The new coronavirus infection (COVID‑19) caused by the SARS-CoV‑2 coronavirus is rightfully recognized as a pandemic of the 21st century and poses a threat to the health of all human race. According to the World Health Organization, at October 4, 2020, were registered worldwide 34,804,348 confirmed cases of COVID‑19, including 1,030,738 deaths. According to currently available data, children accounted for 1 to 5% of patients diagnosed with COVID‑19 [4]. Children aged between 10–18 years dominated (45.9%), and patients first years of life accounted 26.1%. At the same time, over the period since the beginning of the pandemic, only a few fatal outcomes of the disease in children have been recorded in world statistics.

The high contagiousness of the SARS-CoV‑2 coronavirus, the ability for long-term replication, and tropism for the cells of the immune system provide the virus with the possibility of almost simultaneous multiple organ damage with the rapid development of complications of both the respiratory tract and other organs and systems.

The gastrointestinal tract is involved in this pathological process, representing one of the “shock organs”. In addition to common respiratory symptoms, some COVID‑19 patients experience dyspeptic disorders such as diarrhea, nausea, and vomiting. Anal swab samples from patients positive for COVID‑19, are positive for SARS-CoV‑2 nucleic acid, and SARS-CoV‑2 were isolated from stool samples from COVID‑19 patients. In addition, in both adults and children, there is a strong association between damage to the digestive system and SARS-CoV‑2 infection. This review summarizes the manifestations and potential mechanisms of gastrointestinal manifestations in COVID‑19 in children.

The aim of the work is a review of current data on the lesion of the gastrointestinal tract in children with COVID‑19 infection, and its impact on the management of patients with chronic diseases of the digestive tract.

Materials and methods of research. Was carried out the analysis of publications in PubMed, EMBASE and Web of Science systems in the period from December 2019 to June 2020, documenting the clinical course of COVID‑19 disease with gastrointestinal lesions. The following search terms are used: “COVID‑19”, “SARS-CoV‑2”, “coronavirus”, “SARS-CoV‑2 pandemic, epidemic”, “outbreak”, “diarrhea”, “gastrointestinal symptoms”, “stool”, “feces” without any language restrictions. The main source of information was full-text scientific publications of both, foreign and russian authors.

In addition, clinical cases of COVID‑19 were analyzed among patients of infectious departments of the Children’s Clinical Hospital named after Z. A. Bashlyaeva, Moscow. Clinical manifestations of the disease, data from laboratory and instrumental studies were evaluated. The most informative of them is given as a clinical example.

Objective: to optimize the diagnosis of nutritional status disorders in children born at different gestational periods from mothers with diabetes mellitus by assessing their nutritional status to predict the development of morphofunctional changes in different periods of childhood

Materials and methods: 84 children from mothers with gestational diabetes mellitus, born in the maternity hospital of the Bauman State Clinical Hospital. The assessment of children’s physical development was carried out in accordance with WHO Anthro standards (2006). A comparative analysis of the variables of children in different groups was carried out using the Student’s T-test. “Statistica 10 programm” was used.

Results: preterm children by the age of 3 are not only aligned with full-term children in terms of nutritional status, but also begin to exceed the latter in terms of body weight and length. In further age periods, their indicators do not go beyond the population. In full-term children from 4 years of age, there is a tendency to overweight and obesity.

Conclusion: the nutritional status and physical development of children born to mothers with gestational diabetes mellitus depends on the gestational age and undergoes dramatic changes in different age periods of childhood.

Relevance. Disorders of lipid metabolism are closely related to abdominal (visceral) obesity and MS in adolescence, as well as the development of early cardiovascular complications in adulthood.

The purpose of the study: to Study the features of the blood lipid spectrum in obese children, depending on the presence of signs of MS.

Materials and methods: 483 obese children (SDS BMI ≥ 2.0) (349 boys and 234 girls) aged from 5 to 16 years were. I group — 237 children (145 boys and 92 girls) with MS (IDF, 2007), II group — 246 children (140 boys and 106 girls) with obesity without signs of MS. The examination included anamnesis collection, anthropometry, blood PRESSURE measurement, ultrasound examination of the abdominal organs, biochemical examination of blood serum and lipid profile.

Results. Change in lipid profile were detected in 76.8% of children in I group and 43.9% of children in II group have 38,0% of children in I group the changes on a single metric, the 35.6% of children two, and 3.0% — three and more indicators, whereas in II group the most frequently recorded changes of only one (36,2%), at least two indicators (7,7%). In I group children, there was a significant increase in TG, the atherogenicity coefficient, and a decrease in HDL cholesterol. 53.6% of children of I group and only 8.5% of children of II group had an increase in the level of TG, and 52.8% and 24.0% of children had a decrease in HDL levels, respectively. The combination of hypertriglyceridemia and hypo-α-lipoproteidemia was diagnosed exclusively in I group (27.0%), of which boys –62.5%, girls –31.5%. In I group the frequency of hyperglyceridemia and hypo-α-lipoproteinemia regardless of age was significantly higher than II group, while in both groups a higher frequency compared to hyperglyceridemia had Hypo-α-lipoproteinemia. In II group, children under 10 years of age also had lipid profile disorders-hypo-α-lipoproteidemia in 27.8%, hypertriglyceridemia‑11,1%. An increase in the level of TG in children with signs of NAFLD in I group was diagnosed not only more often than in children without it, but also in comparison with children of II group. 46,5% of children in I group with NAFLD and 58.4% without it had a decrease in HDL cholesterol; in II group, these values were 15.7% and 17.6%, respectively. In I group, the combination of hypertriglyceridemia and Hypo-α-lipoproteidemia was observed in 28.9% of children with NAFLD and 22,5% of children without it; in II group, they were registered separately. Regardless of the group, 48,7% of children who were obese for 1–2 years and 60,1% of children with a disease duration of 5 years or more had lipid profile disorders. Violations of one component had 31,6% and 31.1% of children, respectively, the frequency of violations of two or more components as the duration of the disease significantly increased — from 17.1% to 29.0%.

Conclusions. In half of children with MS, lipid metabolism disorders are detected in the form of an increase in the level of TG (53.6%) and a decrease in HDL (52.8%), which is significantly higher than in children with uncomplicated obesity (8.5% and 24.0%). Exclusively in children with MS, there is a combination of hypertriglyceridemia and hypo-α-lipoproteinemia (27%). In 28% of obese children under 10 years of age, hypo-α-lipoproteidemia was detected, in 11% — hypertriglyceridemia, which indicates that dyslipidemia is formed in them at a young age and progresses with the duration of the disease, and its early manifestation is a violation of the excretion of tissue cholesterol due to a decrease in HDL levels. The presence of a combination of MS and NAFLD in obese children is a prognostically unfavorable risk factor for the formation and progression of more pronounced disorders of lipid metabolism. Installed deterioration of the lipid spectrum of blood serum as the duration of obesity, manifested by a reliable increase in the frequency of combined violations of two or more indicators that indicates a need for complex treatment and preventive measures at earlier stages of the disease (first 1–2 years) to reduce the risk of formation of MS and atherogenic complications in the future.

Purpose of the study. Reveal the typical disorders of nutritional status and identify characteristic disorders of the physical development of patients with cerebral palsy.

Materials and methods. The features of the nutritional status of 128 children with various forms of cerebral palsy and 20 healthy children aged 3 to 14 years were studied. Physical development was assessed using standard public anthropometric parameters: weight, height, measurement of the circumference of the upper and lower extremities, determination of the thickness of the skin-fat fold using an electronic caliper according to the Durnin-Womersly method, as well as the calculated indices of Rohrer, Pigne, Vervac.

Results. In children with cerebral palsy in compare with healthy children a decrease in the rate of increase in muscle mass, the absence of significant changes in the severity of subcutaneous fatty tissue and various variants of disharmonious types of development with characteristic anthropometric features were determined (85.9% in the main group versus 5% in the control group; Р <0.001). The most prominent disorders of the nutritional status were observed in patients with double hemiplegia and hyperkinetic form of cerebral palsy and were significant in relation to patients with hemiparetic, atonic-astatic forms and spastic diplegia (P <0.05–0.001)

According to the WHO report, in 44.0% of cases of the adult population, comorbidity is formed, which increases with the age of the patients. Meanwhile, early detection and impact on a single etiopathogenetic mechanism of comorbid diseases will not only reduce the number of diseases in one and the same patient, but also help solve the problem of polyprogmasia and disability of patients. In pediatric practice, there are isolated works devoted to the problem of comorbidity, in connection with which our studies on the study of comorbid conditions in children with cholelithiasis (cholelithiasis) are of particular interest.

Purpose. The aim of this study was to improve the early diagnosis of comorbid diseases in children with cholelithiasis for the development of therapeutic and prophylactic measures and rehabilitation of patients with cholelithiasis.

Material and methods. This study involved 146 children with cholelithiasis (GSD), selected based on the results of appeals to the consultative-polyclinic and inpatient departments of the State Budgetary Healthcare Institution of the Children’s Regional Clinical Hospital of Krasnodar. Children were divided into three groups according to the number of comorbid diseases. Group I consisted of 59 children, including 38 girls (26.0%) and 21 boys (14.4%), whose average age was 8.6 ± 4.5 years, with 3 comorbid diseases. Group II — 57 children, (29–19.7% girls and 28–19.2% boys, average age was 9.1 ± 4.4 years, with 5 comorbid diseases. Group III — 30 children (14–9.6% of girls and 16–11.0% of boys), the average age was 10.3 ± 4.7 years with 6 or more comorbid diseases.

The clinical trial protocol was approved at a meeting of the ethnic committee of the KubSMU, Krasnodar.

Conclusion. Comorbidity in children with gallstone disease is common. Among them, functional disorders of the biliary tract are in the lead. Among chronic diseases of the digestive tract, diseases of the upper sections of the digestive tract are significantly more common, and somewhat less often of the liver and pancreas. More than half of children with gallstones have comorbidity of other organs and systems, in particular, diseases of the upper respiratory tract and urinary system are more often determined. Comorbid diseases increase the severity of the condition and worsen the prognosis of the disease. Diagnosis of comorbid conditions should be thorough in order to select adequate therapy, taking into account the combination of drugs. At the same time, the environment is one of the risk factors for the development of children with gallstone disease.

Rationale. The global medical community currently studies the influence of microbiocenosis on macroorganism. The metabolome of the human gut microbiome may be a factor in the development of pathology in tissues and organs.

Objective. To improve the early diagnosis of intestinal microecology disorders in infants by determining the species composition and functional activity of the intestinal microflora to predict the health status of children born to mothers with diabetes.

Materials and methods. We studied the intestinal microbiocenosis in 60 infants aged 1–28 days, including 22 infants by healthy mothers (control group) and 38 infants by mothers with diabetes (study group). The following was evaluated: the species composition of the intestinal microbiocenosis; its functional state by concentrations of short-chain fatty acids (SCFA); the content of elastase and simple carbohydrates in feces. The species composition was studied by fecal next generation sequencing (NGS), SCFA concentration was studied by gas-liquid chromatography of acidified fecal supernatant, pancreatic elastase in fecal samples was quantified by ELISA, and fecal carbohydrate content was determined by Benedict’s test. The gut dysbiosis was measured by the biodiversity of the microbial community quantified in biology by Shannon index according to the formula:

where

and corresponds to the number of microbial species in the intestinal microbial community. Normalized Shannon index has a range of values from 0 to 1, convenient for the interpretation of the microbiocenosis condition. An increase in the biodiversity of the microbial community was associated with an increase in dysbiotic changes of the gut microbiocenosis. Statistical analysis was performed with Statistica 8.0 and MS Office Excel 2010.

Results. In children born by mothers with diabetes, the formation of microbial community at the stage of intestinal tract settlement occurs because of the increase of species biodiversity and formation of strong correlation between different classes of microorganisms, indicating a decrease of symbiont relationships of microbiocenosis with macroorganism normally mediated by intestinal epithelial cells condition and cooperation of the cells with intestinal mucosal barrier components. Due to the pronounced biodiversity and interspecies symbiosis of bacteria, compensatory mechanisms are formed in the colon for coexistence of macroorganism and microbiota. Thus, not only the butyric acid is produced in sufficient quantities but also the microbiota consumes SCFA releasing an increased amounts of iso-acids and promoting the growth of putrefactive microbial flora.

Objective: to identify markers of tissue hypoxia in Crohn’s disease in children: markers and methods for overcoming it.

Materials and methods: 27 children with Crohn’s disease (CD) aged from 1 year to 18 years were examined. Histological, histomorphometric and immunohistochemical analysis of biopsy samples of the colon mucosa.

Results: morphological markers of tissue hypoxia in CD were identified: the presence of predominantly immature fibroblasts, infiltration of the muscle plate by neutrophilic granulocytes, necrotizing vasculitis, the phenomenon of the grouping of inactive macrophages with each other with the formation of multinucleated cells, which are the precursors of multinucleated granules according to the Pigorov-Lanhans type

Conclusion: in identifying markers of tissue hypoxia, leading to a worsening prognosis of the course of CD and the development of complications, it is necessary to determine the tactics of accelerated “step-up” therapy using anticytokine drugs and use the method of hyperbaric oxygenation.

The aim of the study was to study the course and clinical manifestations of chronic gastroduodenal pathology (CGDP) in schoolchildren.

Materials and methods. Clinically examined 286 children and adolescents from 6 to 15 years old with СGDP. The research methods included collection of anamnestic data, instrumental and functional (esophagogastroduodenoscopy, pH-metry), clinical and laboratory (general blood analysis, coprology), and Helicobacter pylori infection was tested by respiratory test and fecal immunochromatographic test.

Result. Studies have shown that the main clinical manifestations of СGDP in children were dyspeptic syndrome, vegetovascular dysfunction, and pain syndrome, against the background of objectively visible signs of anemia. Symptoms were more characteristic in patients with СGDP from vegetovascular dysfunction: loss of appetite (83.6%), fatigue (83.2%), recurrent headaches (62.2%), and sleep disturbances (59.1%). Among dyspeptic disorders, unstable stools (85%), periodic nausea (57.7%), belching (56.6%), and a feeling of heaviness in the epigastric region after eating (56.3%) prevailed. Clinical symptoms more pronounced in children with chronic gastritis.

Conclusion. For schoolchildren with CGDP, vegetovascular dysfunction (98.9%) with severe dyspeptic disorders (100%) and pain (79%), against the background of objective signs of anemia (53%), is more characteristic. In adolescents is more often a less symptomatic.

Cholelithiasis (cholelithiasis) has become increasingly common in childhood. Currently, the features of the clinical course have been studied, the criteria for the diagnosis and prevention of cholelithiasis in children have been worked out. However, the features of metabolic disorders are still not studied, among which not the least role in the genesis of the formation of gallstones is played not only by the exchange of lipids, but also carbohydrates.

The main role in the regulation of carbohydrate metabolism is played by insulin. The process of production of insulin in the body in the blood serum fully reflects the concentration of C-peptide. The ratio between insulin and C-peptide is not always constant. It may shift in one direction or another against the background of diseases of the internal organs, including the GI tract.

The analysis for C-peptide and insulin allows you to identify not only hypo — or hyperglycemia, but also to determine insulin resistance, calculate the HOMA index and, accordingly, make a forecast for the development of dyslipidemia. In this regard, it was of interest to study the state of carbohydrate metabolism (glucose, insulin, C-peptide) in children with cholelithiasis.

The purpose of the study. To improve the early diagnosis of the complicated course of cholelithiasis by studying the features of carbohydrate metabolism for practicing therapeutic tactics and preventive measures.

Materials and methods. Under our supervision at the Department of Pediatrics infectious diseases, faculty of postgraduate education of physicians of the Russian national research medical University of Minzdrav of Russia (head.DEP. — M. D., Professor L. A. Kharitonov), city children’s polyclinic № 122 (chief doctor — PhD Bragin A. I.) were 140 children aged from birth to 15 years. Carbohydrate metabolism was studied in 140 children of the study group. Boys were 62, average age 10.0±4.9, girls were 78, average age 8.8±4.5. The parameters of serum glucose, insulin, and C-peptide were evaluated. The Homeostatic Model Assessment (NOMA) Insulin resistance Index will be calculated using the formula: NOMA-IR = (fasting plasma glucose (mmol/l) x fasting serum insulin (mkED / ml))/22.5 (Cuartero B., 2007). The physical development of children was evaluated according to WHO standards (2006) using the WHO Anthro Plus program (2009). We evaluated the values of the average values of body weight(MT), height (body length, DT) and body mass index (BMI) in five groups of newborns. The nutritional status was determined by the values of the Z-score value. Mathematical calculation of the results was carried out on a personal IBM — compatible computer using the statistical program Statistica 6.0.

Results. In children with GI, there was a tendency to increase the NOME index, both in frequency and in absolute terms, from the age of 8 and persisted until the age of 15(0,65±0,14;0,42±0,04; 4,89±1,12; 4,86±0,44; according to the age periods, p< 0.005).

Conclusion. Thus, disorders of carbohydrate metabolism in children with GI depend on the child’s age and body weight. In overweight children, an increase in C-peptide, insulin, and the resistance index was observed, which suggests that children with GI occurring against the background of overweight at the age of 8–11 and 12–15 years are threatened by the formation of metabolic syndrome, diabetes mellitus, and arterial hypertension.

The aim of this work was to study the morphology of adhesion formation under the influence of ozone in the experiment, as well as the development of prediction criteria and methods for correcting increased adhesion in children.

Materials and methods. Experimental studies were carried out on 36 rabbits «Shinshilla» with a body weight of 0.7–1.2 kg., of which 12 animals were included in the control group, which did not carry out ozonation of the abdominal cavity. The main group consisted of 24 rabbits, which were divided into two subgroups (12 animals in each subgroup), which ozonized the abdominal cavity with an ozone-oxygen mixture. In order to study the prognostic value of the acetylation phenotype in the formation of intraperitoneal adhesions, 67 children with symptoms of adhesive intestinal obstruction were examined.

Results. The results of experimental studies showed that in animals of the control group there was the formation of massive adhesions. The basis of adhesions is connective tissue with a significant number of fibroblasts, blood vessels and collagen fibers. In animals of the main group, sharp inhibition of adhesion formation, a delay in the differentiation of fibroblasts and inhibition of their synthetic function were revealed. Acetylation phenotype was determined in 58 patients with appendicular peritonitis. 30 (51%) children turned out to be slow acetylators, and in 28 (49%) patients the phenotype of fast acetylation was established. The results of the study allowed us to isolate fast acetylators as a risk group for excessive adhesion formation and timely start therapeutic and preventive measures.

Surgical diseases of the abdominal cavity of the neonatal period manifest similar symptoms, but require a different treatment strategy. In most cases, when conducting special sonographic studies, there are signs of the cause of the symptoms.

Purpose: to create and estimate surgical tactics depending on the revealed sonographic signs of gastrointestinal pathology in newborns.

Methods: were examined sonographically 1557 newborns with symptoms of congenital intestinal obstruction (CIO), hypertrophic pyloric stenosis (HPS), necrotizing enterocolitis, meconium obstruction, functional disorders (FD) of the GIT: vomiting, abdomen distention, absent meconium. The surgeon’s tactics were created depending on the revealed sonographic signs. Two groups of operated patients were compared: 1st (n = 55) used special ultrasound methods for initial assessment of the newborn, 2nd (n = 44) ultrasound was not performed. The groups the timeliness of diagnosis and postoperative lethality were estimated.

Results: in 86.0% of newborns, symptoms were associated with FD. All types of surgical pathology of the GIT had sonographic signs. According to the ultrasound, the next situations were identified: surgery without further investigations (volvulus, peritonitis); additional examinations are needed to clarify the diagnosis (CIO); additional investigations are not required (HPS, FD). In the 1st group, the diagnosis was significantly more often made in time, less lethality was observed than in patients of the 2nd group (p <0.001; p <0.026, respectively).

Conclusion: sonographic signs during the initial examination of a newborn with symptoms of acute diseases or congenital defects of GIT contribute to the timely diagnosis and allow to determine further tactics of investigation and treatment.

The article is devoted to the experience of surgical treatment of pathology of the pancreas at the Center for the Treatment of Developmental Anomalies and Diseases of the Hepatopancreatobiliary System in Children on the basis of the Children’s City Clinical Hospital No. 13 named after NF Filatova: annular pancreas, acute and chronic pancreatitis, tumors and cysts of the pancreas. From 2016 to 2020, more than 267 reconstructive interventions on the pancreas were performed, including longitudinal and transverse pancreatojejunoanastamosis, pancreatoduodenal resection, cystoenteroanastamosis, sectoral and total resection of the pancreas. In the postoperative period, the most severe complication in this category of patients was arrosive bleeding, which is the main cause of all deaths after surgery.

The purpose of the research. The optimization of the method electrocardiogram’s interpretation (ECG) for diagnosis and prognosis of fatal cardiogenic situations among children and teenagers depending on the severity of myocardial electrical instability.

Materials and methods. The authors propose to use a modified method for assessing the “electrical quality of the heart”, proposed by A. N. Volobuev and co-authors in order to assess the electrical instability of the myocardium among children and teenagers. There is a formula which helps to estimate the index of “electrical quality factor of the heart” among children and teenagers: D=(aR/aT):(QT/QRS), where D is the index of “electrical quality factor of the heart”, aT and aR is the amplitude of R wave and T, QT — QT interval, QRS — interval, QRS. ECG was recorded in 12 leads, ECG assessment was carried out according to generally accepted rules.

Results. Based on the analysis of 234 ECG of children and teenagers from the neonatal period to 18 years, the criteria of the average value of the index of “electrical quality factor of the heart” (D) were defined, D =1,09 +/- 0,03. It is proved that the value of the index “electrical quality factor of the heart” does not depend on the sex and age of the child. There was a decrease in the index of “electrical quality factor of the heart” was revealed among children with the lengthening of the QT interval.

Conclusion. The index of “electrical quality factor of the heart” in pediatric practice allows to predict the risk of fatal cardiogenic conditions, to develop tactics of dynamic monitoring of patients, to evaluate the efficiency of treatment. When D<0.55 it is possible to predict high risk, at a value of 0.55≤D<0.80 — average risk, and at D≥0.80 — low risk of fatal cardiogenic conditions among children and teenagers.

Stress and adjustment disorders are a significant reason for the exponential growth of most chronic noncommunicable diseases. The stress reaction is a genetically determined nonspecific adaptation mechanism, however, with an excessively intense and prolonged course, it becomes a factor in the pathogenesis of many somatic diseases, immunodeficiencies, the cause of a decrease in the threshold of resistance to infectious diseases. The presence of similar mechanisms of adaptation reactions and the development of increased meteosensitivity made it possible to distinguish the «adaptation-meteotropic syndrome». Various methods of treatment and prevention of adaptive disorders have been proposed, including medication and non-medication. Most of the provisions of the theory of the body’s reactivity have been dynamically developed and still have important practical applications.

Rationale. In recent decades, the number of children has increased with chronic diseases characterized by systemic lesions and frequent involvement of the digestive tract, complicating the diagnosis and choice of therapeutic strategy. As the number of diseases in a child increases, the cost of diagnosis and treatment grows exponentially. Given the comorbidity, physicians prescribe multiple medications (polypragmasy), which can lead to adverse effects.

First-line physicians often lack the knowledge about the clinical and therapeutic features of managing comorbid patients. Practical healthcare lacks a “team strategy” for these patients’ treatment, leading to ineffective management of patients by subspecialist physicians significantly affecting the prognosis of the disease and even the life of the patient. The “narrowly specialized” model of medicine is inadequate. An integrative model of healthcare should replace it. Meanwhile, there are currently no international and national recommendations for this problem focused on the needs of “first line” physicians, including pediatric specialists. All the above urged us to provide an in-depth study of this problem in the current literature.

The aim of this literature review was to study the frequency and structure of comorbid conditions in pediatric practice to optimize their diagnostics, therapeutic tactics, and the development of preventive measures.

Results and discussion. The structure of comorbidity differs in different age categories. The comorbidity in children depends mainly on the genetically programmed disorders of metabolism and functioning of cells and tissues, disorders of nutritional status, infectious factors, and interference (pathogenetic relationship of diseases). Understanding the etiology and pathogenesis of comorbid conditions in children, one should identify the Chronic Noncommunicable Diseases formation risk groups and develop a plan for their prevention. Prevention of comorbid chronic noncommunicable diseases should be carried out as part of the “full life cycle”, from the antenatal period (the health of the future mother) to adolescence, using an integrative approach (impact on the child’s physical and mental condition) with teaching patients and their parents the basics of proper diet, healthy lifestyle, sufficient physical activity, and positive attitude.

Knowledge of causal and complicated comorbidity will contribute to the development of optimal diagnostic tactics for the search of the root cause and the selection of efficient therapy for trigger disease, which will avoid polypragmasy. The pediatric physician should play the primary role in the follow-up of comorbid patients. It is necessary to expand the competencies of the pediatric physician with the revision of approaches to his professional training.

The development of clinical guidelines and algorithms for the management of comorbid patients and the collaboration of physicians of various specialties (formation of multidisciplinary teams), while observing the principle of “one doctor”, will significantly improve the quality of medical care for comorbid patients, which will improve their quality of life and significantly decrease the cost of rehabilitation measures.

Ehlers-Danlos syndrome is based on hereditary systemic dysfunction of the connective tissue caused by impaired collagen synthesis. Depending on the individual mutation, the clinical manifestations of the syndrome can range from mild to life-threatening. The result of a violation of collagen synthesis is the proliferation of elastic fibers, loss of compactness and disorientation of collagen fibers, fragility of the vessel wall and expansion of their lumen. And, given that connective tissue fibers are present in almost every organ, the manifestations of Ehlers-Danlos syndrome are polymorphic and generalized, which often complicates the verification of this disease. The most clinically important is the Ehlers-Danlos Syndrome IV (vascular) type, which occurs as a result of mutations in the COL3A1 and COL1A1 genes and manifests itself in a tendency to spontaneous rupture of large arteries and hollow organs (intestinal perforation, strokes, rupture of the spleen, etc.), poor wound healing, fragility soft tissues, impaired hemostasis. The article describes our own experience of treating 4 patients with spontaneous ruptures of internal organs, including those of a recurrent nature.

Relevance: Hereditary connective tissue disorders (HCTDs) are a heterogeneous group of diseases caused by mutations in the genes of extracellular matrix proteins or proteins involved in connective tissue morphogenesis. Mutations of these genes lead to the development of many HCTDs. The best known monogenic variants of HCTDs are Marfan syndrome, Ehlers-Danlos syndrome, and osteogenesis imperfecta. Inheritance is mainly autosomal, dominant or recessive. Although the first signs of HCTDs develop as early as the first year of life, it takes several years for pediatricians and specialty physicians to make the diagnosis of connective tissue dysplasia because of a lack of clear methodological approach. The disease is multi-morbid and may manifest under gastroenterological, cardiological, nephrological, or respiratory masks.

Aim: to present a clinical case of Ehlers-Danlos syndrome with multiorgan digestive, heart, kidneys, and other lesions.

Material and methods: the case history is presented of a 15‑year-old boy with Ehlers-Danlos syndrome, classic type.

Discussion: defective collagen increased the connective tissue extensibility affecting function of many body organs and systems, including gastrointestinal, biliary, and urinary tracts, musculoskeletal and cardiovascular systems. Small developmental anomalies led to functional (motor) disorders, which contributed to the chronic organic pathology (erosive reflux esophagitis, gastroduodenitis, cholelithiasis, proctosigmoiditis, chronic pyelonephritis, or chronic sinusitis). Given the multi-organ character of the lesions, the progredient course of bone and joint changes, and early development of disability, the prognosis for the health of this child is serious. A multidisciplinary approach is important to plan the follow-up (with orthopedist, gastroenterologist, cardiologist, ophthalmologist, and nephrologist). Timely rehabilitation, therapeutic physical training courses, massage, metabolic, and anti-relapse treatment are necessary to slow down the progredient course of the hereditary connective tissue disease.

Relevance. Parasitic invasions of the biliary tract, such as opisthorchiasis, are one of the significant causes of the formation of pigment calculi in the gallbladder, which is known in territories endemic for these diseases. However, visualization of the dynamics of the development of the pathological process using ultrasonography does not allow differentiating gall stones with a high degree of accuracy from the stages of development of the feline fluke. In the absence of an epidemiological history, this invasion can proceed under the guise of gallstone disease, which leads to an unjustified surgical intervention with the removal of a practically healthy gallbladder from a child. Before surgery, differentiation of calculi in the gallbladder from the stage of opisthorchiasis will significantly improve the quality of life of the child.

The aim of the study was to demonstrate a clinical case of opisthorchiasis invasion in a child in a non-endemic territory, proceeding under the guise of cholelithiasis.

Material and methods: the case history of a 17‑year-old girl with opistochiasis invasion is presented.

Discussion. Parasitic invasion (opisthorchiasis) caused the formation of «calculi» of the gallbladder in the child. Not every hyperechoic formation of the gallbladder with the presence of a sound track is a «calculus». Timely diagnosis of the cause of cholelithiasis is important, as well as timely treatment of parasitic invasion to avoid relapse of the disease and errors in treatment, including surgical treatment.

Relevance. Obesity is one of the most pressing problems of modern Pediatrics.

The purpose of the study: to study the morphofunctional state and features of the composition of the stomach microflora in obese children using and comparing various endoscopic methods of biomaterial sampling.

Materials and methods. 164 children aged 7 to 17 years were examined. The main group — 85 obese people, the comparison group‑79 children with normal body weight and digestive diseases. Esophagogastroduodenoscopy was performed, followed by pathomorphological, bacterioscopic, and microbiological examination of the biological material. In addition to sampling the biopsy of the antral part of the stomach with a sterile farcept, 40 patients were additionally taken from the wall biological material by obtaining a smear from the mucous membrane with the author’s endoscopic probe.

Research result. The frequency of inflammatory changes IN the gastrointestinal tract was high in both groups and did not depend on body weight. In the main group, duodeno-gastric reflux (DGR) (32–38% и 9–11%, p<0.05) and cardia insufficiency (46–54% и 36–46%, p>0.05) were more often diagnosed. With an increase in the degree of obesity, the total number of refluxes increased — from 45–53% at grade I to 64–75% at grade IV, and DGR — from 12–14% to 49–58%, respectively. The most frequent localization of inflammatory changes in children of the main group was the antral (43–50%), less often — the stomach body (26–30%), while in the comparison group the body was more often affected (42–52%) and less often the antral (24–30%). In most children, regardless of the group (56–66% и 51–65%), chronic gastritis of moderate activity was registered. A high degree was significantly more often detected in the comparison group (14–16% and 24–30%, p<0.05), while a weak degree was detected in children of the main group (16–19% and 5–6%, p<0.05). In children of the main group, H. pylori (HP) was more often detected (45–53% и 25–32%, p <0.05), while 1 degree of contamination was more often determined (43–51% и 39–48%), while in the comparison group — 3 degree (15–18% и 24–30%). With increasing degree of obesity increased frequency of contamination from the antrum, HP — from 36–42% when I level up to 60–71% in IV degree of obesity. When using the application in HP+ children of the main group were more often sown opportunistic pathogens in a more diverse species composition and a more pronounced decrease in planting indigenous microflora, and regardless of HP significantly more prevalent growth of E. coli and Candida. In the presence of DGR, independently of the group, a significantly higher growth of fecal flora and a more pronounced decrease in the seeding of indigenous microflora was obtained.

Conclusions.

1. A high frequency of inflammatory and functional disorders in children, regardless of body weight, was established.

2. Motor-evacuation disorders in children with obesity recorded often (63% and 43%). As the degree of obesity increases, their frequency increases. DGR in obese children is recorded significantly more often (38% and 11%, p<0.05).

3. Children with obesity have a higher frequency of registering a low degree of activity of chronic gastritis, and children with normal body weight have a high frequency. The degree of activity of the inflammatory process does not depend on the degree of obesity and the duration of the disease.

4. HP in obese children is detected 1.5 times more often than in children with normal body weight; the predominance of low (1 degree) contamination is characteristic. With an increase in the degree of obesity, the frequency of HP contamination increases (from 42% at grade I to 70% at grade IV obesity).

5. HP-positive children show significantly higher growth of E. Faecium, S. viridans and Streptococcus faecalis and lower seeding of Lactobacterium and Bifidobacterium.

6. DGR contributes to a more pronounced decrease in the growth of indigenous microflora, only Streptoco