From Big Medical Encyclopedia

DIGESTION — the initial stage of assimilation of food at the person and animals consisting in transformation of initial food structures into the components deprived specific specificity, their absorption and participation in an intermediate metabolism.

The physiology

Splitting of feedstuffs is provided with system mechanical (e.g., crushing of food in an oral cavity), physical and chemical (e.g., effect of hydrochloric acid in a stomach or surfactants, in particular bilious to - t, in intestines) and chemical (hl. obr. enzymatic) processes.

Splitting of the majority of organic components (proteins, fats and carbohydrates) is carried out under the influence of the hydrolases synthesized specialized (secretory and digestive vsasyvatelnymi) by the cells which are located throughout a digestive tract. Nek-ry enzymes, hl. obr. the endoguide-rolazy, the providing splittings of large molecules and formation of intermediate products, cosecrete sialadens, a stomach and a pancreas whereas the ekzogidrolaza which are chipping off trailer monomers are included an apical digestive and transport membrane of enterocytes — cells went. - kish. path. The key end products of hydrolytic decomposition of the high-molecular substances which are contained in food are monomers (at hydrolysis of proteins — amino acids; fats — fat to - you and glycerin; carbohydrates — hl. obr. glucose).

In a simple proteinaceous molecule endo-and ekzopeptidaza split the following bonds:

Fig. 1. The scheme of hydrolytic decomposition of the triglycerides which are a part of fats.

Stages and possible ways of hydrolysis of the triglyceride which is a part of fats are presented in fig. 1.

Monomers, being exposed to absorption at the level of interaction of digestive and transport complexes, in most cases are a basic element in an intermediate metabolism, and from them in bodies and fabrics complex organic compounds are synthesized again. At the same time the possibility of absorption and utilization is proved in went. - kish. a path of oligomers (dipeptides, monoglycerides, and from endogenous oligomers — conjugated bilious to - t).

Fig. 2. The main types of digestion (according to A. M. Ugolev): and — extracellular — intracellular cytoplasmatic, in — intracellular vacuolar, or ekstraplazmatichesky, connected with phagocytosis and a pinocytic — membrane; 1 — the extracellular environment, 2 — the intracellular environment, 3 — a digestive vacuole, 4 — a lysosome, 5 — a kernel of a cell, 6 — a cellular membrane, 7 — desmoenzymes, 8 — food particles.

By the beginning of 20 century by efforts of such outstanding researchers, as K. Bernard, R. Geydengayn, I. P. Pavlov, Beyliss (W. The m of Bayliss), E. Starling, developed the two-unit scheme of assimilation of feedstuffs: band digestion —» absorption. This scheme remained dominating to the middle of the 60th of 20 century. Later it was replaced with the three-unit scheme: band digestion —> membrane digestion —> absorption. This scheme is based on recognition of three main types of digestion: extracellular, or distantny —> intracellular —> membrane, to-rye differ on localization and some other characteristics (fig. 2).

Extracellular, or distantny, digestion provides intensive initial digestion of food substrates. The enzymes synthesized by secretory cells are emitted on extracellular Wednesday (most often in specialized digestive cavities — oral, gastric, intestinal). Their hydrolytic activity is shown on nek-rum distance from the cosecreting cells. On the classification offered by I. I. Mechnikov, extracellular P. is the main mechanism of digestion at the organisms standing on higher stage of evolutionary development than flat worms. It prevails at annlides, Crustacea, insects, cephalopods, tunicates and chordates. This type P. is especially developed at high-organized animals, and also at the person. At most of them secretory cells are located rather far from cavities where effect of digestive enzymes is implemented (sialadens and a pancreas at mammals). The item, occurring in special cavities, call band. Distantnoye P. can pass also outside the organism producing digestive enzymes. So, at distantny extracavitous P. insects enter digestive enzymes into the immobilized production, and bacteria emit various enzymes in culture medium. As the enzymes cosecreted as a part of digestive juices are dissolved in an aqueous phase, their space organization is almost impossible or very limited. However they are rather effective for splitting both the superficial, and deep-lying peptide, glycosidic, radio and other bonds due to simplification of dimensional orientation of an active center of these enzymes concerning the split molecules. At the same time band P. does not provide effective transition from hydrolysis to absorption.

Intracellular digestion is phylogenetic the most ancient type of the Item. It is widespread among the elementary and most primitive metaphytes, napr, among sponges. Often it is found in flat worms; intracellular additional P. occurs at some highest invertebrates, and also at nemertin, erinaceouses, a number of annlides and many groups of mollusks. At the highest animals it carries out hl. obr. protective functions (see. Pinotsitoz , Phagocytosis ). Distinguish two types intracellular P.: the first is connected with transport of small molecules through cellular membranes and the subsequent digestion by enzymes of cytoplasm, the second — to endocytosis and happens in most cases to participation lysosomes (see). Lysosomes (an organella of cytoplasm) contain a broad set of various hydrolases (phosphatases, proteases, glucosidases, lipases, etc.) with an optimum of action in the acid zone pH (3,5 — 5,5). Food particles (or solutions) in the pericellular environment are taken a plasma membrane and move to cytoplasm. At the same time pinotsitozny and fagotsitozny vacuoles are formed. Connecting to them, lysosomes form phagosomas in which the contact of enzymes with the corresponding substrates is made. The products which are formed as a result of hydrolysis pass through membranes of a phagosoma into cytoplasm of cells. After end of a digestive cycle of a phagosoma turn into residual little bodies, to-rye are thrown out out of limits of a cell. Lysosomes play also important role in splitting of own structures of a cell used then as food material or in the cell, or beyond its limits. The processes combined under the name «endocytosis» are characterized by small speed and, apparently, cannot play an essential role in ensuring nutritive requirements of the higher organisms, but can promote penetration into a cell of some substances, in particular immunoglobulins. Processes of endocytosis, apparently, play an important role in assimilation of feedstuffs in the very first days after the birth.

Fig. 3. The diagrammatic representation of relationship between intracavitary and membrane digestion (according to A. M. Ugolev): 1 — substrate (food particles), 2 — pancreatic enzymes, 3 — not fermental factors, 4 — an active center of enzyme, 5 — membrane enzymes, 6 — the regulatory center of enzyme, 7 — transport system of a membrane, 8 — a microvilli, 9 — a membrane, 10 and 11 — a glycocalyx; and — the scheme of a depolymerization of feedstuffs in a cavity and on a surface of a small bowel; — a fragment of a surface of a lipoprotein membrane with the adsorbed and actually intestinal enzymes.
Fig. 4. Role of digestive and transport complexes in prevention of the competition of monomers at a stage of absorption: and — various monomers (are designated by small kruzhochkaka — 1) at a stage of absorption can compete for the general carrier (3) which is built in a cellular membrane (2) microvillis; — products incomplete gidrolnza-dimeasures (4) under the influence of enzymes (large circles) are split on monomers (small circles), to-rye can enter the competitive relations for possession of the general carrier; in — the fermental and transport complex (5) provides splitting of dimer on monomers and simultaneous transportation of these monomers through a membrane. Shooters specified the possible directions of the movement of monomers.

Membrane, or pristenochny, digestion is intermediate between intracellular and extracellular. It is carried out by means of the enzymes localized on structures of a cellular membrane and its derivatives. At the majority of the highest animals membrane P. occurs on special structures of free surfaces of cells — microvillis. The enzymes participating in membrane P. in a small bowel of mammals have a double origin: 1) adsorbed from a chyme (preferential pancreatic enzymes) and 2) synthesized by enterocytes and included in structure of an exterior surface of their lipoprotein membrane (actually intestinal enzymes). By means of membrane P. intermediate and final stages of hydrolysis of feedstuffs, and also interface of final stages of digestion and the initial stages of absorption (fig. 3) are carried out. It is reached by the special organization of digestive and transport functions of a cellular membrane in the form of peculiar digestive and transport «conveyor» (fig. 4).

Membrane P. is peculiar to the person, mammals, birds, Amphibia, fishes, cyclostomous and many representatives of backboneless animals (insects, Crustacea, mollusks, worms).

Features of digestion in various departments of digestive tract

Serial processing of food is carried out as a result of its gradual movement on went. - kish. to a path through departments, structure and which function are specialized (an oral cavity, a gullet, a stomach, intestines). Alimentary system (see) at the person, the highest and many lowest animals it can be subdivided into a number of departments: 1) perceiving; 2) carrying out, at some animal species expanded with formation of special depots; 3) digestive departments in which distinguish the sites providing a razmelcheniye of food and the initial stages actually of P. (in certain cases it comes to the end in this site), the subsequent P. and absorption (see); 4) department of absorption of water, residual digestion and return absorption of salts, various endogenous components (in particular, salts of bile acids). In each department food weight depending on its properties, and also specializations of department is late for a certain time and then passes into the following department.

Digestion in an oral cavity. Liquid food is swallowed at once whereas firm food at mammals, the majority of other vertebrates and invertebrates is late in an oral cavity (at the person it is here on average 10 — 15 sec.), is exposed to machining — crushing in the way chewing (see) and initial chemical processing under action saliva (see) which at the same time, at the same time moistening food weight, provides formation of a food lump. In the course of chemical processing of food in a mouth at the person and omnivores carbohydrates are exposed to splitting by ptyalin. Saliva possesses independent digestive function at certain insects, some Castropoda of mollusks, and also at those predatory cephalopods, myriapods and snakes at whom modified sialadens together with digestive enzymes cosecrete the paralyzing toxins. At separate species of insects sialadens contain highly active karbogidraza, proteases and lipases. In an oral cavity the flavoring structures which are carrying out tasting of food are also located (see. Taste ). By means of movements of language and cheeks the food lump comes to a gullet, and then — to a stomach.

Digestion in a stomach. Stomach (see) — the specific department of the digestive channel combining functions of a digestive organ and food depot. In it the mechanical processing of feedstuffs which began in an oral cavity reaching extreme intensity at some animal species having special «graters», «gastric mills», especially powerful gizzards etc. continues. In a stomach also chemical processing of food is carried out gastric juice (see). The crushed and chemically processed food masses in mix with a gastric juice forms liquid or semi-fluid chyme (see). The structure of a gastric secret corresponds to quantity and quality of food, and secretory activity is coordinate with motility, i.e. with the mixing and evakuatorny movements of a stomach. Food is in a stomach depending on its number and structure from 4 to 10 hours (the person has on average 3,52 — 4 hours).

Ruminants in a stomach have main transformations of food weight under the influence of activity of microflora of a stomach (bacteria and protozoa). The mucous membrane of a stomach cosecretes an inactive pepsinogen which in the presence of salt to - you pass into active pepsin (see), directly carrying out initial stages of hydrolysis of proteins. Besides, in a stomach parapepsins, gastricsin, a zhelati-naza cosecrete (under natural conditions splitting, apparently, collagen of connecting fabric) and cathepsines (see). Processes of peptic digestion happen mainly in surface layers of food weight. In process of enzymatic processing of surface layers of food weight the last due to peristaltic activity (see. Peristaltics ) moves to peloric department from where after partial neutralization the gastric chyme is evacuated in duodenum (see). Peristaltic waves in fundal department of a stomach are superficial, but amplify to peloric department. Lack of hashing of food in fundal department provides preservation of the neutral or alkalescent environment in deeper layers of gastric contents that creates conditions for continuation of the amylolytic processes which began in an oral cavity.

About 10% of peptide bonds in protein are exposed to peptic splitting in a stomach; at the same time the formed products become water soluble. Enzymatic activity of pepsin is maximum at pH of the environment 1,0 — 2,0. At the same time pH of gastric contents in the course of P. a long time remains much higher (3,0 — 4,0). Therefore it was not clear how pepsin provides hydrolytic processes in a stomach.

In recent years it was established that pepsin is not uniform enzyme, and consists of 4 — 6 fractions which part has hydrolytic activity not only at pH 1,0 — 2,0, but also at pH 3,0 — 4,0. The most active peptic processes proceed in a zone of contact of a gastric wall with contents of a stomach. Active reaction of the environment is closest to an optimum of effect of all enzymes of a peptic row there. In a gastric juice of some ruminant in the period of milk food the enzymes causing curdling of milk and the subsequent splitting of casein and operating unlike pepsin in the subacidic or neutral environment are found. In a stomach there is also partial splitting of fats of food, especially vysokodis-pergirovanny (milk, egg yolk), under action lipases (see). Ability of a gastric lipase to split fat quickly decreases in process of increase in length of chains fat to - the t which are a part of fat. In a gastric cavity also the bile and enzymes of pancreatic juice thrown in a stomach with the antiperistaltic movements of hl work. obr. at reception of greasy food that provides intensive hydrolysis of lipids.

Digestion in intestines. From a stomach food weight comes in the portions to intestines (see) where processes of enzymic hydrolysis and absorption are most intensive. In a small bowel of P. it is carried out at pH of the environment close to neutral. Transition from initial digestion in acid medium (in a stomach) to digestion in neutral (small bowel) is typical for the person and the highest animals, and also for many types of the lowest multicellular and unicells at which in digestive vacuoles acid, and then alkali reaction is supported in the beginning. At the person in a cavity of a gut stream juice pancreas (see) and bile (see), sharply changing pH of food weight. Active reaction of pancreatic juice of vertebrata varies at pH of the environment between 7,5 and 8,5. The mucous membrane of intestines actively cosecretes and absorbs ions of sodium, bicarbonate, chlorine and water. Thereby the ionic balance is supported, neutralized to - that, arriving from a stomach, and pH of the environment remains within 6,5 — 7,5. The majority of supramolecular aggregations and large molecules (proteins and products of their incomplete hydrolysis, carbohydrates and fats) at the person and the highest animals are split in a cavity of a small bowel preferential under the influence of the enzymes cosecreted by a pancreas and coming to a duodenum.

One of key intestinal enzymes is enterokinase (see) which activates finally all proteases of pancreatic juice. The peptides formed under the influence of proteases of a stomach and a не-расщегшенные of a squirrel are hydrolyzed by proteases of pancreatic juice: trypsin (see), chymotrypsin (see), carboxypeptidases (see) and elastase (see). As a result of consecutive effect of these enzymes in a cavity of a small bowel low-molecular peptides and insignificant amount of amino acids are formed of large proteinaceous molecules and polypeptides. The intestinal secret contains also the cathepsines splitting proteic matters in the subacidic environment. Carbohydrates (starch and a glycogen) are hydrolyzed under influence and - the amylase of pancreatic juice splitting them to three - and disaccharides without considerable accumulation of glucose. In hydrolysis of fats an essential role is played by the bile emitted to cookies. It is known that the food fat coming to a small bowel is generally unavailable to a lipase because of blocking of border of fatty weight amfipatichesky substances (proteins or phospholipids). Bilious to - you have ability to clear border of the emulsified fat of protein, but among these proteins there is a lipase which is inactivated in these conditions owing to physical separation from substrate. The colipase arriving with a secret of a pancreas has property to contact triglycerides even in the presence of bilious salts. Then Colipase «anchors» a lipase to substrate so the active center of enzyme is located closer to radio bonds. Food phospholipids, apparently, shall be (at least partially) are hydrolyzed by a pancreatic phospholipase of A2 before triglycerides contact with a lipase. In a cavity of a small bowel under the influence of a lipase are formed di - and monoglycerides fat to - t and insignificant amount of free glycerin.

The formed hydrolysates as a result of the mixing movements of intestinal muscles adjoin to a surface of a gut where there is their further processing. Products of partial hydrolysis come to a zone of a brush border (if the sizes of their molecules are not too big) that is promoted by their transfer in the flows of solvent resulting from absorption of ions of sodium and water enterocytes. Here membrane digestion is carried out. Intermediate stages of hydrolysis of biopolymers are carried out by the pancreatic enzymes (and - amylase, a lipase, proteases — trypsin, chymotrypsin, elastase, etc.) adsorbed on structures of a brush border in various layers of the glikoka-liks covering microvillis and representing mukopolisakharidny three-dimensional network. Final stages of membrane P. are carried out by actually intestinal enzymes (7 amylase, and - and R-glikozidazy, various hydrolases, a monoglitseridlipaza, an alkaline phosphatase and its isoenzymes, etc.) connected with a lipoprotein membrane of enterocytes. Nek-ry enzymes (e.g., 7 amylase and aminopeptidase) are capable to hydrolyze the high-polymerized products. In a glycocalyx enzymes can preferential be adsorbed on its surface, forming a boundary layer in an apical zone, or be distributed in all glikoka-liksny space. Contact to an exterior surface of a glycocalyx as small molecules of substrate for which it is not a considerable diffusion barrier, and the large molecules discarded in a cavity of a small bowel. To a surface of a glycocalyx also polymers arrive, to-rye, being split, can get in glikokaliksny space where there is their further depolymerization. Oligopeptida, coming to the area of a brush border, are split to the amino acids capable to direct absorption, except for glycyl-glycin and some dipeptides containing proline and oxyproline, to-rye are soaked up in not split look. The disaccharides arriving with food and which are formed as a result of hydrosplitting of starch and a glycogen are hydrolyzed by actually intestinal glucosidases (see) to monosaccharides, to-rye are transferred then through an intestinal barrier to internal environment of an organism. Triglycerides are split under action not only lipases of pancreatic juice, but also actually intestinal enzyme — a monoglitseridlipaza. Partially absorption of fats happens in the form of 2 monoglycerides. Dlinnotsepochny fat to - you in a mucous membrane of a small bowel are esterified again and come to a lymph in the form of chylomicrons, korotkotsepochny fat to - you do not resintezirutsya and come generally to blood (their smaller part comes to a lymph).

Fig. 5. The simplified scheme of allosteric (space) interaction between fermental and transport parts of fermental and transport ensemble (according to A. M. Ugolev): I \an allostericheskiyevliyaniya of enzyme on an entrance to transport system (and — the lowered affinity of the contact platform of a carrier to a hydrolysate, biv — the increased affinity of the contact platform of a carrier to a hydrolysate; II \allosteric influences of a condition of transport system on activity of enzyme (— less active condition of the catalytic center of enzyme, d — more active condition of the catalytic center of enzyme). At interaction of food substrates (polymers) with enzyme affinity of the contact platform of a carrier to a hydrolysate (monomer) increases, and the carrier takes the corresponding monomer. Respectively, change of a condition of the catalytic center of enzyme leads to the corresponding increase in affinity of the contact platform of a carrier to a hydrolysate of feedstuffs — to monomer: 1 — food substrate (polymer), 2 — enzyme, a hydrophilic part (2a — an active center of enzyme), 3 — enzyme, a hydrophobic part, 4 — a carrier (4a — substrate - the connecting platform of a carrier), 5 — monomer (glucose), 6 — floridzin.

In general at membrane P. the most part of all glycosidic, peptide and radio linkages is split. Ideas of close interaction of the enzyme completing membrane P. and transport system received new lighting recently. It is shown that they spatially also are functionally integrated in such a way that transfer of reaction product effectively happens within enzymatic and transport ensemble without an exit in an aqueous phase. At the same time remains not clear whether these ensembles are various molecules or parts of one big molecule (fig. 4, 5) Between fermental and transport systems there are cooperative interactions as a result of which enzyme facilitates binding of the reaction product which is formed at hydrolysis, and the transport system modulates activity of the enzyme. Membrane P. unlike band occurs in a sterile zone as microvillis of a brush border represent the peculiar bacterial filter separating final stages of hydrolysis of feedstuffs from a backterized cavity of a gut.

Fig. 6. Distribution of resorptive functions along a small bowel (according to A. M. Ugolev): in an upper part of a small bowel there is a receipt (it is specified by shooters) bile and pancreatic enzymes, and also absorption of mineral substances, monosaccharides and (partially) fat-soluble vitamins; on average department are soaked up water - and fat-soluble vitamins, proteins and fats; in a lower part B12 vitamin and bilious salts are soaked up (extent of a small bowel within which they are soaked up, is designated by vertical lines).

Digestive processes along a small bowel are distributed unevenly (fig. 6). It is necessary for efficiency of an intestinal stage of processing of food components that the speed and the number of the arriving food weight corresponded to its advance along intestines, and also to enzymatic characteristics of contents and intestinal surface. Therefore digestive and transport processes in a small bowel are distributed unevenly as in the direction from a stomach to a large intestine (a proksimodi-stalny gradient), and in the direction from crypts to tops of fibers that is expressed in the corresponding topography of each of the digestive enzymes which are carrying out band and membrane digestion. Depending on quality and composition of food change of functional topography is observed that, apparently, reflects adaptive behavior of intestines as complete body.

The item in a large intestine at the person is practically absent. Low intensity of enzymatic processes in a large intestine was developed in the course of evolution and is connected with the fact that the chyme coming to this department is poor in undigested feedstuffs. However activity of some enzymes of a large intestine kompensatorno increases at disturbance of functions of overlying departments of the digestive channel (a resection, an ileostomy etc.). The final department of a digestive tract is especially well developed at those land animals at whom it performs important function on absorption of water (e.g., at insects and vertebrata). In contents of a large intestine the insignificant amount of enzymes which secretion is a little subordinated to influences, coming from other departments is found, and it is caused mainly by local mechanisms. The large intestine is the place of intensive reproduction of the microorganisms causing degradation of carbohydrates and rotting of proteins therefore are formed organic to - you, gases (carbon dioxide gas, methane and hydrogen sulfide), toxic agents (phenol, skatole, an indole, cresol) which are neutralized in a liver. Owing to microbic fermentation cellulose is split. Species composition and a ratio of separate groups of microbes considerably differ at different types of animals and the person. The prevailing microbes at the adult are obligate and anaerobic sticks (apprx. 90%), on a share of optional and anaerobic microbes (colibacillus, milk bacteria, streptococci) and sporiferous anaerobe bacterias it is necessary apprx. 10%. In a large intestine processes of the return absorption (a reabsorption of water, mineral and organic components of a chyme) prevail. Here water (to 95%), the salts, glucose, nek-ry vitamins and amino acids produced by intestinal microflora are soaked up. In process of advance and consolidation of contents of intestines the fecal masses which accumulation causes form defecation (see).

Regulation of digestion

Activity of the digestive device is controlled by a sympathetic and parasympathetic nervous system (see. Autonomic nervous system ), and also the humoral factors (hormones, mediators) developed in went. - kish. a path and in the structures possessing endocrine functions (area Gipotalamo-Gipofizarnaya, adrenal glands, etc.). Exist both the influences on synthesis of digestive enzymes, their transfer and inclusion in lipoprotein complexes of a membrane of microvillis, secretion, motility and absorption stimulating and braking. Various nervous and hormonal effects interact among themselves. A typical example of such interaction is activation of secretory activity of a stomach and pancreas during food. In 1897 I. P. Pavlov established that the stimulating influences on synthesis of enzymes are carried out through vagus nerves. It is proved that increase in a tone of the centers of vagus nerves at food is followed by secretion gastrin (see) and some other intestinal hormones. Owing to irritation of a mucous membrane of a duodenum are emitted the secretin (see) stimulating secretion of a liquid part of pancreatic juice, and the cholecystokinin (see) causing release of enzymes a pancreas and reduction of a gall bladder. At the same time comes to blood enteroanthelone (see) which, perhaps, consists of two components or possesses double action (slows down gastric secretion and motility). Secretory function of a small bowel is regulated enterokrininy, secretory processes of brunnerovy glands — duokrininy (this term is used for designation of joint effect on secretion of several hormones — cholecystokinin, secretin and gastrin). K. M. Bykov put forward the concept about secretory fields of a stomach according to which the part of «the driver of rhythms» of gastric secretion is assigned to glands of small curvature. The important role in membrane digestion and absorption is played by the strengthened rhythmic reductions of fibers, to-rye are stimulated villikininy (see). Nervous and hormonal vliyaniyakhm it is subject not only activity went. - kish. path in general, but also coordination of functions of its certain parts (stomach, gepatopankreoduodenalny system, various departments of intestines etc.). Besides, trophic influence of the nerves and various hormones (including gastrointestinal — gastrin and cholecystokinin) providing proliferation of various elements is established went. - kish. path. Other hormones, napr, secretin, possess antitrofiche-sky action (remove trophic influence of gastrin and cholecystokinin). The intestinal hormonal system controls also main stages of processes of assimilation, including consumption beggars, its processing, absorption, actually a trophicity of fabrics, specific dynamic effect of food and, at last, protective processes, in particular a food leukocytosis. Influence of hormones and mediators in many cases is connected with their interaction with receptor structures of membranes, to-rye, in turn, by means of system of secondary intermediaries (cyclic adenosine - and guanidinemonophosphates) control metabolism of secretory, resorptive, motive and endocrine elements. Hormones and mediators in many cases carry out stimulation or braking of enzymes (cyclases) controlling concentration in a cell of cyclic nucleotides, to-rye are secondary messengers (transmitters) of the chemical signals operating on a cell from the outside (see Mediators).

There is a certain communication between quality of food and content of various digestive enzymes (substrate regulation). At one animal species (e.g., at predatory) proteolytic enzymes, at others (preferential herbivorous) — karbogidraza prevail. Quality of food caused also adaptivnokompensatorny reorganizations of fermental systems. One of the most striking examples of adaptation of a fermental range is availability of lactase at the majority of mammals in the period of milk food and repression of this enzyme upon transition to definitivny food. Distinctions in a set of digestive enzymes can be both phenotypical, and genotypic character. For example, food can stimulate not only secretion of enzymes, but also their synthesis, and the structure of a diet can define a ratio of digestive enzymes at this organism.

Ferkhmentativny properties and distribution of enzymes along a small bowel change throughout the first stages of post-natal development. At adult mammals splitting of feedstuffs happens generally in a proximal part of body whereas a distal part is a reserve zone. At the sucking animals hydrolysis of proteins and carbohydrates happens in more caudal departments of a gut (because of domination in milk of lipids); the reserve zone is minimum. Any caudal shift leads to the fact that not completely digested food comes to a large intestine and causes the phenomena like a food intolerantnost. At disturbances of secretory, motive, vsasyvatelny and secretory functions went. - kish. a path there are P.'s frustration

Pathological physiology

the Condition of bodies of system P., at Krom normal digestion, absorption and the subsequent digestion of feedstuffs and products of their hydrolysis is not provided, it can be caused by various reasons. P.'s insufficiency can be a consequence of influence of external alimentary factors (quantitatively or qualitatively not the balanced food), disturbances of the central nervous, endocrine, local neuro and humoral and hormonal mechanisms controlling functions of bodies of the alimentary system, various combinations of these factors, and also disturbances of mechanisms of regulation of reception of water and food. More often P.'s insufficiency arises at diseases of bodies of system P. (diseases of bodies of an oral cavity, gastritises, a peptic ulcer, a duodenitis, pancreatitis, enterita, colitis, etc.). Many diseases of bodies of system P. are accompanied by various disturbances of regulatory mechanisms.

P.'s disturbances are most often shown hypo - or hyperfunction of body (or bodies). However high ductility and adaptability of system P. promote ensuring function P. on rather high level for a long time. The same functional disturbances, napr, strengthening of a kislotoobrazovaniye in a stomach, can be caused absolutely different patol, mechanisms (e.g., easing fiziol, brake or, on the contrary, by excessive stimulation of exciting mechanisms, increase or decrease in sensitivity of actually secretory device to physiologically adequate incentives etc.). In most cases in the conditions of pathology difficult combinations of disturbances from separate bodies, groups of bodies and all alimentary system take place in general.

Disturbances appetite (see) are shown in the form of its decrease up to total failure from food — anorexia (see) — or patol, increases — bulimia (see), followed raised meal. Intoxication, fever or a disease, the proceeding g of decrease in secretion of digestive glands can be the cause of a loss of appetite. In particular, according to Litl and Messing (L. D. Lytle, R.В.Messing, 1976), Pakey (R. Paquay, 1978), L. L. Bellinger and soavt. (1978), etc., anorexia can be caused by damage of structures of ventrolateralny, dorsomedial and arkuatny kernels of a hypothalamus or oppression of their functions. P. D. Edminson et al. (1978), Noul (J. Knoll, 1978, 1979), etc. allocated at patients with anorexia of various origin a humoral factor of «feeling of saturation» which introduction to mice or rats caused decrease in consumption of food and reduction of body weight. Patol, increase in appetite develops at various diseases of c. N of page (tumors of a brain, neurosises, weak-mindedness) and endocrine system (thyrotoxicosis, excess products of insulin, etc.). Bulimia with the subsequent obesity was reproduced in an experiment by destruction of ventromedialny kernels of a hypothalamus.

P. D. Edminson et al. (1978) at patients with obesity emitted peptide which at introduction to his mice caused the increased consumption of food and increase in body weight twice against control. In experiences on rabbits by Rezek (M. of Rezek) et al. (1979) showed an essential role of insulin in fiziol. regulation and development patol, forms of consumption of food.

Disturbances of processes of P. in an oral cavity can arise at caries, periodontosis, inflammatory and paralytic damages of chewing muscles, at craniofacial injuries.

Increase in salivation (hypersalivation) can be a consequence of long reflex stimulation of the center of the salivation located in a myelencephalon or secretory nerves of sialadens that is observed at various defeats of c. the N of page (bulbar paralyzes, paresis), long effect of some vegetative poisons (Pilocarpinum, physostigmine), nausea and vomiting, some diseases of a gullet and stomach, inflammatory processes in an oral cavity, helminthic invasions, toxicosis of pregnancy etc. So-called paralytic hypersalivation well is reproduced in an experiment by switching off of a parasympathetic innervation and (or) a desimpatization of sialadens. At a desimpatization sensitization alpha and beta adrenoceptors of postsynaptic structures to an izoprenalin and noradrenaline, and hypersensitivity of glands is observed at parasympathetic denervation, as shown in 1979 Mr. of Talamo (V. of R. Talamo, with sotr.), it is connected with other mechanisms. Reduction of salivation (hypoptyalism) arises at diseases of sialadens and their channels (parotitis, tumors, salivary stones). It is shown also that the hypoptyalism can develop as a result of the central braking arising at strong emotions or pain stimulations. Insufficient salivation leads to development of dryness in a mouth, to disorders of processes of chewing and swallowing, inflammatory processes in an oral cavity.

Disturbance swallowing (see) which highest regulatory centers are located in a hypothalamus, subcrustal structures and a cerebral cortex, is the independent or accompanying other diseases syndrome; it can be observed at inflammatory processes in an oral cavity, disturbances of reflex mechanisms of regulation of swallowing. Permanent disturbance of swallowing can lead to aspiration pneumonia as a result of hit of a part of food in respiratory tracts, and also to starvation and the general exhaustion.

Dysfunction gullet (see) it is observed most often owing to mechanical obstacles in a way of food (cicatricial narrowings, tumors, spasms). Cicatricial narrowings develop as a result of chemical (acid, alkali) or thermal burns. According to V. of X. Vasilenko, etc. (1976), A. JI. Grebeneva, A. A. Gepp (1977), A. V. Frantske-vich (1977), Mellou (M. of Mellow, 1977), etc., diffusion esophagospasms, a spasm of the lower esophageal sphincter (achalasia) most often have neurogenic character and are expressed in the form of a delay of a food lump in a gullet. Difficulty of passing of food can be a consequence of weakening of a tone of a gullet (an atony of the gullet) which is followed by easing of peristaltic activity of a gullet. Diverticulums of a gullet (gryzhevidny protrusions of a wall) can also lead to disturbance of passing of food.

Disturbances of secretory function of a stomach are connected with changes of these or those nervous or gormonalnogumoralny links of regulatory mechanisms. Most often hyper - and the hyposecretory changes which are followed by increase, decrease or total absence of secretion salt to - you meet. Also characteristic of many patol, processes form of disturbance in an organism a kislotoobrazova-niya in a stomach — «spontaneous secretion», or «an acid stomach» is allocated (on E. Yu. Linar, 1968). As a rule, hyper - and hyposecretory syndromes are connected with increase or reduction of quantity of obkladochny cells or disturbance of regulatory mechanisms of secretion (increase in a tone of a vagus nerve, disturbance of normal products of gastrointestinal hormones). Hypersecretion is observed at a peptic ulcer of a duodenum, some forms of gastritises, at Zollinger's syndrome — Ellisona when the content of gastrin in blood is increased in hundreds of times against norm. At the same time stomach ulcers can be followed by the increased, not changed or reduced secretion of a stomach.

Total absence salt to - you in a gastric juice, or achlorhydria (see), it is observed at atrophic gastritis when thinning of a mucous membrane with an atrophy of gastric glands takes place, and also at a carcinoma of the stomach.

At gastric hypersecretion (see. Hyperacidity ) excessively acid contents of a stomach, getting into a duodenum, can cause a long spasm of the gatekeeper with the subsequent phenomena of stagnation in a stomach, an eructation and even vomiting. However at an ulcer of a duodenum the mechanism of locking of the gatekeeper is broken, long or his even constant gaping in this connection acid contents of a stomach come to a bulb of a duodenum in the quantities exceeding fiziol, possibilities of its neutralization is noted.

At hyposecretory, or anacid, the states which are not compensated by pankreatoduodenalny secretion (see. Hypochlorhydria ), deep disturbance of P. owing to sharp depreciation or the termination of secretion of proteolytic enzymes is observed. However in some cases, as showed A. G. Barakov, etc. (1979), I. L. Jansson (1975), at an achlorhydria the gastric juice can contain the proteolytic enzymes showing the activity at pH values higher than 7,0. Such patients usually do not show complaints to the broken digestion. Shifts in secretions of gastric proteases and increase in proteolytic activity of a gastric juice at pH 4,0 — 5,0 connect with formation of ulcer process above.

Refer to secretory frustration also disturbances of secretion of gastric slime. Yu. M. Lazovsky (1948), B. P. Babkin (1950), Glass (G. Century of J. Glass, 1964, 1967), etc. found out that high-molecular biopolymers of gastric slime are produced by cells of a superficial cylindrical epithelium of a stomach, additional cells of necks of glands of a bottom and a body, mucoid cells of cardial and peloric glands, and also (partially) main and obkladochny cells. Gastric slime consists of insoluble and soluble fractions. The first fraction includes polysaccharides, glycoproteins, proteoglycans, and contains enzymes and electrolytes in the adsorbed state. The dissolved fraction contains a complex of acid mucopolysaccharides, the sulphated ami-nopolisakharid, sialomutsin, pepsin in connection with mukoproteida and. internal factor of Kasl, neutral mukoproteid and other connections. Insoluble fraction performs protective function in relation to a cover epithelium of a mucous membrane of a stomach — function of inhibitor of pepsins and converter salt to - you. An internal factor of Kasl (see. Kasla factors ) provides normal absorption of B12 vitamin in intestines. Thus, disturbance of synthesis and secretion of mucoid substances in a stomach can lead to sharp decrease in barrier function of his mucous membrane and promote a canker or secondary development of pernicious anemia.

Disturbances of secretion of a pancreas (see) lead, as a rule, to serious violations of P. in intestines since the pancreas delivers the enzymes necessary for a proteopepsis, fats and carbohydrates. Common feature of disturbances of external secretion of a pancreas is partial, sometimes its full loss fiziol, adaptedness to qualitative and quantitative features of the food chyme coming from a stomach to a duodenum. Occlusion of a channel of gland from within (stones) or outside (tumors), tumors of gland, an atrophy of acinar fabric, regulatory disturbances, especially disturbances of its hormonal regulation, an inflammation (pancreatitis acute and chronic) can be the reasons of insufficiency of external secretion of a pancreas. N. N. Lebedev and E. R. Cherkezov-Kinov (1979) in experiences on dogs was shown that decrease in external secretion of a pancreas and dissociation of concentration of enzymes in juice at acute pancreatitis are connected with decrease in reactivity of gland in relation to intestinal hormones at simultaneous decrease in their products a mucous membrane of a duodenum. In an acute stage or at aggravations hron, pancreatitis the increased release of pancreatic enzymes in the general circulation takes place. At acute pancreatitis as a result of plentiful enzyme-emii with the subsequent falling of blood pressure and the necrotic phenomena in vitals process quite often has a lethal outcome. Intestinal P.'s disturbances are possible also in the conditions of normal external secretion of a pancreas owing to insufficiency of intestinal enterokinase. Such disturbances connected with hereditary insufficiency of enterokinase or a secondary lack of enterokinase as a result of an atrophy of fibers at a Gee's disease are known.

Exocrine insufficiency of a pancreas and the corresponding disturbance of P. take place as well at cystous fibrosis or a mucoviscidosis — the heavy inborn disbolism which is observed more often at children's or young age (see. Mucoviscidosis ).

Disturbances zhelchevydeleniya (see) take place at mechanical obstacles for outflow of bile on biliary tract (stones, tumors) or at disturbance of zhelcheobrazovatelny function of a liver (hepatitises, cirrhoses). Components of bile in an organism are used very economically — due to their continuous hepatoenteric circulation. Disturbance of this circulation most often conducts by a flood of blood components of bile. Losses bilious to - t and other compounds of bile with intestinal contents or (on an animal) at full removal of bile outside bring in an experiment to considerable (sometimes 10-fold) stimulations of their secretion by a liver, however over time hypersecretion is replaced by hyposecretion. At insufficient intake of bile in intestines emulsification of fats therefore the lipolysis and absorption of fats seriously is at a loss worsens; the steatorrhea develops (see).

P.'s disturbance in a small intestine most often arises because of insufficiency of vneshnesekretorny activity of a pancreas, zhelcheobrazovatelny or zhelchevydelitelny functions of a liver. At the same time, according to Riley and Glik-mena (J. W. Riley, R. The m of Glickman, 1979), H. J. Freeman et al. (1979), etc., as a rule, suffers band digestion — first of all fats, and also proteins and carbohydrates. In these cases with excrements significant amounts of fats (to 60 — 80% of the absorbed quantity), and also undigested proteins (muscle fibers after reception of meat food) and carbohydrates are allocated.

Fig. 7. The diagrammatic representation of ultrastructure of cells of an intestinal epithelium is normal (and) and at various forms to a spr: 1 — microvillis, 2 — pinotsitozny granules, 3 — mitochondrions, 4 — a basal membrane. It is visible that in the presence of pathology the form, the sizes and number of microvillis, and also other intracellular organellas change.

Pristenochnoye P. provides splitting formed after band P. or arrived with food proteinaceous (and carbohydrate) oligomers on an exterior surface of membranes of enterocytes to the monomers which are immediately soaking up in internal environment. By data A. M. Ugoleva (1967, 1972), pristenochny P.'s disturbances first of all can be connected with reduction of number of fibers and microvillis by a surface unit (fig. 7) that is observed at tropical and not tropical forms to a spr, a Gee's disease, Asian cholera, an ileojejunitis, after intensive neomycin or tetracycline care etc.

The genetic or acquired insufficiency of key enzymes or fermental systems of pristenochny P. (e.g., intolerance of milk also leads to pristenochny P.'s disturbance and absorptions of hydrolysates of feedstuffs at partial or total absence of lactase). As a result under the influence of flora of intestines all or almost all arrived lactose is exposed to fermentation, the formed metabolites, according to Bennett and Elie (A. Bennett, To. G. E1eu, 1976), render laxative, and at absorption — toxic action. The similar phenomena can come also at the isolated or combined insufficiency of invertase, maltase, isomaltase, trehalose. Intolerance of a gluten at a Gee's disease, according to Sam-loffa (I. M of Samloff et al., 1965), Schreiber (To. Schreiber, 1977), Cornell and Taunli (N. of J. Cornell, R. R. Townley, 1973), etc., is combined with deficit of acid phosphatase, a succinatedehydrogenase, cytochrome oxydase, leucineaminopeptidase, gamma glutamiltranspeptidazy; ATP-ase and other intestinal enzymes.

Disturbances of motive function of intestines are followed by essential shifts in processes of the Item. According to Styyuart (J. J. Stewart et al., 1976), the inflammatory phenomena in went. - kish. a path, creation of the hypertensive environment in intestines (e.g., owing to reception of laxative salts), injuries of receptors of intestines by inadequate irritants (toxicants, undigested food, products of fermentation, unavailable oils) lead to acceleration vermicular movement (see) and diarrhea (see).

Humoral excitement of the center of regulation of intestinal motility can also promote acceleration of a vermicular movement and developing of a diarrhea. In a case one - double release went. - kish. a path from inadequate substances of a ponosa have protective character. Long, sometimes wearisome ponosa (e.g., at enterita, cholera, dysentery) lead to deep disturbances of processes of intestinal secretion, digestion and absorption, development of insufficiency of P., dehydration, starvation.

The delay of a vermicular movement which is usually followed locks (see), can have spastic or tonic character. Spasms of different departments of intestines carry inborn (a disease of Girshsprunga) or acquired (plumbisms, psychogenic influences) character. I. A. Kirillova, L. A. Leontyuk (1974), showed that at a disease of Girshsprunga (see. Megacolon ) the normal innervation of sigmoid and direct guts due to the lack of ganglionic cells of an auerbakhov of a texture is not provided. The atony of intestines or decrease in its tone and peristaltic activity which are also followed by locks can be connected with quantitative and qualitative insufficiency of food (a lack of salts of potassium and calcium, vitamin of Vkh, etc.). Long tonic and spastic locks lead to sharp disturbance of P. due to development of putrefactive processes in intestines, accumulation of gases (carbonic acid, ammonia, hydrogen sulfide, etc.) and the subsequent intoxication of an organism. Accumulation of gases in intestines (see. Meteorism ) is followed by abdominal distention, reirritation of receptors, disturbance of blood supply of intestines. At sharply expressed spastic or atonic phenomena complete cessation of transport of an intestinal chyme, development of dynamic intestinal impassability can take place.

The significant role in origins of disturbances of P. belongs to changes in structure of intestinal microflora (see. Intestines ). Normal intestinal microflora provides implementation of processes of fermentation and the rotting finishing processing of an intestinal chyme and formation of fecal masses. At stagnation activity of microflora sharply increases in intestines with a prevalence of putrefactive processes and significant increase in formation of an indole, phenol, skatole, a histamine, putrestsin, pentamethylenediamine. These substances, being soaked up in blood, bring to endointoxications (see), the barrier function of a liver and secretory function of kidneys which is especially sharply expressed in case of insufficiency. Disturbances of enteral flora with loss of functions of these or those species of microorganisms can take place, e.g., at massive therapy by antibiotics.

Thus, changes of nature of functioning of the alimentary system at various levels of its organization can be followed by emergence of these or those forms of pathology of digestion.

Methods of a research of function of digestion

Methods of a research of function of digestion are diverse and numerous. The choice of a specific method depends on the nature of pathology

of P. or on what body of the alimentary system will be affected by pathology or demands the research (see, e.g., Stomach , Intestines , Liver , Gullet , Pancreas , Roth, oral cavity , Sialadens etc.). See also Duodenal sounding .

Radio isotope research. Tracer techniques of a research of function of digestion are based on assessment of speed and extent of splitting and absorption of various marked connections entered inside. In clinical practice the greatest use at the diseases connected with disturbance of processes of digestion and absorption of feedstuffs in went. - kish. a path, received marked fats (see) and proteins (see).

Use of marked fats and proteins allows to otdifferentsirovat the disturbances of processes of digestion of fats and proteins connected with disorder of vneshnesekretorny function of a pancreas from the insufficiency of absorption caused by disturbance of absorbing capacity of a small bowel, and on extent of disturbance — to characterize weight of disease.

The method of a research is based on introduction in marked fats and proteins with the subsequent definition of intensity of radioactivity of blood, urine and a calla or external radiometry of all body or area of a stomach. This method allows to estimate on the speed and extent of redistribution of marked connections a condition of processes of digestion and absorption in intestines, and also to judge a functional condition of bodies of P. and to control assimilation, distribution and removal from an organism of the drugs administered with the diagnostic or medical purpose.

For assessment of a condition of P. by means of tracer techniques study the nature of advance of food on went. - kish. to a path, composition of the digestive juices and their ingredients participating in digestion of food.

For the purpose of studying motor evakuatornoy functions went. - kish. a path in the conditions close to physiological, researches of a stomach and intestines by methods of scanning (see), stsintigrafiya (see) later introductions as a part of a trial breakfast of radio pharmaceuticals are applied (bengal-roses-iodine-131, colloid zoloto-198, etc.). These methods in comparison with usually used for these purposes rentgenol, a research have a number of advantages, especially at use of a stsintigrafiya after oral administration of colloid drugs 99 of MTS and 113m1p.

In P.'s studying tracer techniques of a research of digestive glands — a gepatografiya (see), a sialogra-fiya (see), etc. have a certain value.

Gained considerable distribution radio immunological method (see) which cornerstone competitive reaction of interaction of marked and not marked antigen with a specific antibody is. This method is used at a research of many functionally important substances that first of all is connected with its extreme sensitivity, high specificity, and also an opportunity to carry out dynamic radioimmunol, researches. It is possible to determine the content of gastrin, secretin and other digestive hormones by this method. Define a number of the hormones produced by a front share of a hypophysis and bark of adrenal glands by radio isotope diagnosis of in vitro to-rye influence synthesis of digestive enzymes, their transfer and inclusion in lipoproteidny complexes of a membrane of microvillis of actually intestinal enzymes, processes of absorption and motility, and also secretory function of digestive organs.


P.'s Disturbances can be caused by many factors. Conditionally they can be broken into three groups: disturbances of food, functional and organic lesions of the alimentary system.

P.'s disturbances can proceed without explicit a wedge, manifestations and to consist in the weakening of participation of some body of the alimentary system in the course of P. compensated by activity of other bodies of the alimentary system. In other cases of disturbance of P. are shown by a row enough characteristic a wedge, syndromes and laboratory signs combined by the concept «dyspepsia» or «dispeptic syndrome».

Disorder of the secretory function which is shown decrease in enzymatic activity of secrets of digestive glands is the cornerstone of formation of a dispeptic syndrome. The leading value for formation of a syndrome has reduction of concentration of enzymes in intestinal juice (enterokinase and an alkaline phosphatase) and juice of a pancreas (a lipase, amylase, trypsin, etc.). A smaller role in emergence of a syndrome is played by the enzymes cosecreted in a stomach. In close connection with decrease in concentration of enzymes in contents of intestines at development of a dispeptic syndrome there are frustration of a zhelchevydeleniye. At the same time the major role is played not so much by quantitative shifts how many change biochemical, properties of bile (see), the formations of a lipidic complex leading to disturbance, disturbance of enterohepatic circulation bilious to - t, and also decrease in bactericidal properties of bile. An important factor which can cause dyspepsia is the quantitative and qualitative change of microflora of a large intestine and hit of its bacterial contents in the proximal, usually sterile or presented by scanty microflora departments of a small bowel (see. Dysbacteriosis ). Among the reasons causing dyspepsia, motive frustration — disturbances of a vermicular movement are of great importance (see). The dispeptic syndrome can arise both at acceleration, and at delay of motor activity of a stomach and intestines. Acceleration of a vermicular movement promotes accumulation in lower parts of intestines of the remains of a food chyme which were not in time to be soaked up, mainly polysaccharides. Staz of intestinal contents as a result of delay of motor activity is followed by increase of quantity of microflora, disturbance of a normal course of processes of digestion and absorption of decomposition products of proteins, fats and carbohydrates. Than normal, participation of bacteria in zymolysis of foodstuff leads more active to formation of a number of the toxic products of half-decay (ammonia, an indole, low-molecular fat to - you, etc.) causing additional irritation of a mucous membrane of a gut, strengthening of a vermicular movement and symptoms of intoxication of an organism owing to absorption of these products and receipt them in blood.

The dispeptic syndrome is caused by also allergic influences, napr, at the expense of an antigen challenge foodstuff and some drugs, and also bacteria, protozoa and worms. Allergen often remains obscure. In displays of dyspepsia autoallergichesky reactions to antigens damaged patol, process of a mucous membrane of intestines are of great importance. The role of an allergic component in development of dyspepsia is rather big in connection with high immune responsiveness of intestines.

The symptom complex of dyspepsia forms as a result of of both band, and pristenochny P.'s disturbance, and also owing to disturbance of processes of absorption (see). The sprue (see Malabsorption a syndrome) at a coloenteritis and enteritis (see Enteritis, a coloenteritis) includes all a wedge, symptoms of dyspepsia.

A wedge, displays of dyspepsia demonstrate frustration of compensatory mechanisms, to-rye usually become effective at damage of separate links of the alimentary system. For example, the anacid condition of a stomach can not be followed a long time by a dispeptic syndrome at a normal functional condition of other bodies of the Item.

The dispeptic syndrome at disorders of vneshnesekretorny activity of a liver is more expressed at the accompanying duodenitis (see), pancreatitis (see), and also in cases of damage of ilealny department of the intestines providing integrity of hepatoenteric circulation bilious to - t. Diseases of a small bowel can not be followed by clinically expressed dispeptic syndrome before involvement in patol, process of a large intestine.

The general concept of a dispeptic syndrome at disturbance of digestive processes joins the following symptoms: disturbance of appetite (see), nasty taste in a mouth also began to smell from a mouth, eructation (see), heartburn (see), nausea (see), vomiting (see), feeling of weight and a raspiraniye, abdominal murmur, a meteorism (see), ponosa (see) or locks (see). The listed symptoms usually are combined with pain in various departments of a stomach and its morbidity at a palpation. Koprol, changes are observed (see. Kal ). Differentiation a wedge, manifestations depends on localization patol, process, degree of its expressiveness and the period of a disease (acute or chronic). The dispeptic syndrome is most brightly shown during the acute periods of a disease, is less expressed or disappears — during the periods of remission. Owing to close functional interrelation of bodies of the alimentary system it is not always possible to carry out strict distinction between a wedge, symptoms of gastric, hepatic, intestinal and pancreatic dyspepsia. In such division the known share of convention is allowed. Nevertheless in a wedge, practice for each type of dyspepsia can allocate a certain complex of symptoms.

The heartburn, an acid eructation, vomiting with plentiful quantity of acid contents, pain in piloroduodenalny area reminding a pain syndrome at a peptic ulcer of a duodenum or a duodenitis are characteristic of gastric dyspepsia at the increased secretory function of a stomach. Locks are more often observed. The dispeptic syndrome arising at hyposecretion of a stomach or an anacid state is shown by heavy feelings in an anticardium, an empty eructation and an eructation food, vomiting, nausea, a loss of appetite. At disturbances of compensatory opportunities of the alimentary system there are ponosa. As a rule, gastric dyspepsia joins in a wedge, a picture gastritis (see) with raised or hyposecretion of hydrochloric acid.

The splash, rumbling and abdominal pains localized by hl are typical for any forms of intestinal dyspepsia. obr. in average and lower it chastig a meteorism, the strengthened gas generation, ponosa or locks. The pain syndrome is usually expressed unsharply and caused by the spastic phenomena or a meteorism. The intestinal dyspepsia arising at alimentary disturbances can be shown by dominance of fermentative or putrefactive processes in intestines. At a prevalence of fermentative processes in intestines the meteorism, rumbling and abdominal distention are followed by allocation of the foamy excrements of light yellow color containing plentiful yodofilny flora and undigested starch. At a lab. researches sharply positive fermentation test, increase in contents organic to - t is noted. Putrefactive processes are followed liquid, dark color by excrements sharply of off-flavor, alkali reaction. In them many muscle fibers with remained cross polosatoyetyyu, and also increase in content of ammonia and amino acids are found. Education in intestines of products of an incomplete albuminolysis (an indole, skatole, etc.) and their absorption are reflected in the general condition of patients. Strengthening of fermentative or putrefactive processes has short-term character more often and the hl is caused. obr. transition to food unusual, excessively rich with a cellulose and carbohydrates, the use of the overfermented drinks (kvass, beer, young wine), overripe or immature fruit and berries, a large number of proteinaceous products. Establishment of the fact of irrational food of patients in the absence of changes in secretory function and morphology of the digestive organs confirmed by a laboratory and tool research (gastric sounding, a research of activity of enzymes of a pancreas in duodenal contents, results gistol, researches of bioptat of a mucous membrane of a stomach and a duodenum, etc.), testifies to the functional (alimentary) nature of dyspepsia. Bystry elimination of symptoms of intestinal dyspepsia at normalization of food of patients confirms this diagnosis.

One more form of intestinal dyspepsia — «soap dyspepsia» — is shown peculiar Koprol, a syndrome: polyexcrements, clay-gray color a calla, a large amount of neutral fat, fat to - t and soaps (see. Steatorrhea ).

Klien, the characteristic of dispeptic manifestations at diseases of a liver and pancreas, and also at disturbances of a zhelcheottok in some cases is identical (see. Hepatitis , Pancreatitis ). The most reliable criterion used for differential diagnosis between dyspepsia of a hepatic, pancreatic and intestinal origin are the indicators of a steatorrhea received by means of a tracer technique of a research. For hepatic and pancreatic dyspepsia disturbance of processes of hydrolysis of fat and increase in contents in Calais of neutral fats, is typical for intestinal dyspepsia owing to disturbance of hydrolysis of fat and its absorption — increase in content of neutral fats and fat to - t.

Distinguish acute and hron, forms of dyspepsia. Acute dyspepsia is caused by hl. obr. alimentary and inf. factors (see. Food poisonings, Toxicoinfections food). Hron, various hron, diseases of bodies of the alimentary system — gastritis usually are followed by dyspepsia, duodenitis (see), peptic ulcer (see), cholecystitis (see), enteritis, colitis, etc.

Diagnosis put by definition of activity of enzymes (amylase, a lipase) at their consecutive desorption in homogenates of pieces of a mucous membrane of a small bowel (receive by means of an aspiration biopsy). The method of studying glycemic curve after peroral loadings disaccharides and monosaccharides allows to differentiate a syndrome of insufficiency of pristenochny P. (the flattened curve after reception of a maltose, sucrose, lactose and normal — at reception of glucose, a galactose) from a syndrome of insufficiency of the band Item. The aspiration biopsy allows to reveal atrophic changes of a mucous membrane of a small bowel (an indirect sign).


At alimentary dyspepsias originally appoint starvation within 1 — 1,5 days, then in a daily diet of the patient with putrefactive dyspepsia increase amount of carbohydrates; at fermentative dyspepsia reduce amount of low-molecular carbohydrates, but increase consumption of proteins. At fatty dyspepsia limit receipt in an organism of fats, especially refractory fats of animal origin (pork, mutton). Further patients are acquainted with philosophy of a balanced diet.

At other forms of disturbances of P. the main attention shall be paid to treatment of a basic disease (hron, gastritis with secretory insufficiency, pancreatitis etc.).

Dietary treatment is of great importance (see. clinical nutrition ). At all types of the dyspepsias which are followed by diarrhea appoint a diet No. 4, at improvement of a state — a diet No. 46. Further the nature of dietary treatment is defined by a current of the basic (and accompanying) diseases. At the same time it is necessary to follow ground rules: frequent fractional food, careful prozhevyvaniye of food, timely sanitation of teeth, personal hygiene.

Purposes of drug treatment: 1) protection of a mucous membrane of a digestive tract from chemical or bruises; appoint enveloping and astringents (a kaolin on 2 — 4 g on reception and calcium carbonate on 0,5 — 1 g on reception of 4 — 5 times a day in 30 min. prior to food; broths or infusions of officinal herbs — rhizomes of a coil, roots of a burnet, a rhizome of a lapchatnik, etc.); 2) establishing digestive processes; appoint enzymatic drugs (abomin, Pancreatinum, festal, etc.); 3) normalization of a vermicular movement of a stomach and intestines; appoint Myotropic spasmolysants (a papaverine a hydrochloride, Nospanum, etc.). At heavy diarrhea it is most effective reazek, appointed on one tablet 3 — 4 times a day or on 6 — 8 drops on reception.

For normalization of an indestinal flora according to indications appoint Enteroseptolum, Intestopanum short courses. Further, in the presence of the corresponding indications, treatment is useful if-bakterinom, bifidumbacterium or bifikoly. If necessary intravenously enter plasma, proteinaceous a hydra lysates (Aminopeptidum, a hydrolyzate of casein, Hydrolysinum, Amincrovinum, etc.), carry out vitamin therapy.

From physiotherapeutic methods of treatment (in the absence of contraindications) appoint thermal procedures: paraffin applications, ozokerite, etc. During the subsiding of inflammatory processes for fixing of results of therapy the dignity is recommended. - hens. treatment.

Prevention of disturbances of digestion: balanced balanced diet, observance of the mode of meal, fight against alcoholism, smoking; early detection and treatment of diseases of the alimentary system; at hron, diseases — medical examination of patients.

Features of digestion at children

Laying of bodies of P. occurs at an early stage of pre-natal development (with 7 — the 8th day formation of primary gut — an arkhi-enteron is noted). However a main type of food in the embryonal period is gistotrofny (after implantation of a blastocyte the germ eats a secret of a mucous membrane of a uterus, then material of a vitellicle), and after formation of a placenta (with 9 — 10th week) — gemotrof-ny (at the expense of transplacental transport of nutrients from mother to a fruit). At this time major importance has intracellular type P. Against the background of gemotrofny food since 16 — activity actually of P.'s bodies is shown 20th week that is expressed partially in am-niotrofny food. Swallowing an amniotic fluid promotes a rekanalization of the alimentary system in the kraniokaudalny direction, stimulates maturing of fermental systems, especially in intestines, and development of membrane type P. The fruit begins to receive enterally a nek-swarm amount of nutrients (protein, glucose, water, mineral salts, etc.). Emergence of proteolytic and aminopeptidazny activity of a small bowel is noted on the 8th week, and is preferential in its distal half; from 23rd week at most dipeptidgidrolaz-ache it is the share activity of proximal departments. Disakharidazny activity forms from V—VI lunar month; the maximum activity of maltase is reached on the VIII lunar month. A bit later saccharose and lactose activity increases, and by the birth the lactase activity reaches a maximum.

Rate of development of bodies of P. by the birth of the child quickly increases, however even at the newborn relative immaturity of those bodies of P. which secrets provide function of distantny digestion is noted (sialadens, a stomach, a pancreas, vneshnesekretorny function of a liver, etc.). Therefore laktotrofny food is the most important stage of adaptation to existence in the first days, weeks and months of postembryonal life, and from all links of P. it is the most developed membrane. The evolution of mammals lasting millions of years resulted also in features of the mechanism of milk feeding for each look. Though milk of various animals is the most available to hydrolysis and assimilation by foodstuff, however significant differences in its structure and biol, properties lead to the fact that the newborn child is most adapted to digestion and digestion of women's milk, a cut in the first days is for it not only a source of nutrients, but also a security measure from infection and allergization; it promotes formation of its immunity.

By the period of a neonatality sialadens are morphologically already created, but their secretory function within the first 2 — 3 months of post-natal development low. and - the Ptyalin (see Amylases) splitting 1,4-glucosidic bonds in polysaccharides at newborns differs in small activity, but in the next months quickly accrues, reaching the maximum activity by 2 — 7 years of life. From karboangidraz (see) contains in saliva and - glucosidase (maltase) capable to split a maltose and sucrose. If in the first months of life saliva promotes the best sealing of an oral cavity at suction, and also to formation of small, friable clots of casein of milk, then at the children who are on artificial feeding and after introduction of the feeding up containing a large amount of carbohydrates, saliva becomes particularly important in digestion of carbohydrates and formation of a food lump. By 4 — 5 months plentiful hypersalivation is observed that is caused still by an insufficient maturity of the central mechanisms of regulation of salivation and swallowing. Bactericidal properties of saliva promote protection against infection.

The gullet at children of early age long, however its cardial sphincter is poorly developed that promotes easy vomiting at children of the 1st year of life.

The volume of a stomach by the birth rather small; its capacity makes apprx. 10 ml/kg of the weight (weight) of a body (the adult has 20 — 25 ml! kg). After the beginning of an enteroalimentation the volume of a stomach quickly increases (on the 1st year of life monthly by 30 — 40 ml). At sufficient development of antropilorichesky department lag in development of the cardia is noted, and in situation «lying» fundal department is located below antral that, on the one hand, promotes ease of flowing of food in a gullet, and with another — prolongs effect of amylolytic enzymes of saliva. The mucosal surface of a cover of a stomach at newborns makes 5270 mm 2 , by 10 years increases by 10 times. Though gastric glands form at early stages of pre-natal development, their number in a mucous membrane of a stomach at the birth averages only apprx. 2 million, increasing by 10 years in 5, and by 15 years — by 10 times. The low secretory function of a stomach inherent to the newborn is explained by it.

At newborns gastric secretion after introduction of a histamine makes 0,1 — 0,3 ml / mik, and pH does not fall lower than 4,0; by the end of the 1st year of life secretion increases up to 1 ml/min., pH decreases to 1,5 — 2,0 that provides an optimum of action pepsin (see). Assume what a source of hydrogen ions at children of the first 2 months is milk to - that and only then — salt to - that. Neyrogumoralnaya regulation of gastric secretion begins to be shown by the end of 1 month of life. Among proteolytic enzymes action of a renin (see Chymosin) and gastricsin prevails. At the same time at children of the 1st year of life rather high activity gastric is noted lipases (see) which feature of action is ability of hydrolysis of fats in the absence of bilious to - t and an optimum of action in Wednesday, neutral or close to it (pH from 4,0 to 8,0). Assume that 1/3 fats of women's milk are hydrolyzed in a stomach. It is also promoted by lipolytic activity of women's milk which by 100 times surpasses lipolytic activity of cow's milk. Thus, at the child of the period of a neonatality the special mechanism of band digestion adapted to laktotrofny food which fatty component makes 50% of its caloric value was evolutionarily created.

The pancreas by the birth is morphologically completely created and is functionally full. However exocrine function remains still unripe, but quite provides hydrolysis of the digestible feedstuffs which are contained in milk. Pancreatic secretion accrues quickly, especially on the 1st year of life after introduction of a feeding up (at artificial feeding functional maturing of a pancreas happens quicker, than at natural food). The amount of pancreatic juice by the end of the 1st year increases by 10 times, and in the next years by 10 times, reaching the figures inherent to the adult. Similar to secretion there is an increase of intensity of a fermentoobrazovaniye. Amylolytic activity at newborns is very low. It reflects evolutionarily developed mechanism of milk food (women's milk contains disaccharide lactose). Only in colostrum and transitional milk there are in a small amount others sugar (sucrose, glucose, fructose). Activity pancreatic and - amylases only within 1 year of life increases approximately by 25 times, and with transition to usual food, at Krom of 60% of caloric requirement begin to become covered at the expense of carbohydrates (preferential at the expense of polysaccharides), amylolytic activity reaches the figures inherent to the adult, by 3 — 5 years. There is an increase in activity of trypsin (see), chymotrypsin (see), lipases, phospholipases more quickly (see. Lecithinases ). Dynamics of activity of other enzymes is less studied.

By the time of the birth at the child the liver is rather big and occupies the most part of an abdominal cavity. Its weight (weight) makes 4% of body weight; by 1 year the weight of a liver doubles, by 3 years — trebles, by 9 years increases by 6 times, by 15 years — by 10 times. Despite the considerable sizes, a liver in the functional relation to the birth relatively did not ripen that is especially shown in anti-toxic and vneshnesekretorny function. Allocation bilious to - t, to-rye play an important role in the course of P., is small that quite often serves as the reason of a steatorrhea (in a koprogramma, owing to insufficient activation of a pancreatic lipase, presence of a large number fat to - t, soaps, neutral fat comes to light). With age education bilious to - t amplifies. At the same time a liver of the child of the first months of life (especially up to 3 months) has bigger glycogenous capacity, than at adults.

Intestines at newborns are rather longer, than at the adult, and are structurally completely created. It as if compensates insufficiency of those bodies, to-rye provide distantny the Item. Therefore at children of early age, especially in the period of a neonatality, the membrane P. which is carried out by enzymes of enterocytes, and also the enzymes of a pancreatic origin (and is possible, salivary and gastric) adsorbed by various layers of a glycocalyx is of particular importance. Though by the birth of the child all enzymes of membrane P. have high activity, the topography of enzymatic activity throughout a small intestine at newborns has distal shift that reduces reserve opportunities of the membrane Item. At the same time the intracellular P. which is carried out as a pinocytic at children of the 1st year of life is expressed much better, than at more advanced age. It is confirmed, e.g. by detection in blood of proteinaceous antigens of cow's milk and the immunological answer — existence of antibodies which maximum is found to 4 — to the 5th month of life. The food sensitization decreases with age.

Thus, formation sekreto-and a fermentoobrazovaniye of the majority of glands of upper parts went. - kish. a path, the providing P., occurs in the post-natal period of development. Therefore at children of early age the Item prevails membrane and intracellular. Over the first year of life there is a bystry development of distantny P. which role and value increases every year; it though has limited value for full hydrolysis of complex biopolymers, however plays an essential role in preparation of feedstuffs for their digestion by enzymes of a small intestine.

Features of digestion of various feedstuffs at children. Evolutionary formation of the mechanism of the milk feeding inherent to each species of mammals led also to formation of specific features of process of digestion of feedstuffs. Children of the first days and weeks have lives along with the general mechanisms P. inherent to the person great value (compensation of insufficiency of band P.) got an autolytic component, at Krom hydrolysis of biopolymers is partially carried out at the expense of the enzymes which are contained in women's milk. In women's milk there are 19 enzymes, and their activity is especially considerable in colostrum. However the newborn child is capable to acquire and the milk mixes prepared from milk of various animals with introduction of various additives (for example, the corresponding fats, carbohydrates used at production of the adapted mixes). It confirms the known maturity of P. at newborns though its artificial feeding and is for the person biol, «accident» that is confirmed by long-term observations of pediatricians.

The role and value of various links of P. depends on those products, to-rye the child receives with food. For the first year of life a key product of food is milk — the high-dispersed product containing in optimum quantities all necessary for life and growth of substance. Carbohydrates of milk are generally presented by lactose (lactose). Contains in women's milk (Z-lak-toza, other di - and monosaccharides (sucrose, glucose, a galactose and fructose) are found only in the first days of a lactation in a small amount. As milk is in an oral cavity very short time, carbohydrates are not exposed to a little essential changes. From a stomach milk is evacuated also quickly. Therefore hydrolysis of lactose generally happens in the field of a brush border of an intestinal epithelium where the formed monosaccharides (a galactose and glucose) are exposed to absorption, R-lactose of women's milk more slowly, than and - lactose of cow's milk, is exposed to hydrolysis in a small intestine and partially comes to a large intestine where it is split by a bacterial flora. It promotes preservation and maintenance of a normal biocenosis of intestines and dominance of intestinal bifidium-flora.

The milk mixes prepared on the basis of cow's milk contain and - lactose, and also other types of carbohydrates (starch, sucrose, a maltose, isomaltose, etc.). alpha Lactose of cow's milk is exposed to splitting and absorption in a small intestine more fully. Disaccharides (sucrose, a maltose, isomaltose), as well as lactose, are exposed to hydrolysis in a small intestine the corresponding disaccharidases with the subsequent absorption of monosaccharides. On process of assimilation of di - and monosaccharides in a small intestine the great influence is exerted by osmolarity of a food chyme which generally depends on the content of electrolytes and sugars, and among the last the role mono - and disaccharides is especially big. Osmolarity of women's milk almost corresponds to osmolarity of a blood plasma. At the same time at equal osmolarity of each molecule of sugar the caloric value of disaccharides is twice more than corresponding quantity of monosaccharides. Preferential content in milk of disaccharides is essentially the evolutionary adaptation providing maintenance of optimum osmolarity of a chyme at children of the first year of life.

The monosaccharides (galactose, glucose) which are formed at hydrolysis are exposed to activation in enterocytes then they pass into blood through system of a portal vein and depending on requirement of an organism turn into glucose, are postponed in a liver in the form of a glycogen or carried with blood in other bodies and fabrics.

After introduction of the feeding up containing a large amount of Starch the role and value of amilazny activity of sialadens and a pancreas increases. As it was specified earlier, amnlotichesky activity develops rather quickly.

Feature of digestion and digestion of proteins at newborns and children of the first days and weeks of life is the big role of membrane and intracellular links of P. that is confirmed by easier transition of food protein in not changed state in blood. Especially easily pass lactoglobulins. The caseinogen is exposed to curdling in a stomach under the influence of a renin in the beginning. During the curdling of women's milk small gentle flakes while curdling of a caseinogen of cow's milk is followed by formation of large clots that complicates its further digestion are formed. The fact that digestion of proteins of women's milk at children of the first two weeks of life reaches 90 — 95% while protein of cow's milk is acquired during this period for 60 — 70% is explained by it. However in the next weeks and months of life comprehensibility of protein quickly increases. Higher absorption of proteins of women's milk is promoted by the proteolytic enzymes (pepsin, trypsin) which are contained in it. The milk mixes prepared on the basis of cow's milk are deprived of similar enzymes therefore at preparation of milk mixes for feeding of children of the first months of life attempts to reduce the maintenance of a caseinogen become and to enrich mixes with other milk proteins (albumine-globulinovymi by fractions). Under the influence of enzymes of gastric and pancreatic juice of a squirrel are split to polypeptides, to-rye are exposed to further hydrolysis to the amino acids making them proteases of enterocytes. The formed amino acids are activated and soaked up.

After introduction of a feeding up the role and value of band hydrolysis of protein increase. At children 1 years are more senior process of digestion of protein does not differ from that at the adult.

At children of the first months of life digestion of fat depends on a type of feeding. The fats of women's milk containing bigger quantity polyunsaturated fat to - t and phosphatides, thanks to existence of a lipase in milk and a gastric lipase begin to be split in a stomach. Hydrolysis of fat at the same time happens without participation bilious to - t. The gastric lipase is capable to split the fats formed fat to-tami with a short carbon chain (C12). Fats with longer carbon chain are split under the influence of steapsin in the presence of bilious to - t. Critical concentration bilious to - t for formation of micelles of fat depends also on pH, temperature, a ratio various bilious to - t and contents of lecithin. Relative immaturity of vneshnesekretorny function of a liver has significant effect on coefficient of absorption of fat. The newborn is capable to absorb to 95% of fat of women's milk. However fats of cow's milk are acquired in this period in much smaller quantity. In this regard for preparation of the adapted milk mixes additive of fats of a plant origin (fat of soy, a coco) is used, to-rye, than fats of cow's milk easier are exposed to hydrolysis and assimilation. After introduction of a feeding up and especially upon transition to usual food absorption of fat happens the same as at the adult. Absorption of fat in a small bowel is carried out preferential in proximal and average departments of a small bowel. Fat to - you with an average and long carbon chain in a mucous membrane of a small bowel are etherified again and come to a lymph in the form of chylomicrons. Fat to - you with a short chain of carbon atoms do not resintezirutsya and come to blood more than in a lymph.

Disturbances of digestion at children can be acquired and inborn. The acquired diseases caused by viral and bacterial infections after which there are secondary sprues are most often observed. Slee's E of disturbance of P. are hereditarily caused, as a rule, they remain for life. At the same time the acquired sprues, and also syndromes caused by a delay of maturing of separate fermental systems after the relevant dietary activities gradually from-chezayut. About a wedge, positions it is reasonable to allocate the malabsorption arising in connection with organic lesions of various departments went. - kish. path, anomalies of its development (e.g., syndrome of «a short gut», «a congestive loop» etc.) or anomalies of development of the enterocytes (revealed at gistol, a research of a mucous membrane of a small bowel), and also functional disturbances at which there is only the selection insufficiency of enzymes (e.g., deficit of enterokinase, disaccharidases, etc.). P.'s disturbances are clinically shown by a sprue (see Malabsorption a syndrome) in the form of two groups of disturbances: 1) diarrheas from a polifekala - «y and 2) a syndrome of deficit of various substances (protein, vitamins, etc.).

The simple dyspepsia (see) caused by inadequacy of the used milk mixes and dishes of a feeding up to limited functionality of system P most often occurs at children of the first year along with intestinal infections. Clinically it is shown by vomiting and a diarrhea without the expressed symptoms of toxicosis and an eksikoz. Quite often at it the intestinal dysbacteriosis (see) developing owing to accumulation in intestines of the food chyme which is a fine medium for bacteria comes to light. The syndrome of «a short gut», or malabsorption owing to reduction of an absorbing surface, a thicket is observed after a resection of a considerable part of intestines, especially ileal gut, and also owing to its functional loss after rentgeno-and radiotheraphy, use of cytostatic drugs. At the heart of these patol, states sharp disturbance of membrane P. and absorption lies.

At the same time there is also a rupture of an enterohepatic cycle of exchange bilious to - t (the last are not utilized) that provokes hydroelectrolytic diarrhea from an irritatsiy large intestine. Besides, there is an insufficiency of formation of fatty micelles that causes a steatorrhea.

The syndrome of «a congestive loop» is observed at anomaly of development of intestines (a dublikatur of a gut with a blind pocket, a diverticulum etc.) or atonies with local expansion of department of intestines. Frustration is the cornerstone staz of a food chyme and accumulation of a bacterial flora that is clinically shown by diarrhea.

Anomaly of enterocytes with an atrophy vorsin is observed at a Gee's disease, tropical to a spr, prolonged use of medicamentous therapy, deficit of immunity, parasitic diseases, x-ray radiation, etc.

The selection malabsorption can be a consequence of deficit of intestinal enterokinase, disakharidazny insufficiency (an alaktaziya, intolerance of sucrose, etc.), can be inborn or arise after the postponed intestinal infections (virus, bacterial) or disturbances of activation of monosaccharides, amino acids, fats, vitamins, etc. The sprue as manifestation of dysfunction of P. can also arise at defeat of chorion of an intestinal wall owing to inflammatory infiltration — Whipple's disease, Krone a disease (see) etc., tumoral infiltration — the Mediterranean lymphoma, lymphosarcoma (see), lymphogranulomatosis (see), a lymphoreticulosarcoma (see. Reticulosarcoma ), Shaved — Simmersa a disease, at an amyloidosis of intestines, and also at defeat of absorbent vessels most of which frequent reason the exudative enteropathy (is see. Enteropathy exudative ).

P.'s disturbances in the form of malabsorption can be observed also at Zollinger's syndrome — Ellisona (see. Zollingera — Ellisona a syndrome ), at parasitic defeats (a lambliasis, a strongyloidosis, etc.), a kistofibroza of a pancreas, a syndrome of an upper mezenterialny artery, as a result of side effect of medicines (the long use of antibiotics), cytostatic drugs, and also at some endocrine (a diabetic neuropathy, tumors of a thyroid gland etc.) and nervous (diarrhea after vagisection) the diseases causing sharp acceleration of transport of a food chyme on intestines.

For a research of digestion and absorption at children the same methods of a research, as at adult patients, with some modifications and the tools adapted for children and the equipment are used.

See also Alimentary system .

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A. M. Ugolev, G. M. Roshchina, V. A. Tsvetkova; N. Sh. Amirov, H. N. Lebedev (patofiziol.), A. L. Grebenev, E. A. Beyul (pathology), A. I. Ishmukhametov (I am glad.), A. V. Mazurin (ped).