The main symptoms of acute gastritis – nausea, vomiting, abdominal pain, fever – occur in the initial period of many childhood diseases, including those requiring urgent medical measures (appendicitis, intussusception, peritonitis). This determines the exceptional complexity and responsibility of differential diagnosis. A significant difficulty is the differentiation with atypical forms of acute appendicitis. At the same time, clarification of the fact of food error preceding the development of acute gastritis, a large degree of intoxication in the initial period of the disease helps, on the other hand, the comparative intensity and increasing nature of abdominal pain with appendicitis. Invagination occurs mainly in young children, her clinic differs from the characteristic of acute gastritis in good condition and the absence of an increase in body temperature in the first hours after the appearance of mandatory vomiting with it, delayed stool and gas. The diagnosis of peritonitis is ruled out on the basis of the absence of symptoms of peritoneal irritation in acute gastritis. Differentiation with various infectious and somatic diseases (scarlet fever, meningitis, dysentery, pneumonia, etc.) is carried out taking into account the data of general and epidemiological history, clinical examination and observation.
Treatment with an alimentary form is reduced to the appointment of bed rest, a water-tea diet, after which the child receives easily digestible food with a restriction of fats and fiber (tea with breadcrumbs, mashed soups and cereals, jelly, etc.) and is transferred to a few days later general diet. In case of incomplete emptying of the stomach, it is advisable to begin treatment with washing it with warm water. With the appearance of loose stool, a laxative is prescribed.
In severe alimentary forms of acute gastritis, after obligatory gastric lavage in these cases, a tea and water diet should be prescribed for 18-24 hours. Vomiting stops faster after intramuscular administration of chlorpromazine (1 to 2 mg / kg body weight per day). With a sharp dehydration, it is advisable to drip intravenous administration of isotonic solutions of sodium chloride and glucose, as well as blood plasma. The appointment of corticosteroids helps to reduce toxicosis; according to indications, cordiamine, caffeine are injected subcutaneously, strophanthin or korglikon are added to the infusion fluid . Subsequent expansion of the diet is carried out more carefully than with a mild alimentary form of acute gastritis, since unreasonably early or irrational nutrition can worsen the condition of a sick child and cause persistent digestion with prolonged anorexia, emaciation, decreased reactivity, etc. Treatment for toxic infectious form of the disease depends on the degree of toxicity and differs from treatment of acute gastritis alimentary form only purpose antibacterial Terapii.pri Salmonella current ikoinfektsii effective chloramphenicol succinate , gentamicin, kanamycin , polymyxin M, Biseptolum. With moderate severity and severe course of the disease, the combined use of several antibiotics is shown (taking into account the sensitivity of flora to them). This applies equally to staphylococcal toxic infectious gastroenteritis, in which also prescribed zeporin , oxacillin, antistaphylococcal immunoglobulin. It is also necessary to prescribe vitamins, especially group B, as well as stimulants – blood plasma, γ-globulin, pentoxyl , etc.
After resection of the stomach for peptic ulcer of the stomach and duodenum, post-resection disorders often develop . The most commonly observed dumping syndrome.
With dumping syndrome, a special type of metabolic disturbances is noted, which are based on shifts in biochemical homeostasis associated with a breakdown of the neurohumoral regulatory activity of the body. With a frequent repetition of expressed vegetative reactions, serious metabolic status disorders occur – metabolic maladaptation , as a result of which the coordinated and synchronous activity of the organs of the gastrointestinal tract is disturbed. With functional disorders of the liver and pancreas, a decrease in enzymatic activity and micro-changes in the mucous membrane of the gut with the development of conditionally pathogenic microflora in the intestinal lumen and a decrease in the acid-producing function of the gastric stump, these metabolic disorders can lead to poor absorption and absorption of nutrients. Patients have asthenia, weight loss, anemia, hypovitaminosis, as well as a change in neuropsychic status.
Some patients have marked metabolic disorders with the development of alimentary dystrophy.
The neurohumoral disorders detected in patients with dumping syndrome, pathophysiological changes in the digestive system, metabolic changes are the theoretical justification for the development of the principles of differentiated dietary therapy for these patients, taking into account different periods after surgery, the severity of dumping syndrome, the nature of the accompanying diseases and the consequences of reconstructive operations. Its main principle is the appointment of frequent high-calorie meals in fractional portions. The protein content is increased to 2-2.2 g per 1 kg of body weight, easily digestible carbohydrates significantly limit. The content of fat and complex carbohydrates is provided within normal limits.
After partial resection of the stomach, the secretion of gastric enzymes, pepsin and gastricin , is significantly upset , which can lead to violations of protein digestion in the stomach. Given this factor, it is necessary to include crushed protein dishes in the diet of patients, which are easier to digest and are attacked by pancreatic and small intestine enzymes.
In the very first days after the operation, when it is possible to start feeding the patient, protein dishes are included in the diet, protein entit is
administered. The appointment of an increased amount of protein in the early postoperative period is necessary due to a tendency to catabolic processes, as well as an electrolyte imbalance.
The high protein content in the diet provides the body with enough fat. Patients with dumping syndrome tolerate fat in protein products well. The amount of fat is reduced to the lower limit of the norm with concomitant pancreatitis.
Recommendations to increase the proportion of fat in the diet of patients with dumping syndrome to the upper limit of the norm are due to biologically important properties of fat (rich in vitamins, lipotropic substances, fatty acids, participation in the synthesis of a number of hormones, enzymes and biologically active substances, the ability to improve the taste of food). Due to frequent complications from the biliary tract and gall bladder, as well as a tendency to lipidemia, patients should not abuse fats. Refractory fats and fat breakdown products must be limited.
The content of complex carbohydrates should be within the lower limit of normal (for patients with severe dumping syndrome no more than 300 g per day). A sufficient amount of polysaccharides provides the correct ratio in the diet of basic nutrients, increases the calorie intake and is well tolerated by patients. Complex carbohydrates, being slowly absorbed, do not cause sharp changes in enzyme and hormonal systems. 1 Enpits are new drugs intended for the enteral nutrition of seriously ill patients, developed by the Institute of Nutrition of the Academy of Medical Sciences.
Along with all the above principles, the diet should contain the maximum possible number of food factors that stimulate hematopoiesis . It is important to ensure a sufficient intake of iron with food.
In the first 2-4 months after surgery, in connection with the postoperative inflammatory process, it is recommended to observe the principle of mechanical dizziness . In the long term in the presence of peptic ulcers, pancreatitis, aiastomositis , enteritis, food should also be mechanically sparing. In all other cases, you need to give unprotected food, it is better tolerated by patients with dumping syndrome, and the assimilation of peppermint food is not much different from the assimilation of rubbed.
It is better to cook food with a viscous or jelly-like consistency, limit the amount of liquid during meals, since mostly liquid food containing readily soluble nutrients causes dumping syndrome. Such a diet has the least irritating effect on the receptors of the mucous membrane of the small intestine, thereby preventing the development of a dumping reaction. In addition, opa promotes the formation of adaptation mechanisms to new digestive conditions.
Given the changes in the hepatobiliary system, small intestine, pancreas, stomach stump, anastomosis, in the preparation of diets for patients demping- sipdromom the principle of moderate chemical schazheniya , t. E. Chemical irritants are eliminated gastrointestinal secretion and harsh stimulants, as well as limited foods containing coarse fiber are limited.
For patients with dumping syndrome with a deficit of body weight, an increase in the calorie content of the diet is provided.
When preparing medical nutrition, dishes and products that provoke the occurrence of dumping syndrome are excluded.
Diet therapy is built differentially and in stages, depending on the clinical picture of the syndrome, the presence of concomitant diseases, and the time elapsed after the operation.
For patients with peptic ulcer who underwent a resection of the stomach, several diet options are offered: with mechanical sparing , without mechanical pressing , with severe form of dumping syndrome, for patients with concomitant pancreatitis, in the early postoperative period, etc. In all recommended dietary options, the principle of chemical sparing , the patient’s daily need for vitamins, minerals and essential amino acids is provided.
The diet was built on the principle of a gradual increase in the load on the gastrointestinal tract and the inclusion of a sufficient amount of protein for faster and more complete restoration of the functions of the digestive system.
During the day after surgery, patients are not given any food. On the 2-3rd day, with good health and the absence of signs of stagnation in the stomach, tea with a small amount of sugar, broth of wild rose, slightly sweet compote and kissel (mashed), 25% protein entpit in 30-50 ml 2 times a day are prescribed .
On day 4-5, you can include soft-boiled eggs, mucous soups, meat and cottage cheese purees and soufflés. The number of meals – 5-6 times a day in the amount of 70-100 ml per meal.
On the 6-7th day, the diet is expanded, the portion of protein and other dishes is increased, mashed cereals (preferably oatmeal, longitudinal and rice) are added, white crackers (pa on the 8th day). By the 10th day, the volume and chemical composition of the diet are close to normal. They include mashed vegetable dishes (potato, carrot shore ). Meat and fish dishes are given in the form of steamed souffles, dumplings and meatballs. Soft-boiled eggs, steam omelets, curd soufflé are recommended. Food is consumed 6-7 times a day in an amount of 200-400 ml. With each meal, the patient should receive a protein dish.
A variant of a diet with mechanical sparing for patients undergoing a resection of the stomach. This diet is prescribed to patients 1-2 weeks after surgery for 2-4 months. It can be recommended, and for a longer time in the presence of diseases of the operated stomach (gastritis, anastomositis , peptic ulcer, enterocolitis).
Diet helps to reduce the inflammatory process in the gastrointestinal tract, stimulates reparative processes, and also prevents the occurrence of dumping syndrome.
General characteristics of the diet
The diet is physiologically complete, with a high protein content, normal complex carbohydrate content and a sharp restriction of easily digestible carbohydrates, normal fat content. It limits mechanical and chemical irritants of the mucous membrane and the gastrointestinal tract receptor apparatus, nitrogen extractives (especially purines), refractory fats, and fat splitting products from frying (aldehydes, acroleips ) are minimized . Strong stimulants of bile secretion and pancreatic secretion, as well as products and dishes that can cause demi-pan syndrome (sweet liquid milk porridges, sweet milk, sweet tea, hot fat soup, etc.) are excluded . Diet giponatrievaya .
With severe dumping syndrome, separate intake of the liquid and solid parts of the diet is recommended: the liquid is consumed 30 minutes after eating solid food, during lunch, you must first eat the second dish, and then the first. Eat bed in bed.
Culinary processing. All dishes are cooked boiled or steamed, mashed. The third dishes that the patient receives during dinner are prepared unsweetened (without sugar) or on xylitol (10-15 g per serving). Sugar is given to the patient’s hands (20-40 g per day), it is better to eat it with bite. Chem matic composition and caloric content. Proteins 140 g, fats 110 g, carbohydrates 380 g. Calories 3000 kcal. Salt 8-10 g. Dietary regimen is fractional (5-6 times a day). Food temperature. Avoid hot and cold meals. The recommended temperature of the poor is 55-56 ° C. The list of recommended foods and dishes. Bread and bakery products. Yesterday’s wheat bread, crackers made from wheat bread, Yesdobioe cookies . Soups On vegetables (excluding white cabbage)., Cereal broths, mashed, low-fat meat broth 1 time per week. Meat and fish dishes. Low-fat meat without tendons (beef, chicken, veal) and fish (cod, pike perch, carp, pike, bream, saffron cod, silver hake, carp) in minced form (mashed potatoes, souffle, dumplings, meatballs, meatloaf, meatballs). These products are boiled, cooked on iaru , baked (with preliminary boiling). Dishes from eggs. Soft-boiled egg ( pe more than 1 pc per day), protein omelet or one egg. Milk, dairy products and dishes from them. Milk in dishes and for tea, with tolerance – whole milk. Kefir is allowed 2 months after surgery. Sour cream as seasoning. The cottage cheese is non-acidic, freshly prepared, mashed. Dishes and side dishes from vegetables. Boiled vegetables, mashed. Boiled cauliflower with butter, stewed squash and pumpkin, carrot, potato june . Fruits, berries, sweets. Fruits and berries (fresh and dry) in the form of unsweetened mashed compotes, jelly, jelly, mousses. Baked apples without sugar. Fruits and berries with coarse fiber (pear, quince) are not allowed .. Stewed on xylitol (10-15 g per serving). Sugar, honey, sweets, jams are sharply limited. Dishes and side dishes from cereals, pasta. Unsweetened mashed, viscous cereals, puddings, casseroles of rice, longitudinal cereals, oatmeal. Semolina is limited. Finely chopped pasta, boiled. Fats. Butter, ghee, olive, sunflower, refined (do not fry) add to the dishes in their natural form. Snacks Uncooked cheese (Yaroslavl, Russian, Uglich ) grated, spawned caviar, granular, home-made meat paste, jelly. Sauces and spices. Sauces on vegetable broth, sour cream sauces. Drinks and juices. Weak tea and coffee with and without milk. Juices unsweetened fruit (except grape), berry and vegetable. Decoctions of rose hips. It is forbidden: products from butter and hot dough, brains, liver, kidneys, various pickles and smoked products, marinades, canned meat, fish and other snack foods, smoked sausage, cold and carbonated drinks, chocolate, cocoa, ice cream, alcohol, white cabbage, legumes , spinach, sorrel, mushrooms, radishes, rutabaga, onions, garlic, spices. An approximate one-day menu of the wiped diet option is given in table. In the first 2 weeks after the operation, the number of dishes and servings is reduced, in the future they gradually include a complete set of products.
Indications for the purpose of the diet. 2-4 months or more after resection of the stomach with a mild form of dumping syndrome and a moderate form, in the presence of complications of cholecystitis and hepatitis.
Special purpose. Prevent and reduce the manifestation of dumping reactions, contribute to the normalization of the functional state of the liver and biliary tract.
General characteristics of the diet
The diet is physiologically complete, with a high protein content, normal fat and complex carbohydrate content with a sharp restriction of simple carbohydrates, a normal salt content (15 g), mechanically non-sparing, with a moderate restriction of chemical irritants of the gastrointestinal tract, with the exception of strong biliary stimulants and pancreatic secretion, with the exception and restriction of foods and dishes that cause the development of dumping syndrome.
Culinary processing. All dishes are cooked boiled or steamed, give uncooked . Allowed individual dishes in baked form without a rough crust. The third dish at lunch is unsweetened or cooked on xylitol (10-15 g per serving). Sugar is given to the patient. The chemical composition and calorie content. Protein 140 g, fat 110 g, carbohydrates 390 g. Caloric content about 3100 kcal. Salt 12-15 g. The diet is fractional (5-6 times a day). Food temperature. The food is given warm; hot and cold meals should be avoided. A list of recommended foods and dishes. Bread and bakery products. Wheaten gray bread of yesterday’s baking, undesirable and unsweetened varieties of bakery products and cookies. Seeded rye bread. Soups On vegetable broths and cereals, vegetarian. Borsch, cabbage soup, beetroots from fresh cabbage. Low-fat meat soup 1 time per week. Meat and fish dishes. Various products of low-fat beef, veal, chicken, rabbit, low-fat fish (cod, pike perch, common carp, saffron cod, pike, carp, etc.) are boiled, baked, stewed, you can not chop. Dishes from eggs. Soft-boiled eggs (no more than 1 pc. Per day), protein omelet. Dishes and side dishes from cereals, pasta. Crumbly and viscous cereals, pudipgi , cereal casseroles – unsweetened; boiled pasta in the form of casseroles. Buckwheat, hercules and rice cereals are recommended. Semolina is limited. Dishes and side dishes from vegetables. Raw, boiled, baked, stewed vegetables. Non-acidic sauerkraut is allowed. Boiled cauliflower with butter, zucchini and stewed pumpkin, salads, vinaigrettes, green peas. Tomatoes with vegetable oil. Early raw finely chopped greens can be added to various dishes. Fruits. berries, sweet dishes, sweets. In raw form, not very sweet fruits and berries. Unsweetened compotes, jelly, mousses. Limit the grape juice that! causes bloating. Sugar, mod, sweets, jams are sharply limited. Milk, dairy products and dishes from them. Milk with tea and other drinks or as part of various dishes, with tolerance – whole milk, yogurt, kefir, acidophilus milk. Sour cream as seasoning and in salads. The curd is not acidic, fresh. Fats. Butter, ghee, olive, sunflower. Snacks Mild cheese, low-fat herring, doctor’s sausage, diet sausages, home-made meat paste, ham without lard. Salads, vinaigrettes, jellied fish on gelatin, jelly on gelatin. Sauces and spices. Sauces on vegetable broth, sour cream sauces. Onions and chives in very moderate amounts. Drinks and juices. Weak tea and coffee with and without milk. Juices unsweetened fruit and berry, vegetable. Rosehip broth. The same foods and dishes are prohibited as with the rubbed version of the diet, except for white cabbage. An approximate one-day menu of the unprotected diet option is given in table. The methodology of medical nutrition. In the first days after gastrectomy, the patient is prescribed a special diet. After 1-2 weeks, in the absence of complications, you can prescribe the wiped diet option. First, bread in the form of crackers is recommended, and then you can eat stale white bread. In the first days of using the mashed version of the diet at a time, give no more than 1-2 dishes, limit the side dishes. Then, they gradually switch to a full diet of a pureed diet. After 2-4 mine (in some patients after 4-5 months ) it is recommended to switch to an unapproved diet. The transition must be made gradually, in the first days, non-mashed vegetables are given in limited quantities, including them in the first dish. Brown bread, sauerkraut, salads are recommended to be included later, also gradually. If the patient has anastomositis , a peptic ulcer of any localization, then the wiped version of the diet is prescribed. For patients who ate gastric resection, in which the symptoms of nancreatitis predominate in the clinical picture , a variant of a pureed diet with a certain decrease in fat content is proposed. With a severe degree of doming-indroma, a diet is prescribed without mechanical sparing with the restriction of complex carbohydrates to the lower limit of the norm (300 g per day) and the complete exclusion of simple angles . All dishes are cooked boiled or steamed. This version of the diet provides for the complete exclusion of sugar, a decrease in the amount taken at one meal (due to side dishes), and more frequent meals. You must eat lying down and staying in bed for 20-30 minutes after each meal. The chemical composition of the diet: protein 130 g, fat 100 g, carbohydrates 320 g. Calorie content 2600 kcal.
If in the clinical picture of the disease inflammatory phenomena come to the fore (enterocolitis, neuriviscritis ), then the tin diet of the rubbed version is used, but with a sharper restriction of carbohydrates, mainly easily digestible, they exclude sugar, reduce the number of side dishes, and limit salt.
In case of complication of the dumping syndrome with enterocolitis or intestinal dyskinesia , a diet is used depending on the nature of the course of the disease. When administered exacerbation rubbed embodiment diet with the exception of cabbage, beet, ropy , radish, radish, spinach, onion, garlic, mushrooms, barley and millet CSGNs , melons, apricots and plums.
With colitis with a tendency to constipation and flatulence, an unprotected diet option is given . In raw form, ripe tomatoes and leafy salad are allowed. Black bread, turnips, radishes, radishes, sorrel, spinach, onions, garlic, mushrooms are excluded. Fruits are allowed without peel. Milk is consumed with good tolerance, better diluted. It is recommended to introduce an increased amount of food stimulants of peristalsis (cream, vegetable oil in dishes, vegetable juices, vegetables and fruits, bran bread, dairy products).
After G-12 months after surgery, in the absence of complications from the liver, pancreas and intestines, it is recommended to switch to a diet with the usual culinary processing. But even when receiving diet No. 15, the patient must comply with the principles of fractional nutrition and restriction of dishes that provoke dumping syndrome.
The transition to a more diverse diet is carried out in these patients by reducing the degree of mechanical sparing , while chemical sparing is preserved for a longer time due to persistent secretory disorders of the digestive tract.
In patients who have undergone a resection of the stomach, without signs of dumping syndrome, the clinical picture for prophylactic purposes also recommends fractional nutrition (4-5 times a day), restriction of foods and dishes that most often cause dumping syndrome (sweets, sweet milk porridges, very hot and cold dishes). Food should be taken slowly, chewing it carefully.
Patients operated on for gastric cancer should be prescribed a complete diet to limit the amount of simple carbohydrates, foods containing animal fat, cholesterol, and with an increase in vegetable oil, buckwheat, sago.
Observations of recent years have shown that in patients operated Io gastric cancer, quite often there are complications from other digestive organs (pancreatitis, cholecystitis, enteritis, colitis). It is known that in patients with organic lesions of the stomach by the time of surgery there are significant violations of the functional state of the digestive system and metabolic processes. Therefore, after surgery, as a rule, complications arise from a number of digestive organs. This fact sets before gastroenterologists the task of compiling a diet for patients who underwent surgery for gastric cancer, taking into account the existing complications.
Patients after gastrectomy who have complications from a number of digestive organs can be recommended the same diet options as for patients who underwent partial resection of the stomach, only slightly reduced calorie content and limited animal fat.
The general principles of nutrition of patients after total resection of the stomach are:
Balanced therapeutic nutrition with sufficient protein content.
Consideration of the nature of osloashei arising after the operation.
Limitation of easily digestible carbohydrates (sugar, honey, steam) and animal fats.
After a gastrectomy in the first 1-2 months , a wiped version of the diet is recommended. Then you can switch to the non – rubbed version. In the long term after surgery, patients after total removal of the stomach, having concomitant pancreatitis, it is better to identify the wiped version of the diet. Often in patients after gastrectomy , various types of intestinal dyskinesia occur. With a tendency to diarrhea, apples are given in a baked form or raw without a peel, exclude milk, sugar. With constipation, vegetable juices, prune broth, cream in tea, vegetable oil in cereals, vegetables, soups can be added to the non-mashed version of the diet; boiled beets. In the absence of complications from the digestive system, a peppermint diet with the usual culinary treatment is prescribed .
Patients operated on for gastric cancer are advised to limit the amount of fat and, if possible, include low-fat products (low-fat cottage cheese, milk, etc.).
Diet option for patients after total removal of the stomach with the presence of complications from the digestive system 1.5-3 months after surgery
General characteristics of the diet
The diet is physiologically complete, with a high protein content, fat content at the lower normal range , with a restriction of complex carbohydrates to the lower pore border and a sharp restriction of easily digestible carbohydrates, with a moderate restriction of chemical irritants of the gastrointestinal tract. Exclude stimulants of bile secretion and pancreatic secretion. Gynoatria diet .
Culinary processing. All dishes are cooked boiled or on the bun, roasting is not allowed. The food is given unprotected . Dishes can be baked with preliminary boiling or stewed with the removal of the first portion of the juice released during braising. The chemical composition and calorie content of the diet. Proteins 120-130 g, fats 80-90 g, carbohydrates 330 g. Calories 2700-2800 kcal. Salt of 8-10 Directed power their fractional (5-6 times a day). The set of products and dishes in this diet is not significantly different from that in the diet for patients with severe dumping syndrome. This diet includes low-fat protein foods – meat, fish, cottage cheese. Oil is introduced into dishes; they don’t give it to the table. An approximate one-day menu of this diet is given in table. The same foods are prohibited as in the diet for patients after partial resection of the stomach.
The study of acute intestinal infections has a long history, but it has become especially intense at the end of the last century and in the last decades of the 20th century. The concept of dysentery is very ancient, before it included a variety of intestinal disorders ( dys – disorder, enteros – gut). At the end of the last century, dysentery was isolated from the group of intestinal disorders as an independent infectious disease with a specific pathogen. Other diseases were determined by clinical syndromes: dyspepsia, enteritis, colitis, gastroenteritis, enterocolitis, gastroenterocolitis . In the course of the study, in parallel with the successes of microbiology, virology, immunology, their etilogy also revealed a predominantly infectious factor.
Acute gastrointestinal infections in children have been studied by many domestic scientists (M. G. Danilevich, A. I. Dobrokhotova , V. D. Zinerling . M. A. Skvortsov, M. N. Sukhareva. E. M. Novgorodskaya. M. Berman. N.I. Nisevich , G.A. Timofeeva and many others).
To date, it has been established that the vast majority of acute intestinal diseases has an infectious origin. They can occur as a result of nutritional disorders, but such cases are rare and violations are short-lived. With severe manifestations and severe forms, the infectious nature is detected almost always, with the exception of rare cases of poisoning. ” Syndrome | L > 1e” diagnoses are becoming increasingly rare.
The group of acute gastrointestinal infections in children includes dysentery, salmonellosis, coli infection, staphylococcal infection. They can justifiably be classified as “childhood” infections in connection with the predominant distribution in the pathology of children. For practical measures to combat intestinal infections in children, diarrhea with viral infections is usually included in this group. Typhoid fever is not included in this group, as it has a distinct distinct morphological, pathogenetic, clinical characteristic. Typhoid fever is described in a separate chapter.
Dysentery was identified as an independent nosological unit at the end of the last century, after the discovery of dysentery bacillus. The role of salmonella in the etiology of diseases in humans was clarified at about the same time as dysentery, but in those years only the occurrence of foodborne toxicoinfections was associated with salmonella , subsequently toxicoinfections and toxico-septic conditions in newborns. Salmonellosis received a more complete clinical characterization only in the 50-60s of our century.
The situation was similar with a group of staphylococcal diarrhea. Since the end of the last century, a form in the form of foodborne toxicoinfection has been known . The remaining forms began to be intensively studied in the 50s and even 60s of the present century in parallel with the opportunity to differentiate individual strains of staphylococcus and use immunological methods that confirm the etiological role of staphylococci.
Intestinal coli infection was isolated into an independent nosological form mainly in the 50s in connection with the refinement of the antigenic structure of Escherichia coli; among them, a group of enteropathogenic Escherichia coli (EPA) of various serological types causing intestinal diseases was found.
Finally, intestinal infections caused by viruses were also detected relatively recently – mainly in the 60s, in parallel with the introduction of virological and serovirusological methods of examination.
In recent years, observations have been accumulated suggesting that intestinal diseases can also be caused by Pseudomonas aeruginosa, Proteus, and other microorganisms, but the frequency of these diseases is small, and the clinic has not yet been adequately studied. In addition, intestinal diseases caused by Klebsiella and Yersinia are possible .
Acute intestinal infections are often of mixed etiology (mainly in younger children and in severe forms of the disease). The following concomitant infections are most common: with staphylococcus, with coli infections, with dysentery; dysentery and salmonellosis. Mixed infections can be of a viral and microbial nature, of a mixed viral nature.
Dysentery, salmonellosis, and coli infection are justifiably referred to as intestinal infections. These are intestinal infections, in which intestinal changes are the main essence of the disease, and staphylococcal, viral diarrhea is just one form of staph infection or viral diseases. An intestinal lesion caused by staphylococcus can be an independent, isolated disease, and can also be combined with other localizations of the pathological staphylococcal process.
Acute intestinal infections of various etiologies have
much in common in epidemiological patterns. A number of common features in pathogenesis and morphological changes, some common features in clinical manifestations are noted, therefore, similar, sometimes completely identical, hygienic and therapeutic measures are used. Along with the similarity, each etiological form has its own specific features, which necessitate various preventive measures. Therefore, an accurate clarification of the etiology of each individual case is necessary. Nizho given the epidemiology of acute intestinal infections with the indication of the identities of specific etiologic forms. Separately described pathogenesis, pathological anatomy and clinical characteristics, and differential diagnosis, treatment and prevention in view of the identity of the main provisions are presented in general chapters. An independent chapter is devoted to typhoid fever.
The source of infection is patients and carriers. Patients are contagious from the onset of the disease, the maximum contagiousness occurs at the height of the disease, as the condition of the patients improves, stool contraction decreases, the contagiousness decreases, but it can persist for a long time. It has been proven that bacterial excretion often remains after recovery and is usually supported by pathological changes in the intestine. The end of the infectious period is determined only bacteriologically . The smallest role in the spread of infection is played by patients with erased atypical forms in which the diagnosis is not established; staying in groups, they infect others. Children play a large role in the spread of intestinal infections, as they often suffer from erased forms, they may still lack hygiene skills, as a result of which they easily infect the environment. Newborn babies are often infected by mothers. Carriers of intestinal infections are relatively rare, but they are also involved in the spread of infection). In salmonellosis, the source of infection can be not only humans, but also animals (livestock, cats, mice, rats). A powerful reservoir of infection are birds, especially waterfowl (ducks, geese). Salmonella are found in them not only in organs, as in animals, but also in eggs (on the shell, in the contents of the egg), carriage is long. Transmission ways. All intestinal infections are fecal-oral: pathogens are excreted from the body with feces (can be in vomit) and enter the body through the mouth. These infections are called dirty hands disease: patients, carriers, or caregivers infect their hands, transfer the infection with their hands to surrounding objects (linen, dishes, door handles, toys, etc.), from where the infection is brought directly into the mouth by hands. or through food scheme 2, 3). Staphylococcal intestinal infection is also characterized by infection with sputum from patients with damage to the pharynx, respiratory tract or separable from skin lesions. Staphylococcus can be infected with surrounding objects, air, dust, etc. Carriage of staphylococci is widespread especially among staff of departments where patients with purulent diseases are located. Mothers with diseases of the genital tract can infect the baby during childbirth, mothers with nipple lesions – during feeding. In addition, autoinfection is possible, i.e., the development of an inflammatory process in the intestine caused by staphylococcus, which previously existed in other pathological foci. Intestinal infections are highly contagious . In children’s groups, in hospitals, with crowding, with violations of the sanitary-anti-epidemic regime, with a delay in isolation of patients or carriers, large foci of diseases can occur. Foodborne infection is possible for all intestinal infections; food workers, food workers, maintenance staff infect food, food with dirty hands; flies may have some significance. With dysentery, foodborne infection is most often associated with infected dairy products (milk, cottage cheese, sour cream), and with coli infections, with milk mixtures. Staphylococci reproduce especially well in creams used in the manufacture of cakes and cakes. Foodborne infection in infants can occur through mothers milk. In these cases, staphylococcus in breast milk is determined in high concentrations. With salmonellosis, infection most often occurs after eating foods prepared from meat products, eggs, egg powder. The foodborne infection route is dangerous because it can cause large outbreaks and severe illnesses to quickly occur. Due to the multiplication in products, a massive dose of the pathogen along with the toxin can enter the body, and diseases in these cases often proceed as a type of toxicoinfection . There are water outbreaks associated with infection of drinking water, water sources. The epidemiological patterns of intestinal disorders caused by viruses are not well understood. It is known that both patients and carriers are sources of infection. Many viruses ( enteroviruses , adenoviruses, etc.) can be excreted for a long time with feces. The susceptibility of children to intestinal infections is very high. It increases with a decrease in reactivity, with various diseases, rickets, eating disorders, hypovitaminosis, etc. The incidence is directly related to social factors. Poor sanitation of homes, child care facilities, crowding, poor sanitation, and lack of medical care contribute to the spread of intestinal infections. Among all patients with dysentery, salmonellosis, up to 60-80% of cases occur in children; coli infection due to EPI category I and staphylococcal intestinal infection are diseases that affect mainly children. The ratio of different etiological forms of intestinal infections in children is not constant, it changes significantly over time, in different geographical locations and depends on many factors. Among intestinal diseases, dysentery predominates, but the distribution of etiological forms by age has differences. Dysentery can occur at any age, but susceptibility to it increases by the end of the first year of life and reaches a maximum at the age of I-3 years (E.M. Novgorodskaya, L.V. Hazanson ). Salmonellosis mainly affects children up to 2-3 years old (from 50 to 85%). Coli infection (EPI category I) is most often observed in the first half of the life of children (starting from the first month), by the year its frequency decreases, and after 1 – 2 years it becomes a rarity. Among the cases, 55% were children under the age of 6 months , 30% from 6 months to I year, and 15-16% from I year to 2 years. (E.M. Novgorod). Approximately the same ratios are observed with staphylococcal diarrhea, excluding foodborne infections that occur at all ages. The incidence of intestinal forms of staphylococcal infection is often not sufficiently taken into account: in infancy, among all intestinal infections, it can reach 30% or more. Acute intestinal infections can occur throughout the year, seasonality is typical for dysentery, salmonella, to a lesser extent for coli infection. Seasonality is manifested by an increase in incidence in the second half of summer and autumn. Among the causes of seasonality indicate a change in the reactivity of children in the summer, a decrease in the bactericidal effect of gastric juice, the use of a large number of berries, fruits, vegetables, which in turn creates great opportunities for infection. In all seasons, in acute gastrointestinal infections, the contact-household route of infection prevails. Along with this, it should be borne in mind that outbreaks of food and water origin occupy a large place in morbidity.
Peptic ulcer is a chronic recurrent disease in which an ulcer is formed in the stomach as a result of a violation of the nervous and humoral mechanisms that regulate trophic, motor and secretory processes in the gastroduodenal zone.
Etiology, pathogenesis of gastric ulcer
With localization of an ulcer in the stomach, the main etiopathogenetic mechanisms are caused by a violation of local factors, manifested in a decrease in the resistance of the gastric mucosa, weakening of its resistance to the damaging effects of gastric juice, against the background of existing ultrastructural changes in the mucous membrane and disturbances in tissue metabolism.
P azlichayut ( Johnson , 1965), three types of stomach ulcers: I – ulcers small curvature (60%), II – combination of gastric and duodenal ulcers (20%), III – prepiloricheskie ulcers (20%). The basis of the formation of ulcers of lesser curvature of the stomach is duodenogastric reflux, resulting from a violation of the neurohumoral regulation of the motility of the pyloroduodenal segment of the digestive canal. Prolonged exposure of the contents of the duodenum (especially lysolecithin and bile acids) to the gastric mucosa violates the protective mucous barrier. The resulting enhanced reverse diffusion of H + leads to the development of chronic atrophic gastritis. The latter usually affects the antrum of the stomach and spreads along the lesser curvature to its acid-producing α-zone. Regenerative disturbances arising from gastritis, local ischemia and immunological changes, insufficient mucus formation lead to necrosis of the stomach wall with the formation of an ulcer. With an ulcer of lesser curvature of the stomach, the production of hydrochloric acid decreases, which is associated with reverse diffusion of H +, a decrease in the mass of parietal cells due to atrophic gastritis. The higher the ulcer is located along the lesser curvature, the more pronounced is the manifestation of gastritis and the lower the production of hydrochloric acid. The formation of a combined gastric and duodenal ulcer is explained on the basis of the theory of antral stasis ( Dragstedt , 1942, 1970). The starting point in such patients is considered to be a duodenal ulcer, which alone or due to stenosis leads to impaired evacuation from the stomach, stretching of the antrum , and increased gastrin excretion . Hypersecretion of the latter leads to the formation of gastric ulcers. The pathogenesis of prepiloric ulcers is the same as duodenal ulcers.
Clinic of gastric ulcer
The clinic of gastric ulcer has its own characteristics and depends on the location of the ulcer, the age of the patient and the presence of complications. Common to gastric localization ulcers is a lower intensity of the pain syndrome than with localization of the ulcer in the duodenum. The pain is noted in 0.5-1.5 hours after eating, while in case of duodenal ulcer – after 2.5-3 hours. In case of gastric ulcer, the pain syndrome is traced to the composition of the food taken. Pain intensifies after eating spicy and poorly processed foods. Radiation of pain usually depends on the location of the ulcer and the presence of complications. With localization of the ulcer in the cardial part of the stomach, the pain is localized in the xiphoid process, radiating to the heart, left shoulder, back, left shoulder blade. The pain occurs with food or shortly after it. The intensity of the pain increases when penetrating ulcers pancreas zhelezu.Yazvy pylorus and prepiloricheskie ulcers are characterized by pain, irradii – ruyuschey back, early dyspeptic disorders such as nausea, heartburn, regurgitation, rvoty.V middle and old age, when there are already atherosclerotic vascular changes ulcers in the stomach often have significant sizes, quickly become callous, accompanied by various complications.
Diagnosis of gastric ulcer
Diagnosis of gastric ulcers, as well as duodenal ulcers, is based on gastroduodenoscopy data , during which sampling of material for a biopsy from 4-5 points at the edge of the ulcer is mandatory, followed by cytological examination. Subsequently, during drug treatment, dynamic endoscopic monitoring of the treatment results is performed, and after its completion, a control gastroduodenoscopy and biopsy are performed. X-ray diagnosis of gastric ulcer is based on the identification of characteristic symptoms, which are divided into direct and indirect. At the same time, attention is drawn to the anatomical changes caused by the ulcerative process (ulcer size, its localization), as well as the accompanying functional disorders of the lower esophageal sphincter, motor-evacuation function of the stomach and duodenum.
In gastric ulcer, disorders of gastric secretion, as a rule, are the opposite of those observed with duodenal ulcer. Usually, with gastric ulcer, the secretion of hydrochloric acid and pepsin is normal or reduced, which should be considered when choosing treatment tactics. The course of gastric ulcer is torpid in nature with exacerbations in the spring-autumn period.
Complications of gastric ulcer
Like duodenal ulcer, gastric ulcer is accompanied by a number of complications. The penetration of gastric ulcers is due to the localization of the ulcer defect and its size. Most often, a stomach ulcer penetrates into the small omentum, pancreas, left lobe of the liver, less often into the transverse colon, its mesentery.
Large ulcers localized in the antrum or prepiloric section of the stomach lead to stenosis of the outlet section of the stomach and impaired evacuation function. Abundant vascularization of the stomach and torpid course of peptic ulcer with unexpressed pain syndrome are often accompanied by bleeding of various intensities. One of the severe complications of stomach ulcers is malignancy of ulcers, the frequency of which, according to the literature, ranges from 5.5 to 18.5%. It is this complication that forces surgeons at an earlier stage to switch from conservative treatment to surgical treatment. Absolute indications for surgery are: stenosis of the output section of the stomach with impaired evacuation, suspicion of mapignization or malignancy of a stomach ulcer, unstoppable bleeding from an ulcer; relative – ulcers of great curvature and the cardiac section of the stomach, as the most frequently malignant , callous ulcers with a diameter of more than 2 cm, recurrent and re-bleeding ulcers. The operation of choice in gastric ulcer is pyloropreserving resection of the stomach, which is feasible with localization of the ulcer on the lesser curvature of the stomach and the absence of inflammatory changes in the wall of the stomach within 3-4 cm from the pylorus. With double localization of the ulcer or the spread of ulcerative infiltrate to the prepyloric stomach, a resection of the stomach is indicated. by Billroth-1. In patients with gastric ulcer complicated by perforation or bleeding, when it is necessary to quickly complete the operation, vagotomy with wedge-shaped excision of the ulcer and pyloroplasty is acceptable . Gastric resection by Billroth- N in various modifications can be used only with the technical complexity of the formation of gastroduodenal anastomosis, after extensive excision of the stomach and in the presence of duodenostasis . The choice of the method of operation for gastric ulcer complicated by malignancy is carried out taking into account oncological requirements.
Peptic ulcer occurs under the influence of various causes and predisposing factors. Peptic ulcer can develop with significant deviations in the rhythm and quality of nutrition, contributing to a violation of the neurohumoral regulation of the function of the alimentary canal and its trophism. The digestion of the mucosa and other membranes is facilitated by the observed increase in the secretory-pepsic activity of the digestive juices and a decrease in the stability of the mucous protective barrier, which depends on the peculiarities of the peristalsis of the stomach and duodenum, their vascularization , insufficient synthesis of prostaglandins E and low adrenal cortex activity with resulting epileptic regenerative cells. It should be borne in mind that neurohumoral regulatory disorders can worsen and even occur primarily against the background of negative emotions, allergies, and the protective properties of the mucous barrier decrease when certain drugs are used (acetylsalicylic acid, butadione , steroid hormones, etc.).
A certain role in the implementation of the ulcerative process can play constitutional and hereditary factors. It is enough to indicate that diseases of the alimentary canal, and first of all peptic ulcer disease, were observed in parents of more than half (68.7%) of the examined sick children.
The size and depth of ulcerative defects of the stomach and duodenum can be different: in some cases, their healing is accompanied by the formation of gross scars, deformation and narrowing of the lumen of the organ.
Clinic of peptic ulcer of the stomach and duodenum
Despite the usually gradual unfolding of the clinical picture of peptic ulcer disease and the extreme rarity of the sudden appearance among its full health of its formidable symptoms and complications (perforation, massive bleeding, etc.), the correct diagnosis is often made late. A significant part of sick children for a long time (sometimes years) is observed due to biliary dyskinesia, hepatocholecystitis , chronic gastritis, falsely mistaken for the underlying disease. This is primarily due to the lack of awareness of pediatricians about the features of the clinic and the patterns of the course of peptic ulcer in childhood.
The first signs of peptic ulcer in children and its exacerbation usually occur in spring and autumn. The most striking and constant symptom of the disease is abdominal pain: usually intense, having a paroxysmal character, localized in the epigastric region, less often in the umbilical region and clearly associated with food intake. With the localization of ulcers in the stomach, pain often occurs shortly after eating; A duodenal ulcer is characterized by the Moynitan formula for the rhythm of pain (hunger – pain – eating – relief – hunger – pain). A thorough analysis of the internal picture of the disease reveals just such a sequence of pain development in most patients, including the smallest. Ng should also forget about the diagnostic significance of attacks of abdominal pain in connection with emotional stress, increased physical exertion. Neglect of these complaints in some cases leads to a late diagnosis of the disease.
The next group of symptoms of peptic ulcer is a characteristic dyspeptic syndrome. In many ways, it is similar to that described in chronic superacid gastritis. This is due to a clear increase in the secretion and acidity of gastric juice in most children with peptic ulcer. Patients very often experience nausea and especially vomiting, followed by temporary relief and relief of pain . Heartburn and belching are somewhat less common. A significant decrease in appetite is rare and is combined with a reduced active acidity of the gastric juice. Inclination to constipation is one of the most common symptoms and pathogenetic factors of peptic ulcer disease, further exacerbating the violation of the function of the alimentary canal. An attempt to link the occurrence of constipation with the use of an appropriate antiulcer diet seems insufficiently justified, since it often persists even after exacerbation with a sufficiently wide or completely unlimited diet.
A significant part of sick children is characterized by an unbalanced nature, increased excitability, emotional instability, the presence of signs of dystopia of the autonomic part of the sympathetic nervous system (sweating, rapidly occurring persistent red dermographism, etc.). Some children, especially those in family conditions, where excessive anxiety about the state of health is manifested, develop suspiciousness, constant depressed mood, and “going into illness”.
Peptic ulcer of the stomach and duodenum almost never affects the growth of children. Noticeable emaciation is observed only in individual patients during the period of exacerbation with severe pain and sleep disturbances.
An objective study usually draws attention to the intense texture of the tongue. In some cases, during an exacerbation, slight bloating is noted. The area of pain in the epigastric region to the right of the midline is often determined only with deep palpation. One of the most persistent symptoms is soreness in this area when striking with a bent finger (Mendel symptom). Some patients have an enlarged liver, soreness in the gallbladder, which sometimes gives rise to incorrect diagnosis and late detection of peptic ulcer.
The state of the secretory function of the stomach is characterized by an increase in a significant number of patients with active acidity of gastric juice, debit hour of free hydrochloric acid and pepsin not only at the height of digestion, but also on an empty stomach (basal secretion); the release of uropepsinogen is equally increased . Unlike adults, this applies not only to patients with duodenal, but also to the gastric location of the ulcer.
After an exacerbation, pain and dyspeptic symptoms gradually decrease and completely disappear. As for secretory changes, they do not disappear in all cases, which emphasizes the need for constant observance by convalescents of the proper general and nutritional regimen.
During X-ray examination, in addition to the “niche”, which is a direct sign of peptic ulcer, indirect radiological symptoms are observed – fasting hypersecretion, deformation of the duodenal bulb, symptom of “irritated bulb” (its immediate emptying from barium sulfate), etc. In some cases, ulcers can be detected to prevent spasm, inflammatory swelling of the gastric mucosa, significant mucus layering, etc. An endoscopic method for diagnosing peptic ulcer disease is a highly informative one. examination of the stomach and duodenum.
Among the complications that are observed in children less often than in adults (in about 10% of cases), ulcer bleeding, perforation and stenosis of the pyloroduodenal zone should be mentioned . Bleeding can be minor, detectable only when examining feces for occult blood, and massive, manifested by bloody vomiting, tarry stools. Massive bleeding is accompanied by general weakness, dizziness, tachycardia, a decrease in blood pressure, a subsequent decrease in blood hemoglobin and the number of red blood cells. Perforation of an ulcer with the development of acute peritonitis is usually accompanied by rather vivid symptoms: acute “dagger” pain in the epigastric region, muscle protection of the abdominal wall, etc. Analysis of anamnestic data allows us to reject the widespread opinion that the disease course is not symptomatic in the period preceding ulcer perforation. This applies equally to the perforations that occur during treatment with glycocorticoids , which once again indicates the importance of targeted interrogation before their appointment for various diseases in children. In the initial period of stenosis of the pyloroduodenal zone, especially persistent pain is observed, occasionally profuse vomiting, belching “rotten” even with high active acidity of gastric juice. Subsequently, vomiting becomes more frequent, appetite decreases, progressive emaciation develops, constantly, even on an empty stomach, the fluid in the distended stomach is determined. In such cases, only timely surgical treatment can save the life of the child. Despite the good direct result of treatment obtained in almost all patients, it is impossible to consider the course and outcome of peptic ulcer in children as favorable; according to some researchers, exacerbations and relapses requiring re-hospitalization occur in almost every fourth child.
Differential diagnosis of peptic ulcer of the stomach and duodenum
. Many researchers believe that peptic ulcer and usually concomitant, and often preceding, gastroduodenitis (gastritis) are pathogenetically uniform, therefore, the differentiation of these diseases is of considerable complexity. It should be borne in mind that with peptic ulcer, pain in the epigastric region is more intense, more often there is “hungry” and nocturnal, a more pronounced tendency to seasonal exacerbations, higher basal secretion, more frequent nausea and vomiting, and there may be hidden bleeding. In the absence of x-ray confirmation in patients with clinical and laboratory research and observation data typical of the ulcer process, they diagnose chronic gastroduodenitis, suggest a pre-ulcerated condition and prescribe the same treatment as for peptic ulcer disease.
Pain in the epigastric region with hepatocholecystitis is usually not associated with food intake, is not “hungry” and does not subside after eating. Exacerbations of the disease do not bear a clear connection with the season of the year; there is no family predisposition to diseases of the stomach.
A thorough analysis of the anamnesis, clinical and laboratory data and, especially, X-ray examination allows for differential diagnosis with processes such as diverticula of the segments of the alimentary canal, chronic colitis, pancreatitis, etc.