Download physiologicoanatomical features of the digestive system in children

Bukovinian State Medical University
Department of Developmental Pediatrics
METHODICAL INSTRUCTIONS
to the practical class for medical students of 3-rd years
Modul 1: Child’s development
Submodul 2:
Topic 4:
Subject: PHYSIOLOGICOANATOMICAL
PECULIARITIES OF THE DIGESTIVE SYSTEM IN
CHILDREN. SEMIOTICS OF DIGESTIVE DISORDERS.
It is completed by:
MD, MSc, PhD Strynadko Maryna
Chernivtsy – 2007
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2.3. practical skills:
- to collect the anamnesis for the mother of sick child of difetrent age;
- carrying out of objective inspection of the digestive system in healthy child;
- carrying out of objective inspection of the digestive system in sick child.
Теми №10:
1. Anatomico-physiological peculiarities of mouth cavity, oesophagus, stomach, liver and
intestines in children.
2. The age peculiarities of secretion of saliva, reasons of increase and decrease of salivation.
3. Methods of objective investigation of digestive system.
4. Laboratory methods of research of digestive system.
5. Instrumental methods of research of digestive system.
Themes 11:
Semiotics, main syndromes of affection of digestive system in children.
6.3.2. Control of practical skills:
Individual control of practical skills:
1. A clinical investigation of children with the affections of digestive system.
2. Estimation of the general state of sick child.
3. Exposure of symptoms and syndromes of affection of digestive system.
4. Interpretation of results of additional methods in research of digestive system.
SUBJECT: Developmental Pediatrics.
TOPIC:
OBJECTIVES: 1) Anatomico-physiological peculiarities of digestion system in children:
- mouth cavity;
- oesophagus;
- stomach;
- bowels;
- liver and gall-bladder;
- pancreas.
2) How to calculate the stomach volume in children up to the year.
3) Functional peculiarities of the digestive system.
4) Semiotics of the main diseases of digestive system.
5) Clinical methods of inspection of children with the digestion problems.
6) Psychological aspects in preparation of child to clinical, laboratory and instrumental
researches.
2.2. Вміти:
1. To conduct the clinical inspection of digestive system in children of different age.
2. To estimate the state of the digestive system in children of different age, based on information
of objective inspection and anamnesis.
3. To find out the most informing signs of diseases of digestive system.
4. To be able practically to conduct the collection of gastric juice and duodenal intubation.
5. To be able to estimate results of laboratory and functional diagnostics.
PROFESSIONAL MOTIVATION: Every period of childhood has the inherent
peculiarities of anatomic structure, physiological functions and metabolism. For children of
early age, first of all infants, there is relative immaturity of the digestive system. At the
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same time some mechanisms which can be considered as a sign of such immaturity have
important physiological expediency. The structure and functions of digestive glands are
gradually improved in the process of growth, adaptation possibilities to the qualitative new
meal are increased. It should be remembered about the fundamental peculiarities of
functioning of the digestive system in children, about connection with the vegetative
nervous system, that it is necessary for the estimation of functional indexes, timely to
diagnose and prescribe of rational therapy.
BASIC LEVEL: Basic knowledge of pediatrics.
INTEGRATED SKILL ACTIVITY:
1. Care of the children. 2. Anatomy. 3. Histology. 4. Pysiology.
STUDENT’S PRACTICAL SKILLS:
- to collect the anamnesis for the mother of sick child of difetrent age;
- carrying out of objective inspection of the digestive system in healthy child;
- carrying out of objective inspection of the digestive system in sick child.
THE BASIC THEORETICAL ITEMS OF INFORMATION
PURPOSE
The digestive system prepares food for use by hundreds of millions of body
cells. Food when eaten cannot reach cells (because it cannot pass through the
intestinal walls to the bloodstream and, if it could not be in a useful chemical state.
The gut modifies food physically and chemically and disposes of unusable waste.
Physical and chemical modification (digestion) depends on exocrine and endocrine
secretions and controlled movement of food through the digestive tract. Children
have a special fascination with the workings of the digestive system: they relish
crunching a potato chip, delight in making "mustaches" with milk, and giggle
when their stomach "growls." As adults, we know that a healthy digestive system
is essential for good health, because it converts food into the raw materials that
build and fuel our body's cells. Specifically, the digestive system takes in food
(ingests it), breaks it down physically and chemically into nutrient molecules
(digests it), and absorbs the nutrients into the bloodstream. Then it rids the body of
the indigestible remains (defecates).
Embryogenesis
The digestive system develops from endoderm at 11-15 days after
fertilization. Liver and pancreas appear as buds at 26-30 days after fertilization.
Physiologicoanatomical peculiarities of the digestive system
The main function of the digestive system
1. To process and absorb nutrients.
2. The excretory function
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3. Detoxication.
4. Maintain fluid and electrolyte balance.
5. The mechanical function.
Morphology peculiarities of all parts of digestive system in infant
1. The mucous membrane is thin, soft, dry and easy to damage.
2. The submucosal layer is well vascularised.
3. The submucosal layer consists of loose connective tissue.
4. Under development (immaturity) of muscular and elastic tissues.
Physiological peculiarities of digestive system in infant
1. The secretory function of digestive system is impaired.
2. Digestive system produces only small amounts of digestive juice.
3. Digestion is worsened when the food is not adequate to the age of the child.
Peculiarities of oral cavity in infant:
1. It is relatively small.
2. Teeth are absent.
3. The palate is flat.
4. The tongue is relatively thick and wide.
5. The sucking fat in the cheeks fill the mouth and help to maintain negative
pressure.
Peculiarities of pharynx in infant:
1. It is relatively wide and short.
2. The oral part is on the same level as oral cavity.
3. The way which is called the food passage is as the lateral part of larynx.
4. The baby can breathe and breathe and swallow the food at once.
Peculiarities of oesophagus in infant:
1. Average length of the oesophagus in newborn is 10 cm.
2. It is relatively narrow.
3. The entrance into the oesophagus is:
in newborn – between the III-IV cervical vertebra;
2 years old – IV-V cervical vertebra;
12 years old - VI-VII cervical vertebra
4. The localization of lower oesophagus’ sphincter is the same in children of
different age groups (X-XI thoracic vertebra).
5. Ratio between the length of the oesophagus and the length of the body is the
same in children of different age groups (1:5).
Length of oesophagus in children of different age groups
in newborn is 11-16cm.
in 1.5-2 years – 22-24.5cm.
in 15-17 years – 48-50 cm.
The constriction of the oesophagus:
Anatomical:
1. Upper constriction - at the place of entrance into the oesophagus.
2. Middle constriction - at the place of adjacent the trachea to oesophagus.
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3. Lower constriction - at the place of entrance through the diaphragm.
Physiological:
1. Upper constriction - at the begining of the oesophagus.
2. Middle constriction - at the place of adjacent the aorta to esophagus.
3. Lower constriction - at the place of entrance into the cardial part of the stomach.
Peculiarities of the stomach in infant:
1. The stomach lies horizontally, is round until approximately 2 year of age.
2. In horizontally lying baby, the gastric fundus is lower as the antral part of the
stomach.
3. Gastroesophageal reflux is frequent.
4. Cardial sphincter has a poor development of mucous membrane and muscular
tunic.
5. Pyloric part is developed well.
6. The fundus of stomach is -under the left dome of diaphragm.
7. The weight of the stomach is 6-7 g in newborn, in 1 year old 18-21 g.
Peculiarities of the stomach secretion in infant:
1. The proteolytic function of the stomach juice in baby is 1/3 less than in adult.
2. Figures of common gastric acidity is in 2.5-3 times lower than in adult.
3. The fats of human's milk are easy digested by enzyme lipase of human's milk,
saliva and stomach juice.
4. Highly saturated fats are digested only in a small intestine.
Peculiarities of the bowels in infant:
1. The length is relatively longer than in adult.
2. Ratio of bowels length and body length are: in newborn - 8.3:1; 1 year-6.6:1; 16
years - 7.6:1; in adult - 5.4:1.
3. The increasing of bowels length is slower tttpttbift^feafjl^g of length of the
body.
4. The bowels are more mobile in infant.
Peculiarities of the small intestine in infant:
1. The length is two times less than in adult.
2. The length of small intestine mesentery is relatively longer.
3. The membrane is thin and well vascularisied.
4. The intestinal glands are bigger than in adult.
5. The lymph cells are located in each little part of small intestine.
Peculiarities of the large intestine in infant:
1. The large intestine is not completely developed.
2. The length of the large intestine is the same as the body length (in any age of a
child).
3. Haustrume appear after 6 months of life.
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Peculiarities of the sigmoid colon in infant:
1. It is longer.
2. It is mobile.
3. Increasing in size during the life.
4. The localization of sigmoid colon is upper in children who are younger 5 years
than in schoolchildren (in schoolchildren it is in the pelvic cavity).
Peculiarities of the rectum in infant:
1. The localization is under the entrance into the small pelvis in preschoolchildren.
2. In schoolchildren the rectum is in the small pelvis.
3. It is longer.
3. It is mobile.
4. The ampulla of rectum is absent in newborn.
Peculiarities of the liver in infant:
1. Before the birth the liver is the largest organ of the body.
2. It is in the upper quadrant of the abdomen and one part of the right epigastrium.
3. The left lobe is very large before the birth.
Liver functions
1. Bile salts emulsify fats making them available to intestinal lipases.
2. Bile helps make the products soluble and available for absorption by the
intestinal mucosa; it stimulates peristals.
3. Detoxification.
4. Glucose metabolism.
Hepatocytes functions
1. Synthesis of bile.
2. Storage (glycogen, fat)
3. Biotransformation.
4. Synthesis of blood components.
GENERAL OVERVIEW
The digestive system is made up of the alimentary canal and the other
abdominal organs that play a part in digestion, such as the liver and pancreas. The
alimentary canal (also called the digestive tract) is the long tube of organs including the esophagus, stomach, and intestines - that runs from the mouth to the
anus. An adult's digestive tract is about 30 feet (about 9 meters) long.
Digestion begins in the mouth, well before food reaches the stomach. When
we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are
located under the tongue and near the lower jaw, begin producing saliva. This flow
of saliva is set in motion by a brain reflex that's triggered when we sense food or
think about eating. In response to this sensory stimulation, the brain sends impulses
through the nerves that control the salivary glands, telling them to prepare for a
meal.
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As the teeth tear and chop the food, saliva moistens it for easy swallowing.
A digestive enzyme called amylase, which is found in saliva, starts to break down
some of the carbohydrates (starches and sugars) in the food even before it leaves
the mouth.
Swallowing, which is accomplished by muscle movements in the tongue and
mouth, moves the food into the throat, or pharynx. The pharynx, a passageway for
food and air, is about 5 inches (12.7 centimeters) long. A flexible flap of tissue
called the epiglottis reflexively closes over the windpipe when we swallow to
prevent choking.
From the throat, food travels down a muscular tube in the chest called the
esophagus. Waves of muscle contractions called peristalsis force food down
through the esophagus to the stomach. A person normally isn't aware of the
movements of the esophagus, stomach, and intestine that take place as food passes
through the digestive tract.
At the end of the esophagus, a muscular ring called a sphincter allows food
to enter the stomach and then squeezes shut to keep food or fluid from flowing
back up into the esophagus. The stomach muscles churn and mix the food with
acids and enzymes, breaking it into much smaller, digestible pieces. An acidic
environment is needed for the digestion that takes place in the stomach. Glands in
the stomach lining produce about 3 quarts (2.8 liters) of these digestive juices each
day.
Some substances, such as water, salt, sugars, and alcohol can be absorbed
directly through the stomach wall. Most other substances in the food we eat need
further digestion and must travel into the intestine before being absorbed. When it's
empty, an adult's stomach has a volume of one fifth of a cup (1.6 fluid ounces), but
it can expand to hold more than 8 cups (64 fluid ounces) of food after a large meal.
By the time food is ready to leave the stomach, it has been processed into a
thick liquid called chyme. A walnut-sized muscular tube at the outlet of the
stomach called the pylorus keeps chyme in the stomach until it reaches the right
consistency to pass into the small intestine. Chyme is then squirted down into the
small intestine, where digestion of food continues so the body can absorb the
nutrients into the bloodstream.
The small intestine is made up of three parts:
 the duodenum, the C-shaped first part
 the jejunum, the coiled midsection
 the ileum, the final section that leads into the large intestine.
The inner wall of the small intestine is covered with millions of microscopic,
finger-like projections called villi. The villi are the vehicles through which
nutrients can be absorbed into the body.
The liver (located under the rib cage in the right upper part of the abdomen),
the gallbladder (hidden just below the liver), and the pancreas (beneath the
stomach) are not part of the alimentary canal, but these organs are essential to
digestion.
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The pancreas produces enzymes that help digest proteins, fats, and
carbohydrates. It also makes a substance that neutralizes stomach acid. The liver
produces bile, which helps the body absorb fat. Bile is stored in the gallbladder
until it is needed. These enzymes and bile travel through special channels (called
ducts) directly into the small intestine, where they help to break down food. The
liver also plays a major role in the handling and processing of nutrients, which are
carried to the liver in the blood from the small intestine.
From the small intestine, food that has not been digested (and some water)
travels to the large intestine through a muscular ring, that prevents food from
returning to the small intestine. By the time food reaches the large intestine, the
work of absorbing nutrients is nearly finished. The large intestine's main function
is to remove water from the undigested matter and form solid waste that can be
excreted.
The large intestine is made up of three parts:
 The cecum is a pouch at the beginning of the large intestine that joins the
small intestine to the large intestine. This transition area expands in
diameter, allowing food to travel from the small intestine to the large. The
appendix, a small, hollow, finger-like pouch, hangs at the end of the cecum.
Doctors believe the appendix is left over from a previous time in human
evolution. It no longer appears to be useful to the digestive process.
 The colon extends from the cecum up the right side of the abdomen, across
the upper abdomen, and then down the left side of the abdomen, finally
connecting to the rectum. The colon has three parts: the ascending colon and
transverse colon, which absorb fluids and salts, and the descending colon,
which holds the resulting waste. Bacteria in the colon help to digest the
remaining food products.
 The rectum is where feces are stored until they leave the digestive system
through the anus as a bowel movement.
Control signs:
1. Painful syndrome. Pain intensive, paroxysmal, after the meal, more often at
night, and on empty stomach. The pain is localized in epigastrium, umbilicus, right
subcostal area, sometimes irradiates to waist or has spread character. Tenderness
on palpation in pyloroduodenal area, muscular defence, and hyperesthesia of skin
in tender zones (Zakhariev-Ged), positive sign of Mendel.
2. Dyspeptic syndrome: vomiting, nausea, heartburn, vomiting frequently causes
relief, removing pain, decrease of appetite. Tendency to constipation (in patients
with increased gastric acidity), or unstable stool (in patient with low gastric
acidity).
3. Intoxication syndrome: weakness, lucidity, bad sleep, headaches, irritability,
tearfulness, increased disposition to perspiration, blue shadows under the eyes.
EXAMINATION
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Mouth: examination of the mouth and throat usually is the most resistant part of
the examination and should be performed near the end of the examination. The
child should be sitting so that the tongue is less likely to obstruct the pharynx.
Deformities or infections around the lips are recorded. Count the number and note
the condition of the teeth. Similarly, note the condition and color of the tongue,
buccal mucosa, palate, tonsils, and posterior pharynx. Normally, these are pink in
color. Exudate indicates infection by bacteria, viruses, or fungi, but etiology
usually cannot be determined by physical examination alone. Note also the
presence of the gag reflex and the voice or cry. If the child seems hoarse, question
the parent concerning the normal voice. Laryngitis can lead to airway obstruction.
After the age of 2 years, children should not drool. Chronic drooling may suggest
mental deficiency, but acute onset of drooling is a grave sign of epiglottitis or
poison ingestion.
The teeth are inspected for number in each dental arch, hygiene, and
occlusion or bite. The general rule for estimating the number of temporary teeth in
children who are 2 years of age or younger is: the child's age in months minus 6
months equals the number of teeth. Discoloration of tooth enamel with obvious
plaque (whitish coating on the surface of the teeth) is a sign of poor dental hygiene
and indicates a need for dental counseling. Brown spots in the crevices of the
crown of the tooth or between the teeth may be caries. Teeth that appear greenish
black may be stained from oral ingestion of supplemental iron. Although unsightly,
this disappears after the iron is no longer given. Malocclusion or poor biting
relationship of the teeth is evaluated in terms of (l) how the jaws relate to each
other in vertical, transverse, and anteroposterior directions, for example, the
"bucktoothed" appearance that results when the maxilla is forward in relation to
the mandible, (2) how the teeth are aligned, and (3) how the teeth interdigitate
when in occlusion. Although parents frequently express concern regarding thumbsucking and the development of orthodontic problems, thumb-sucking that ceases
before the age of 6 years probably does little harm.
The gums surrounding the teeth are examined. The color is normally coral
pink, and the surface texture is stippled, similar to the appearance of orange peel.
In dark-skinned children the gums are more deeply colored and a brownish area is
often observed along the gum line.
The tongue is inspected for the presence of papillae, small projections that
contain several taste buds each and give the tongue its characteristic rough
appearance. Changes in the surface texture are noted, such as (1) "geographic
tongue", unusual patterns of papillae formation and denuded areas, (2) coated
tongue, such as in thrush, or (3) an exceptionally beefy red and swollen tongue,
which is a sign of various systemic diseases.
The doctor also notes the size and mobility of the tongue, especially
protrusion, which is frequently seen in children with mental retardation. Normally
the tip of the tongue should extend to the lips. If the child is unable to move the
tongue forward to this point, the frenulum, or central band of mucous membrane,
which attaches the tongue to the floor of the mouth, may be too short. "Tongue-tie"
can result in speech problems.
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The roof of the mouth consists of the hard palate, near the front of the cavity,
and the soft palate, toward the back of the pharynx, which has a small midline
protrusion called the uvula. Both are carefully inspected to be sure that they are
intact. Sometimes there is a pinpoint cleft in the soft palate, which may go
undetected unless carefully inspected. Such a cleft is especially important if the
uvula is bifid or separated into two appendages. A submucosal cleft may result in
speech problems later on, since air cannot be effectively trapped for vocalization.
The arch of the palate should be dome shaped. A narrow-flat roof or higharched palate affects the placement of the tongue and can cause feeding and speech
problems. Movement of the uvula is tested by eliciting a gag reflex. It moves
upward to close off the nasopharynx from the oropharynx.
As the recesses of the oropharynx are inspected, the size and color of the
palatine tonsils are also noted. They are normally the same color as the
surrounding mucosa, glandular, rather than smooth in appearance, and barely
visible over the edge of the palatoglossal arches. Enlargement, redness, and white
patches on the tonsils and surrounding area are recorded. Such signs are indicative
of suppurative tonsillitis or pharyngitis.
Observe the shape of the abdomen. A flat abdomen may indicate diaphragmatic
hernia; a distended abdomen may indicate intestinal obstruction or ascites.
Auscultate before percussing or palpating. Normally, peristaltic sounds are heard
every 10 to 30 seconds. High-pitched frequent sounds occur with obstruction or
peritonitis; absent sounds indicate ileus. Next, palpate gently, beginning in the left
lower quadrant and proceeding to the left upper, right upper, right lower, and
midline areas. Then palpate more deeply in the same areas and follow with
palpation in the same areas with the unused hand, pushing toward the front hand
from the child's back. Feel especially for the liver in the right upper quadrant and
the spleen in the left upper quadrant, and estimate their size. Any other masses are
abnormal. Determine tenderness and attempt to locate the maximum point of any
tenderness, which may indicate intra-abdominal infection such as peritonitis,
cystitis, or appendicitis, or rapid enlargement of organs, as occurs with
enlargement of the liver in heart failure. Percuss to verify findings. Feel in the
costovertebral angles to determine kidney size. Tenderness usually indicates
pyelonephritis.
Rectal. Inspect the anus for fissures, inflammation, or lack of tone. The latter may
indicate child abuse. The rectum is not examined routinely, but is examined in all
children with abdominal or gastrointestinal complaints, including diarrhea,
constipation, or bleeding from the rectum
Inspection. The contour of the abdomen is inspected while the child is erect and
supine. Normally the abdomen of infants and young children is quite cylindrical
and, in the erect position, fairly prominent because of the physiologic lordosis of
the spine. In the supine position the abdomen appears flat. During adolescence the
usual male and female contours of the pelvic cavity change the shape of the
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abdomen to form characteristic adult curves, especially in the female.
The size and tone of the abdomen also give some indication of general
nutritional status and muscular development. A large, prominent, flabby abdomen
is often seen in obese children, whereas a concave abdomen is frequently
suggestive of undernutrition. However, careful note is made of a protruding
abdomen, which may indicate pathologic states such as abdominal distention,
ascites, tumors, or organomegaly. A protuberant abdomen with spindly extremities
and flat, wasted buttocks suggests severe malnutrition that may occur from
inadequate nutritional intake such as kwashiorkor or from diseases such as cystic
fibrosis. Likewise, a scaphoid abdomen may indicate dehydration or diaphragmatic
hernia, in which the abdominal organs rise into the thoracic cavity, or a
"scaphoidlike" abdomen that only appears sunken in relationship to pneumothorax
or high intestinal obstruction. A midline protrusion from the xiphoid to the
umbilicus or pubic symphysis is usually diastasis recti, or failure of the rectus
abdominis muscles to join in utero. In a healthy child a midline protrusion is
usually a variation of normal muscular development. A tense, board like abdomen
is a serious sign of paralytic ileus and intestinal obstruction.
The nurse also notes the condition of the skin covering the abdomen. It
should be uniformity taut, without wrinkles or creases. Sometimes silvery, whitish
striae are seen, especially if the skin has been stretched as in obesity or with
distention resulting from ascites. Any scars, ecchymosed areas, excessive hair
distribution, or distended veins are noted.
Movement of the abdomen is observed. In infants and thin children
peristaltic waves may be visible through the abdominal wall, and they always
warrant careful evaluation. They are best observed by Standing at eye level across
from the abdomen. Visible peristaltic waves most often indicate pathologic states,
particularly intestinal obstruction such as pyloric stenosis.
A doctor may observe pulsation of the descending aorta in the epigastric
region (midline and below the xiphoid). Although visible pulsations are normally
seen, especially in thin children, the nurse should auscultate and palpate the aorta
for any evidence of an aneurysm, a saclike enlargement of the vessel.
In children under 7 or 8 years of age, breathing is primarily abdominal. If the
abdomen fails to move during respiration, even in older children, this may indicate
serious abdominal problems. Conversely, if the thoracic muscles fail to move,
caused by breathing confined to abdominal movement, pulmonary problems may
be at fault. Normally chest and abdominal movements are synchronous.
The umbilicus is inspected for herniation, fistulas, such as a patent rachus
(an abnormal connection between the umbilicus and bladder), iischarge, and
hygiene. If a herniation is present the sac is palpated [for abdominal contents and
the approximate size of the opening is estimated. Umbilical hernias are common in
infants, especially in slack children. Since "home remedies" for treatment such as
taping coins over the umbilicus or using "belly binders" may be harmful to |the
skin and actually delay natural closure, a doctor should ask parents /nether such
procedures have been used. Umbilical hernias normally protrude and expand when
the child coughs, cries, or strains.
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Hernias are looked for elsewhere on the abdominal wall, such as in the
inguinal or femoral region. An inguinal hernia is a protrusion of peritoneum
through the abdominal wall in the inguinal canal. It most often occurs in males, is
frequently bilateral, and may be visible as a mass in the scrotum. It is palpated by
sliding the little finger into the external inguinal ring at the base of the scrotum and
asking the child to cough. If a hernia is present, it will hit the tip of the finger.
A femoral hernia, which occurs more frequently in girls, is felt or seen as a
small mass on the anterior surface of the thigh just below the inguinal ligament in
the femoral canal (a potential space medial to the femoral artery). Its location can
be estimated by placing the index finger of the right hand on the child's right
femoral pulse (left hand for left pulse) and the middle ring finger flat against the
skin toward the midline. The ring finger lies over the femoral canal, where the
herniation occurs. Palpation of hernias in the pelvic region, particularly inguinal
ones, is often part of the examination of genitalia.
Auscultation. Each of the four quadrants should be auscultated using the
diaphragm and bell chestpieces. Unlike listening to the heart or lungs, in which the
stethoscope rests gently on the skin, to hear bowel sounds the stethoscope must be
pressed firmly against the abdominal surface. With the diaphragm chestpiece this
usually presents no difficulty, but with the bell chestpiece, especially one with a
short cone, the skin may occlude the opening and prevent transmission of sound.
The most important sound to listen for is peristalsis, or bowel sounds, which
sound like short metallic clicks and gurgles. Loud grumbling noises, known as
borborygmi, are the familiar "stomach growls" usually denoting hunger. A sound
may be heard every 10 to 30 seconds and its frequency per minute should be
recorded (for example, 5 bowel sounds/minute). However, the nurse may need to
listen for several seconds before audible peristalsis can be heard. Bowel sounds
may be stimulated by stroking the abdominal surface with a fingernail. Absent
bowel sounds or hyperperistalsis is recorded and reported, since either one usually
denotes abdominal disorder.
Various other sounds may be heard in the abdominal cavity. Normally the
pulsation of the aorta is heard in the epigastrium. Sounds that resemble murmurs
(called bruits), hums, or rubs are always referred for further evaluation.
Percussion. Percussion of the abdomen is performed in the same manner as
percussion of the lungs and heart. Normally dullness or flatness is heard on the
right side at the lower costal margin because of the location of the liver. Tympany
is typically heard over the stomach on the left side and usually in the rest of the
abdomen. An unusually tympanitic sound, like the beating of a tight drum, usually
denotes air in the stomach, a common cause of which is mouth breathing.
However, it can also denote a pathologic condition such as low intestinal
obstruction or paralytic ileus. Lack of tympany may occur normally when the
stomach is full after a meal, but in other situations it may denote the presence of
fluid or solid masses.
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Palpation. Two types of palpation are performed, superficial and deep. In
superficial palpation a doctor lightly places the hand against the skin and feels each
quadrant, noting any areas of tenderness, muscle tone, and superficial lesions, such
as cysts. Superficial palpation is often perceived as "tickling" by the child, which
can interfere with its effectiveness. The nurse can avoid this problem by having the
child "help" with the palpation by placing his hand over the doctor's palpating hand
or by distracting him with statements such as, "I am trying to feel what you had for
lunch". Admonishing the child to stop laughing only draws attention to the
sensation and decreases cooperation. Positioning the child in supinated position
with the legs flexed at the hips and knees helps relax the abdominal muscles.
Tenderness anywhere in the abdomen during superficial palpation is always
noted. There are two types of abdominal pain: (1) visceral, which arises from the
viscera or internal organs such as the intestines, and {2) somatic, which arises from
the walls or linings of the abdominal cavity such as the peritoneum. Visceral pain
is usually dull, poorly localized, and difficult for the patient to describe. Somatic
pain is generally sharp, well localized, and more easily described. When assessing
abdominal pain, it is important to remember that the child will often respond with
an "all-or-none" reaction - either there is no pain or great pain. Therefore all
aspects of the examination must be carefully considered when ruling out conditions
such as appendicitis.
A special phenomenon called rebound tenderness, or Blumberg's sign, may
be performed if the child complains of abdominal pain. It is performed by pressing
firmly over the part of the abdomen distal to the area of tenderness. When the
pressure is suddenly released, the child feels pain in the original area of tenderness.
This response is only found when the peritoneum overlying a diseased visceral or
organ is inflamed, such as in appendicitis.
Deep palpation is used for palpating organs and large blood vessels and for
detecting masses and tenderness that were not discovered during superficial
palpation. If the child complains of abdominal pain, the area of the abdomen is
palpated last. Normally palpation of the midepigastrium causes pain as pressure is
exerted over the aorta, but this should not be confused with visceral or somatic
tenderness.
The doctor palpates the abdominal organs by pressing them with a free hand,
which is placed on the child's back. Palpation begins in the lower quadrants and
proceeds upward. In this way the edge of an enlarged liver or spleen is not missed.
Except for palpating the liver, successful identification of other organs, such as the
spleen, kidney and part of the colon requires considerable practice with tutored
supervision.
The lower edge of the liver is sometimes palpable in infants and young
children as a superficial mass 1 to 2 cm (1/2 to 3/4 inch) below the right costal
margin (the distance is sometimes measured in fingerbreadths). If the liver is
palpable 3 cm (l'/4 inches) or 2 fingerbreadths below the costal margin, it is
considered enlarged and this finding is referred to a physician. Normally the liver
descends during inspiration as the diaphragm moves downward. This downward
displacement should not be mistaken for a sign of hepatomegaly. In older children
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the liver frequently is not palpable, although its lower edge can be estimated by
percussing dullness at the costal margin.
The spleen is palpated by feeling it between the hand placed against the
back-and the one palpating the left upper quadrant. The spleen is much smaller
than the liver and positioned behind the fundus of the stomach. The tip of the
spleen is normally felt during inspiration as it descends within the abdominal
cavity. It is sometimes palpable 1 to 2 cm below the left costal margin in infants
and young children. A spleen that is readily palpated more than 2 cm below the
right costal margin is enlarged and is always reported for further medical
investigation.
Other anatomical structures that are sometimes palpable in children include
the cecum, and sigmoid colon. The cecum is a soft, gas-filled mass in the right
lower quadrant. The sigmoid colon is felt as a sausage-shaped mass that is freely
movable over the pelvic brim in the left lower quadrant and is normally tender.
Although most of these structures are not routinely felt, one should be aware
of their relative location and characteristics in order not to mistake them for
abnormal masses. The most common palpable mass in children is feces. It may be
associated with pain in the right lower quadrant because with constipation the left
colon fills with stool and gas until the ileocecal valve is reached. Then the cecum
becomes distended, causing pain, which may be erroneously associated with
appendicitis.
Special methods of investigation.
Laboratory examination
1. Routine blood examination
2. Urine tests (bile pigments, ketonuria)
3. Biochemical analysis of urine for diastase
4. Biochemical blood analysis (bilirubin total, unconjugated and conjugated
bilirubin, protein, cholesterol, ALAT, ASAT, amylase, tripsin, lipase).
Disorders
1. Syndrome of cholistasis (increased level of total and conjugated bilirubin and
cholesterol).
2. Syndrome of cytolysis (increased level of AsAT, A1AT, LDG).
3. Syndrome of dysfunction of pancreas (increased level of amylase, tripsin,
lipase).
4. Chain polymerizes reaction for virus of hepatitis A, B, C.
5. Examination of feces for intestinal parasites (ascarides, lamblia cysts,
enterobiosis)
6. Coprogram.
DISORDERS
Nearly everyone has a digestive problem at one time or another. Some
conditions, such as indigestion or mild diarrhea, are common; they result in mild
discomfort and get better on their own or are easy to treat. Others, such as
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inflammatory bowel disease, can be long lasting or troublesome. A doctor who
specializes in the digestive system is called a GI specialist or gastroenterologist.
Conditions Affecting the Esophagus
Conditions affecting the esophagus may be congenital (which means a
person is born with them) or noncongenital (meaning a person can develop them
after birth). Some examples include:
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Tracheoesophageal fistula and esophageal atresia are both examples of
congenital conditions. Tracheoesophageal fistula is where there is a
connection between the esophagus and the trachea (windpipe) where there
shouldn't be one. In babies with esophageal atresia, the esophagus comes to
a dead end instead of connecting to the stomach. Both conditions are usually
detected soon after a baby is born - sometimes even beforehand. They
require surgery to repair.
Esophagitis or inflammation of the esophagus, is an example of a
noncongenital condition. Esophagitis can be caused by infection or certain
medications. It can also be caused by gastroesophageal reflux disease
(GERD), a condition in which the esophageal sphincter (the tube of muscle
that connects the esophagus with the stomach) allows the acidic contents of
the stomach to move backward up into the esophagus. GERD can sometimes
be corrected through lifestyle changes, such as adjusting the types of things
a person eats. Sometimes, though, it requires treatment with medication.
Conditions Affecting the Stomach and Intestines
Almost everyone has experienced diarrhea or constipation at some point in
their lives. With diarrhea, muscle contractions move the contents of the intestines
along too quickly and there isn't enough time for water to be absorbed before the
feces are pushed out of the body. Constipation is the opposite: The contents of the
large intestines do not move along fast enough and waste materials stay in the large
intestine so long that too much water is removed and the feces become hard. Some
other examples of the common stomach and intestinal disorders are:
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Gastrointestinal infectionscan be caused by viruses, by bacteria (such as
Salmonella, Shigella, Campylobacter, or E. coli) or by intestinal parasites as
in amebiasis and giardiasis. Abdominal pain or cramps, diarrhea, and
sometimes vomiting are the common symptoms of gastrointestinal
infections.These conditions usually go away on their own without the need
for medicines or other treatment.
Appendicitis is an inflammation of the appendix, the finger-like pouch
extending from the cecum located in the lower right part of the abdomen.
The classic symptoms of appendicitis are abdominal pain, fever, loss of
appetite, and vomiting. Kids and teens between the ages of 11 and 20 are
most often affected by appendicitis, and it requires surgery to correct.
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Gastritis and peptic ulcers. Under normal conditions, the stomach and
duodenum are extremely resistant to irritation by the strong acids produced
in the stomach. Sometimes, though, a bacterium called Helicobacter pylori
or the chronic use of drugs or certain medications weakens the protective
mucous coating of the stomach and duodenum, allowing acid to get through
to the sensitive lining beneath. This can irritate and inflame the lining of the
stomach (a condition known as gastritis) or cause peptic ulcers, which are
sores or holes that form in the lining of the stomach or the duodenum and
cause pain or bleeding. Medications are usually successful in treating these
conditions.
Inflammatory bowel disease is chronic inflammation of the intestines that
affects older kids, teens, and adults. There are two major types: ulcerative
colitis, which usually affects just the rectum and the large intestine, and
Crohn's disease, which can affect the whole gastrointestinal tract from the
mouth to the anus as well as other parts of the body. They are treated with
medications and, if necessary, intravenous (IV) feedings to provide nutrition.
In some cases, surgery may be necessary to remove inflamed or damaged
areas of the intestine.
Celiac disease is a disorder in which a person's digestive system is damaged
by the response of the immune system to a protein called gluten, which is
found in wheat, rye, and barley and in a wide range of foods from breakfast
cereal to pizza crust. People with celiac disease have difficulty digesting the
nutrients from their food and may experience diarrhea, abdominal pain,
bloating, exhaustion, and depression when they consume foods with gluten.
The symptoms can be managed by following a gluten-free diet. Celiac
disease runs in families and can become active after some sort of stress, such
as surgery or a viral infection. A doctor can diagnose celiac disease with a
blood test and by taking a complete medical history.
Irritable bowel syndrome (IBS) is a common intestinal disorder that affects
a person's colon and may cause recurrent abdominal cramps, bloating,
constipation, and diarrhea. There is no cure for IBS, but the symptoms may
be treated by changing eating habits, reducing stress, and making lifestyle
changes. A doctor may also prescribe medications to relieve diarrhea or
constipation. There is no one test to diagnose IBS, but a doctor may identify
it based on a person's symptoms, medical history, and a physical exam.
Disorders of the Pancreas, Liver, and Gallbladder
Conditions affecting the pancreas, liver, and gallbladder often affect the
ability of these organs to produce enzymes and other substances that aid in
digestion. Some examples are:

Cystic fibrosis is a chronic, inherited illness where the production of
abnormally thick mucus blocks the ducts or passageways in the pancreas and
prevents its digestive juices from entering the intestines, making it difficult
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
for a person with this condition to properly digest proteins and fats. This
causes important nutrients to pass out of the body unused. To help manage
their digestive problems, people with cystic fibrosis can take digestive
enzymes and nutritional supplements.
Hepatitis is a viral condition in which a person's liver becomes inflamed
and can lose its ability to function. Viral hepatitis, such as hepatitis A, B, or
C, is highly contagious. Mild cases of hepatitis A can be treated at home;
however, serious cases involving liver damage may require hospitalization.
The gallbladder can develop gallstones and become inflamed - a condition
called cholecystitis. Although gallbladder conditions are uncommon in kids
and teens, they can occur when a kid or teen has sickle cell anemia or in kids
being treated with certain long-term medications.
The kinds and amounts of food a person eats and how the digestive system
processes that food play key roles in maintaining good health. Eating a healthy diet
is the best way to prevent common digestive problems.
Instrumental methods of examination
1. Esophagogastroduodenoscopy.
2. Ultrasound investigation.
3. Intragastric pH-metry.
4. Colonoscopy.
5. Proctosigmoidoscopy.
6. Laparoscopy.
8. Irrigoscopy and irrigography.
Gastroesophageal reflux
Gastroesophageal reflux (GER, chalasia, cardiochalasia) denotes relaxation
or incompetence of the lower esophageal sphincter, causing frequent return of
stomach contents into the esophagus. In newborns this is considered a normal
phenomenon because of immature neuromuscular control of the gastroesophageal
sphincter. However, in a small percentage of infants reflux continues, producing
symptoms that warrant investigation. The exact cause is not known, although it is
thought to result from delayed maturation of lower esophageal neuromuscular
function or impaired local hormonal control mechanisms.
Clinical manifestations includes: vomiting, weight loss, respiratory problems,
bleeding.
Vomiting is the most frequent symptom and in infants is quite' forceful. It is
frequently so severe that there is a loss of calories sufficient to cause weight loss
and failure to thrive.
Reflux of stomach contents to the pharynx predisposes to aspiration and the
development of respiratory symptoms, especially pneumonia. Repeated irritation
of the esophageal lining with gastric acid can lead to esophagitis and consequently
bleeding. Blood loss in turn causes anemia and it is seen as hematemesis or melena
(blood in stools). Heartburn is also a frequent symptom in older children who can
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describe it but may go unrecognized in infants.
Malabsorption syndromes
The term "malabsorption syndrome" is applied to a long list of disorders
associated with some degree of impaired digestion and /or absorption. Most are
classified according to the locations of the supposed anatomic and biochemical
defect.
Digestive defects mainly include those conditions in which the enzymes
necessary for digestion are diminished or absent, such as cystic fibrosis, in which
pancreatic enzymes are absent biliary or liver disease, in which bile production is
affected, or lactase deficiency, in which there is congenital or secondary lactose
intolerance.
Absorptive defects include those conditions in which the intestinal mucosal
transport system is impaired. It may be because of a primary defect, such as in
celiac disease or gluten enteropathy, or secondary to inflammatory disease of the
bowel, hat results in impaired absorption because bowel motility is accelerated,
such as ulcerative colitis.
Obstructive disorders, such as Hirschsprung's disease, can also cause
secondary malabsorption from enterocolitis, chronic inflammation of the distended
small and large bowel, megacolon or large colon.
In addition, there is failure of the internal rectal sphincter to relax, which adds to
the clinical manifestations because it prevents evacuation of solids, liquids, and
gas.
Clinical manifestations: clinical manifestations vary according to the age. In the
newborn the chief signs and symptoms are failure to pass meconium within 24 to
48 hours after birth, reluctance to ingest fluids, bile-stained vomitus, abdominal
distention.
If the disorder is allowed to progress, other signs of intestinal obstruction,
such as respiratory distress and shock, develop.
During infancy the child does not thrive and has constipation, abdominal
distention, episodes of diarrhea and vomiting.
The occurrence of explosive, watery diarrhea, fever, and severe prostration
is ominous because it often signifies the presence of enterocolitis, which greatly
increases the risk of fatality. Enterocolitis may also be present without diarrhea and
is first evidenced with unexplained fever and poor feeding.
During childhood the symptoms include: constipation, passage of ribbonlike,
foul-smelling stools, abdominal distention, visible peristalsis. Fecal masses are
easily palpable. The child is usually poorly nourished, anemic, and
hypoproteinemic from malabsorption of nutrients.
Syndromes of digestive system
1. Painful syndrome.
2. Dyspeptic syndrome.
3. Intoxication syndrome.
4. Malabsorption.
5. Acute abdomen.
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6. Exicosis.
7. Toxicosis.
8. Hypotrophy.
9. Obesity
10. Jaundice.
11. Hepatolienal syndrome.
12. Cholestasis.
13. Cytolysis.
14. Portal hypertension.
15. Pylorospasm.
16. Pylorostenosis.
17. Hypovitaminosis.
18. Dyskinesia.
INDEPENDENT WORK OF THE STUDENTS:
Make a general conclusion on a theme of a class №1 and conducted practical
work.
REVIEW QUESTIONS:
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Name the organs of the alimentary canal and accessory digestive organs and
identify each on an appropriate diagram or model.
Identify the overall function of the digestive system as digestion and
absorption of foodstuffs, and describe the general activities of each
digestive system organ.
Describe the composition and function(s) of saliva.
Explain how villi aid digestive processes in the small intestine.
Describe the mechanisms of swallowing, vomiting, and defecation.
Describe how foodstuffs in the digestive tract are mixed and moved along
the tract.
Describe the function of local hormones in the digestive process.
List the major enzymes or enzyme groups produced by the digestive organs
or accessory glands and name the foodstuffs on which they act.
Disorders.
TEST PROBLEMS
Situation tasks.
REFERENCES:
1. Nursing care of Infants and Children / editor Lucille F. Whaley and I. Wong.
Donna L. - 2nd ed. - The C.V. Mosby Company. - 1983. - 1680 p.
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2. Nykytyuk S.O. et al. Manual of Propaedeutic Pediatrics. – Ternopil: TSMU,
2005. – P. 6-22.
3. Pediatric Nurse Practitioner Certification Review Guide / editor, Virgina layng
Milloing: contributing authors, Ellen Rudy Clore and all. - 2nd ed. - Health
Leadership Associates,Inc.,1994. - 628 p.
4. Nelson Textbook of Pediatrics / edited by Richard E. Behrman, Robert M.
Kliegman, Ann M. Arvin; senior editor, Waldo E. Nelson - 15th ed. W.B.Saunders Company, 1996. - 2200 p.
5. Whaley L.F., Wong D.L.: Nursing care of infants and children, St. Louis,
Toronto, London, 1983.
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