MINISTRY OF HEALTH OF UKRAINE

ODESA NATIONAL MEDICAL UNIVERSITY

Departments of Pediatrics №2

	CONFIRMED by

Vice-rector for research and educational work

____________________ Svitlana KOTYUZHYNSKA

September 1st, 2022	

METHODOLOGICAL RECOMMENDATIONS
on LECTURE for students

International Medical Faculty, сourse  4

Educational discipline "PEDIATRICS"

Approved 
at the meeting of the department of Pediatrics №2
Protocol No. 1 dated 28/08/2022

Head of the department of Pediatrics №2    __________________              Tetiana STOIEVA 
                                                                                Signature                                      

Authors: 
Head of the department of Pediatrics №2, MD, PhD in Pediatrics, DM, Professor Stoieva Tetiana
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Prokhorova Svitlana
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Titkova O. V. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Portnova O. O. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Vesilyk N. L. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Godlevska T. L.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Fedin M. V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Jagiashvili O. V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Reshetilo O.V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Soboleva H. B.
Assistant of the department of Pediatrics №2 Bratkova L. B.

Lecture №4  «Functional gastrointestinal disorders (FGID)" - 2 hours.
1. Relevance of the topic.
Functional gastrointestinal disorders are the most common disorders of the gastrointestinal tract in children. In infants and children the first two years of life the most frequent regurgitation syndrome, intestinal colic and functional constipation, and older children - cyclic vomiting syndrome and functional dyspepsia. Such violations of the digestive system related to the anatomical and physiological characteristics of the child, which adapts to the environment and nutrition. Functional disorders can be mild and almost do not bother parents, or violate the child's condition and worsen the quality of life of the whole family. Such conditions usually require some corrective measures regarding the dietary habits and the care of the child. If symptoms increase, accompanied by a violation of the physical development of the child, the phenomena of hypertrophy, should think about the baby's organic disease of the digestive system, which requires careful laboratory and instrumental studies of the child with the use of modern medical technology.
    2. Goal of the lecture:
         - Educational: to acquaint students with modern ideas about etiology and pathogenesis, classification, clinical course, and additional methods of diagnostics of cyclic vomiting syndrome, functional dyspepsia, intestinal colic and vomiting in children, the student should be able to diagnose this pathology, prescribe treatment and to plan preventive measures.
         - Educative: read s contribution of scientists to the study of functional gastrointestinal disorders in children, to be able to bring the parents of treatment is the prevention expediency activities for functional gastrointestinal disorders in children.
    3. Plan and organizational structure of the lecture.
№	The main stages of the lecture and its contents	Goals of abstraction levels	Type of the lecture.
  Equipping  of lectures	The distribution of hour	
1	2	3	4	5	
І

1.

2.

ІІ.
3.

ІІІ.
4.
5.
6.	Preparatory stage.
to acquaint students with modern ideas about etiology and pathogenesis, classification, clinical course, and additional methods of diagnostics of cyclic vomiting syndrome, functional dyspepsia, intestinal colic and vomiting in children, the student should be able to diagnose this pathology, prescribe treatment and to plan preventive measures.
Diseases of the digestive system are the second most common among childhood diseases. Over the last decade has changed the structure of gastrointestinal diseases in the direction of functional pathology and there is "rejuvenation" of some organic disease that requires careful differential diagnosis

The main stage.
The presentation of the lecture material on the plan:
1. Intestinal colic.
2. Regurgitation syndrome
3. Cyclic vomiting syndrome.
4. Functional dyspepsia.

The final stage.
Summary of the lecture.
General conclusions.
A lecturer at the possible questions. Tasks for self-study.	І

ІІ

ІІІ	

According to the publication, "Methodical planning recommendations, lecture preparation and analysis

List of literature, questions, tasks.	

5 %

90%

5 %	

    4. The content of the lecture material:
Definition. Throughout the period of the study definition of GI risk factors varied according to the social perspectives of the disease, scientific data, as well as training of clinicians and personal prejudice. Even today, GI risk factors are considered by many to be less than a confirmed diagnosis, the diagnosis of a pathological basis, and patients s FD of GI tract can be determined for the symptoms they find it is very real. It emerged after the previous discussion about the impact of the dualistic principles that separate the organic and functional disorders, which are often considered psychiatric or remain without definition [Drossman, 2005]. However, with the passage of time and the publication of each new article has definitely changed from the absence of organic disease to mental illness through stress disorder to the motor, and with the Rome III criteria - to the functioning of the gastrointestinal disorders [Drossman, 2006].
But there is still a need for a constructive working definition to approach these disorders from a scientific point of view, and without prejudice. To achieve this in the Rome criteria IV, a new definition was established by the Board of Directors and the spread between the heads of the Roman committees criteria IV, to get feedback for editing i final approval.
The agreed definition is as follows:
Functional disorders of the gastrointestinal tract are disorders of the interaction between the intestine and brain [Drossman, 2016]. This group of diseases classified for gastrointestinal symptoms, tied with any combination of the following functions: motor skills, violation of visceral hypersensitivity, altered mucosa and immune function, changes in intestinal microbiota, the robot changed the central nervous system (CNS).
According to experts, this definition corresponds to the most modern sense of several pathophysiological processes, which separately or together determine the characteristics of symptoms that characterize the Roman classification of disorders. According Drossman [2016], this definition is easy to understand and accept the doctors, scientists, regulatory agencies and the pharmaceutical industry, as well as patients.
To complete the understanding of the need to bring the definition of FD of GI, which was agreed by Rome criteria [Drossman, 2006]. Accordingly, the definition of "functional gastrointestinal disorder - a combination of diverse gastrointestinal symptoms without structural or biochemical abnormalities." In this earlier Drossman [2005] defined "functional gastrointestinal disorder as a psychological disorder or absence of organic disease." Accordingly, with this definition, belong to the functional state of the disease, when it is not possible to determine the morphological, genetic, metabolic and other changes, which could explain the observed clinical symptoms.
You feel the difference between the above definitions?
Thus, the new system of classification is an important component for the ordering of these disorders, but effective management requires a biopsychosocial approach that takes into account the variability and complexity of patients with these disorders.
Etiology and pathogenesis. Functional gastrointestinal disorders (FGID) defined self nozoologicheskoy form, are considered as psychosocial disorders. However, this definition, adoption of the Rome criteria in 1999 -2006 y.y., Contrary to the high comorbidity, which is not only in adults but also in children [DV . Pechkurov et al 2014] At this time formed a new biopsychosocial model DF GI tract, including the number of determinants: dysmotility, visceral hypersensitivity, changes in mucosal immunity and inflammatory potential. A fundamentally new in this concept is the fact mucosal homeostasis, by which is meant the ability of the mucosa to ensure stability. In this regard, the definition varies FD of GI, approaches to diagnosis and treatment. The biopsychosocial model considers some infectious and non-infectious factors such as comorbid risk factors gastrointestinal tract, therefore an important component of the treatment of disorders will be the identification and elimination of these factors. There is no doubt poly etiology DF GI tract in children. The main thing in their pathogenesis are considered a violation of the motor function and visceral sensitivity, but they are often joined secretory changes, the suction function of the microflora of the gastrointestinal tract and inflammation of the mucous membrane potential.
The biopsychosocial model (system) of the FD of GI, is a key event that brings together health and disease into one occurred in 1977, when they were published robots George Engel [1977]. These articles have influenced many researchers and clinicians by giving them search out the specific fundamental biological reasons for a more integrated, the biopsychosocial model of disease development [1977] G. Engel, therapist and psychoanalyst, suggested contribution of modern holistic theory (now called the "system"), suggested that the disease is the result of biological, social and psiholo¬gicheskih subsystems that interact at various levels, and the combination of these subsystems defines vzimodeystvuyuschih Drossman disease [2016].
Later, in the late 1990s, new clinical and translational methods to treat intestinal afferent signaling, neural stimulation and recording, assessment of pain perception, assessment ligament kle¬tkami between nerve and immune system functions, as well as brain imaging, have improved our understanding of the relationship of brain and intestine, leading to the concept of "kishechnik- axis of the brain." The term "neyrogastroenterologiya" was mentioned in the Rome II criteria in 1999 in the sections of the fundamental science of physiology i [Kellow et al. 1999; Wood et al 1999] as a means to display a new research field. In fact, the displays neyrogastroenterologiya struk¬turnye and physiological components of the biopsychosocial model, and later was a clinical research and their use. Using neyrogastroenterologii in studies conducted study provides regularity intestine interact with the brain. Over the past two decades, the term used by many scientific and research communities, as well as in magazines and book publications.
At an early age genetics, socio-cultural factors and environmental factors can negatively affect the psychosocial development in terms of personality traits, susceptibility to life stress, psychological state, as well as knowledge and coping skills. These factors also influence the acceptance for bowel dysfunction: abnormal motility or sensitivity, changes in the immune dysfunction or inflammation of the mucous membrane, the microbial environment and the impact of food and nutrients. Furthermore, these changes of brain and intestine communication mutually influence on the expression of the CNS.
Thus, it is believed that the DF GI are the product of interaction between psychological factors and altered gut physiology through the axis of "brain-gut» [Mayer et al. 2014] Human Genetics and interaction with the environment later influence susceptibility to disease, their phenotypic expression, as well as the attitudes and behavior of the patient (including an appeal for medical help). A study of families and twins have shown that genetic component to IBS and other possible risk factors GIT with some polymorphisms and candidate genes may influence the physiological functions, including motor function, membrane permeability and visceral sensitivity [Camilleri et al. 2011].
Although psychosocial factors are not necessary for the diagnosis, they affect the physiological functioning of the gastrointestinal tract through the axis "brain - gut" (motility, sensitivity barrier function), and are modulators of pain and the patient's behavioral symptoms, and ultimately affect the choice of treatment clinical results. In assessing psychosocial factors, clinicians should consider four general observations:
    1. Psychological stress or emotional response to stress enhances gastrointestinal symptoms and may contribute to the development of the FD of GI. This occurs in healthy people and patients with structural diagnoses and well demonstrated in patients with development of functional gastrointestinal disorders, is a common example of IBS or post-infectious dyspepsia [Collins et al., 2012]. Researchers see a high correlation of psychosocial comorbidities, life stress and abuse among patients s FD of GI tract, which leads to worse results.
2. Psychosocial factors alter the course of disease and behavior, such as treatment for medical help. Patients with gastrointestinal risk factors show a clinically significant psychological distress. This is due to the fact that psychosocial trauma (eg, experienced sexual or physical abuse) are more common in specialized medical centers than in a medical emergency, which can reduce the pain threshold in the symptoms, and is associated with poorer clinical outcomes [Drossman, 1996]. These factors can be weakened or relaxed adaptive coping skills and social support. Thus, this means that psychosocial reaction of family, society and culture can also have a palliative effect on the course of the disease.
    3. Functional gastrointestinal disorders may have psychosocial consequences. What - any chronic disease has psychosocial consequences on the overall well-being, the daily status of the function and sense of control over simptoma¬mi, as well as the consequences of the disease from the perspective of the future operation of the robot at home. This is understandable from the point of view of quality of life related to health.
    4. Psychosocial consequences of the disease, namely, emotional stress and not enough adapted cognitive function, may return back to perpetuate and exacerbate symptoms. Patients with severe symptoms may develop painful pessimism and helplessness, as well as the election of concern and vigilance over their symptoms, which leads to a visceral anxiety, lower the threshold of sensitivity and cause a feeling of poor self-esteem. In these cases, behavioral intervention to help resume the psychological substrate of improved health.
	It should also be noted that the various physiological processes may lead to gastrointestinal symptoms, and if they predominate, then to functional gastrointestinal disorders.
	Abnormal motility. Disorders of the gastrointestinal motility can cause symptoms of nausea, vomiting, diarrhea, severe abdominal pain, urinary incontinence, etc. Furthermore, in healthy people, and even more in patients GI FF s, strong environmental stress or emotions golov¬nogo through brain gut axis and can lead to frustration moto¬riki throughout the gastrointestinal tract. Patients with gastrointestinal DF have a greater response to stress factors motility as compared to healthy individuals [Camilleri et al. 2011] However, these motor reactions only partially correlated with symptoms, and are not sufficient to explain the complaints of chronic or recurrent abdominal pain.
	Abnormal motility. Disorders of the gastrointestinal motility can cause symptoms of nausea, vomiting, diarrhea, severe abdominal pain, urinary incontinence, etc. Weak link pain with gastrointestinal motility and a large number of gastrointestinal tract (eg, a functional chest pain, functional dyspepsia - epigastric pain, IBS, etc.) is explained by the concept of visceral hypersensitivity [Mayer et al. 1994].
	These patients have a lower pain threshold through the balloon intestine stretching (visceral hyperalgesia), or they have an increased sensitivity even during normal bowel function (eg, allodynia). Visceral hypersensitivity may be enhanced in patients with FD of GIT: repetition reusable balloon distention in the colon results in a progressive, although short-term increase in pain intensity in healthy people and for longer periods in patients with FD of GIT. Hypersensitivity and sensitization can be enhanced at all levels of the axis of "brain-bowel brain through the factors listed below.
	O people, especially in patients  with FD of GIT, strong environmental stress or emotions through brain gut axis and can lead to frustration motility throughout the gastrointestinal tract. Patients with gastrointestinal DF have a greater response to stress factors motility as compared to healthy individuals [Camilleri et al. 2011] However, these motor reactions only partially correlated with symptoms, and are not sufficient to explain the complaints of chronic or recurrent abdominal pain.
Immune dysregulation, inflammation and barrier dysfunction.
Work on post-infectious IBS and dyspepsia was mated with an increased interest in the permeability of the mucosal membrane through changes of tight junctions, altered intestinal flora and the immune function of the mucous membrane. These ties are expanding access to intraluminal antigens in the submucosa, associated with mild activation and increased matotsitov release - inflammatory cytokines (Ohman, Simren, 2010). These actions have changed the sensitivity of receptors in the intestinal mucosa mienterichnom plexus, providing visceral hypersensitivity. facilitating factors include genetics, psychological stress through the activation of mast cells, as well as changes in receptor sensitivity in the intestinal mucosa mientericheskom plexus. This is enhanced by bacterial environment or direct infection.
Food, diet and intraluminal factors. The recent addition of understanding about the FD of GIT concerns food and diet, as well as their relationship with the intestinal microbiota. Specific changes in the diet, such as oligo-, di- and monosaccharides and polyols with low fermentation or tissue limitation in some patients, produce useful results can reduce osmotic effects of any changes in the intestinal mucosa. Nevertheless, none of the diet does not matter, and treatment must be individualized. In addition, the diet provides a substrate for fermentation, and after that the composition of the intestinal microbiota is replenished with IBS, the relationship between food and diet, the composition of the microbiota and fermentation products can play a huge role in the pathogenesis of IBS. It is worthy of attention because there is a discrepancy between the views of patients and physicians about the food effect on the FD of GIT symptoms while patients find food effect is not relevant.
The axis of "brain-gut". Axis "brain-gut" a neuro-anatomical substrate in which only describes psychosocial factors affect the GI and vice versa. Communication between the brain and the gut is a complex integrated circuit, which transmits information from the emotional and cognitive centers (which contribute to the thoughts, feelings, memories, and the regulation of pain) of the brain using neurotransmitters (software) for the peripheral gastrointestinal functioning, and vice versa [Gaman, Kuo, 2008]. For the structure there are direct links between the CNS and visceral mientericheskim plexus to the muscles and other structures of finite bodies that affect sensory, motor, endocrine, autonomic, immune and inflammatory function [Jones et al., 2006]. Thus, emotions such as fear, anger, anxiety, painful stimuli and physical stress can slow gastric emptying and intestinal transit. They can also stimulate colonic motor function by reducing the duration of the colonic transit, increased contractile activity, induction of bowel movements and diarrhea symptoms. Furthermore, psychological stress can break the pain threshold and degrade intestinal secretory and mucosal barrier function, which is associated with the movement of products of bacterial cells, leading to gastrointestinal pain and diarrhea, as in the case of IBS. On the other hand, enhanced motility, visceral inflammation and damage may enhance upward vistse¬ralny path and affect the parts of the brain, which leads to more pain and promotes mental functioning change, including anxiety and depression. In fact, mutual relations, called the axis of "brain-gut" is a neuro-anatomical and neurophysiological substrates for clinical application systems or biopsychosocial model [Mayer et al., 2015].
Thus, in the biopsychosocial model of GI risk factors are two closely interacting functional level, each in their own way to be in contact with the environment: the central nervous system and mental health on the one hand, and the digestive tract - the other [AN Akopian et al., 2014]. The nervous system through the mental sphere to be influenced by social factors, and gastrointestinal tract - alimentary. At the level of the mind is largely determined exactly which nutritional factors will be presented to the digestive organs and the digestive tract condition generates is not only the nature of the information that comes to the nervous system, but also nutrient flow required for their functioning, as, indeed, and for the existence of the body the whole
Therefore, mucosal homeostasis is itself a necessary condition for ensuring the homeostasis of the system, albeit controlled na¬hoditsya higher nerve and humoral factors. At the same time, a violation of the regulatory chain can lead to gastrointestinal risk factors, and these disorders sometimes develop both at the central and at the peripheral level. For example, they can be the cause of visceral hypersensitivity, it is due to dysfunction of intestinal microbiota, which leads to a respective reaction system ner¬vnoy gipermotoriki development. It is also possible inadequate reaction of the nervous system to the information that comes from the periphery about the condition of the digestive system with the development of the same reaction and inadequate hypermotor her reflection in the psycho-emotional sphere.
Thus, the result biopsychosocial model, as discussed, is that severe psychosocial factors are factors that determine the use of medications in hospital visits, functional ability, loss of working hours and health care expenditures. All these factors can be considered and potentially amended physician the ability to listen, to participate effectively and possess communication skills, as described below, regardless of the diagnostic status. The model determines the need for a comprehensive approach to the correction of the FD of GIT with the obligatory account of social factors, the nature of power, psycho-emotional sphere, the vegetative status and the actual condition of the digestive organs and disorders of mucosal homeostasis. With this concept also implies the evidence of generalized nature of the pathological process, the involvement of all gastrointestinal tract, albeit in varying degrees.
Classification of GI risk factors and Rome criteria IV. Classification of GI risk factors, the development of which was initiated by the Organization «Rome Foundation», based mainly on the symptoms rather than the physiological criteria [Drossman et al.,1990]. This was aided by its usefulness in health care, and limited data on the physiological disorders (eg, motor) to the full extent due to the patient's symptoms are also symptoms has forced patients to seek medical care. However physiologic criteria are still allowed as to anorectal disorders, if they enhance diagnostic accuracy. Drossman [2016] believes that the biomarkers in the criteria to be included in the future, if they can improve their predictive value.
Classification of disorders of anatomical regions (esophageal, gastroduodenal, intestinal, biliary and anorectal) provides a combination of features that are the basis of diagnostics and therapy, and are related to the location of these bodies. Thus, functional heartburn refers to the esophagus, anorectal to fecal incontinence part and the sphincter of Oddi disorder to the biliary system. However, inadequate localization of symptoms, particularly not easily localize FR gastrointestinal pain (e.g., irritable bowel syndrome, functional and centrally mediated dispepsiya abdominal pain syndrome), which have a greater impact on the overall effects on the control paths due to deregulation of the symptoms of the enteric nervous system.
In this paper, we mainly focus on the discussion of diagnostic signs (including the Rome criteria IV) and some aspects of treatment.
Changes to the Roman criteria IV. After extensive discussion, the full criteria for Roman IV was made a number of additions and refinements.
1. Experts find it necessary, where possible, the elimination of the term "functional" in the title of pathological conditions. It should be noted that the debate about saving any changes "function" of the term existed for many decades. However, the term "functional" is so entrenched in nosology, that now it can not be easily replaced. However, the word "functional" is limited, being non-specific. Thus, experts granted by the more precise definition of GI risk factors. According to them will continue to correct the following terminology: "cerebrovascular disorders intestinal interaction", that is, violations of the interaction of the gut and the brain [Drossman, 2016]. Although this compound is difficult to pronounce, it more accurately reflects the pathogenesis of changes that occur in the body. Moreover, experts have eliminated the word "function" of titles (for example, disorders of the esophagus, rather than functional esophageal disorder) and certain diagnoses (e.g. functional fecal incontinence faecal incontinence instead), as in Roman III criteria. Also functional abdominal pain syndrome has been replaced by a centrally mediated syndrome, minimize tavmirovanie term "functional" and display the new information about the interaction of the intestine and brain. However, in certain clinical disorders (e.g., functional diarrhea, functional heartburn) term is retained, to distinguish them from the disturbances, which have similar symptoms but with clear structural etiology Thus, should no longer sound, the term "functional".
2. The classification of diagnoses have been added with a known etiology. Including added opioid bowel dysfunction ( "opioid inducing gastrointestinal hyperalgesia" to the category "Central mediated disorders of the gastro-intestinal pain," "opioid-induced constipation" was added to the category "disorders of the intestine," and "syndrome kanabioidnoy uncontrollable vomiting "was added to the heading" Gastroduodenal disorders »[Drossman, 2016]. these diagnoses are different from other DF GI presence of the substance (opiate), which contributes to the appearance of symptoms, and their avoidance may lead to normalization. as these diagnoses are the result of known etiologic factors, they do not have a truly functional, but the authors have included in the Rome criteria IV of, as they meet the new definition: bowel disorder interaction and brain [Drossman, 2016] they are also characterized by altered CNS function or enteric nervous system, and their clinical manifestations are similar [Drossman, 2016]. Thus, they must be distinguished from one another, and they were not well characterized or have not reached the level of analysis as distinct disorders. But they were also included in the list of new terms, despite the fact that their "functionality of origin" in doubt. On the other hand, sounded a new approach of "violation of cerebrovascular interaction" is much closer in content the case of drugs, than "functional impairment".
     3. It was introduced additions and amendments to certain headings. for example, a new heading called "intestinal microenvironment and functional disorders of the gastrointestinal tract» ( «Intestinal Microenvironment and the Functional Gastrointestinal Disorders») combines knowledge about germs, diet and nutrition for improved understanding of the processes intracavitary gastrointestinal digestion [Drossman, 2016]. The pharmacological and pharmacokinetic aspects of functional gastrointestinal disorders were modified pharmacologic, pharmacokinetic and Pharmacogenomic aspects of functional gastrointestinal disorders that would include the role of genetics in clinical response to pharmaceutical treatment. Gender, age, society, culture and point of view of the patient to the Rome III criteria were divided into two articles, to show a rapid increase in knowledge about the age, gender, women's health, aspects of the patient and the multicultural aspects of the GI risk factors in these areas. Psychosocial aspects of GI risk factors were changed on the biopsychosocial aspects of GI risk factors, To display multi-valued nature of the biopsychosocial processes. Topic in Rome criteria III of "functional abdominal pain syndrome" was changed to "Central mediated disorders gastrointestinal pain" that would display the dominant contribution to the development of CNS symptoms.
     4. Conducted change the thresholds for the diagnosis criteria. Through the limited information about the frequency of symptoms in a healthy intestine and insufficient data in the literature regarding the frequency of gastrointestinal symptoms using the Rome criteria, the organization conducted a study with the regulatory signs, so committees with the development of heads could include thresholds based on factual data to assess, even for symptoms the boundaries of the normal range. Committee survey organization «Rome Foundation» conducted a survey on the topic of physical symptoms, including gastrointestinal symptoms in preclinical FR nationwide sample in the United States. Using this information, the threshold values ​​were set for the diagnosis criteria frequency that differed from the common sampling frequency.    
 5. By classifying the official added a new diagnosis for patients with impaired cerebrovascular interaction "reflux giperchustvitelnosti" (or "reflux giperchustvitelny») [Drossman, 2016]. The Rome III criteria for functional heartburn symptoms heartburn determined in the absence of evidence that the heartburn associated with gastroesophageal reflux disease. However, there are also patients who are at normal levels reflux acids, but they are sensitive to physiologic reflux, and thus develops heartburn. The Rome criteria IV, this situation is described in the section "Reflux hypersensitivity" (AZ) and it should be distinguished from "functional heartburn" (A2) Also, now names such syndromes can be used in medical practice as a "chronic nausea syndrome" that " chronic rvoty- "syndrome [Drossman, 2016].
     6. The new guidelines spent viewing criteria sphincter of Oddi disorder [Drossman, 2016]. Dysfunction of the sphincter of Oddi is now exclude organic pathology, however, takes into account the development of enzymatic defects and disorders as the basis of pathology. Changes in therapeutic approaches. In particular, the recommendations about the conduct of biliary sphincterotomy on the basis of clinical criteria (biliary dilatation and elevated liver biochemistry or elevated levels of pancreatic enzymes) for alleged pain sphincter of Oddi did not have a strong evidence base [Geenen et aі., 1989]. Thus, the advantages of alleviating the symptoms equilibration with potential risk of pancreatitis, perforation and bleeding was difficult task, and Roman III criteria for these disorders has not been particularly useful as the proper recommendations.
7.	At this time, functional bowel disorders have visited in the field of symptomatic manifestations. To identify these disorders most commonly used diagnosis' irritable bowel syndrome (SEC) - Irritable bowel syndrome- IBS) ». Also, SEC is subtypes: constipation, diarrhea, disorders and mixed without classification. In the new classification listed subtypes and are no longer seen yak different. Instead, they are in communication with pathophysiological functions that manifest themselves as opposed to the specific patient, namely in the amount, intensity, severity of symptoms in the clinical aspect. It is well within the clinical signs observed in IBS with predominant constipation, and chronic constipation, wherein the categories can overlap depending on the degree of pain and subclasses IBS, bowel movements associated with the change over time debt [Drossman et al, 2005.; 2008; Wong et al, 2010.; Shekhar et al., 2013]. It can also occur when the SEC with functional dyspepsia or functional constipation with dissenergiey pelvic floor. In clinical studies, specific diagnostic criteria are needed to evaluate the effects of targeted drugs, however, patient care can change a diagnosis from one to another or to a combination of diagnoses, in which you need to complete treatment (eg, antidepressants, pain between several diagnoses).
8.	Expert Committee amended the identifying subtypes IBS. Classification of Rome III criteria for subtypes IBS needed for what would be a quantitative indicator of the total number of bowel movements using the Bristol shaped stool scale used to IBS classification diarrhea-predominant (> 25% of frequent / watery, <25% of the hard / lumpy) IBS with constipation-predominant (> 25% of the hard / lumpy, <25% of frequent / watery), IBS mixed type (> 25% of frequent / watery,> 25% of the hard / lumpy) and the IBS without classification (<25% of frequent / watery, <25 % hard / lumpy). But it may be a long period of time in patients of normal consistency of bowel movements, so there are a large number of patients with the IBS without classification in relation to the other groups [Dorn et al, 2009.; Engsbro et al., 2012]. Based on this observation and the results of studies with regulatory signs on the organization «Rome Foundation», IBS criteria for subtypes have been changed and are quantitative indicators of symptomatic bowel movements, bowel movements and not all (in fact those of normal). The result is that no group classification has decreased significantly.
	9. The expert group has excluded the term "discomfort" of the criteria of the IBS. The Rome III criteria for the IBS used the concept of abdominal discomfort or ball, allowances that these terms exist in a range of severe degree (pain) to less severe (discomfort). However, more recent data [Spiegel et al., 2010] have shown that patients find these two terms other qualitatively, and discomfort may include different symptoms. In addition, the term "discomfort" has different values ​​and different frequencies reported about in other cultures [Shah et al., 2001]. Therefore, to avoid symptomatic and cultural heterogeneity, only used the term "pain" as the primary diagnostic criteria for IBS, thus, of the IBS eliminated the concept of "discomfort" which, according to experts, has no diagnostic importance, and often confuses patients . Now, this concept explains the specific pain at the time of defecation. which the group has decreased significantly without classification.
10. The experts also drew attention to the combined disorder nausea and vomiting as a new diagnosis in mutually Roman IV criteria for adults. Section "Chronic nausea and vomiting syndrome" combines the previous sections s Rome criteria III, as "Chronic idiopathic nausea" and "functional vomiting." This is due to lack of evidence of differentiation of different approaches and treatment of nausea compared with vomiting. Accordingly, with the clinical observations of these two symptoms are usually associated. Though, experts suggest that patients may not only nausea, clinical approach to diagnosis and treatment remains such as before [Drossman, 2016]. In children, according to the classification of) these states were demarcated [Hyams et al., 2016].
		
5. Materials regarding the activation of the students during the lectures (questions, problems, problem situations). 
1. Rome criteria of gastrointestinal disorders in children.
2. Prevalence in the pediatric population, the risk factors of the disease.
3. Clinical fiches of regurgitation syndrome, functional dyspepsia and intestinal colic.
4. Treatment of regurgitation syndrome, functional dyspepsia and intestinal colic.

6. General material and methodical lecture support.
Lecture type - combined; equipment – department auditoria, patient presentation, multimedia slides.

7. Materials for student's self-paced training.
а) from present lecture topic 
Literature:
1.	Kliegman, R.M., St Geme, J.W., Blum, N.J., Shah, S.S., Tasker, R.C., Willson, K.M., & Behrman, R.E. (Eds.). (2019). Nelson Textbook of Pediatrics (21st ed.). 4264 p.
2.	Drossman, DA, and Hasler, WL (2016). Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 150, 1257-1261.
3.	Saps M, Nichols-Vinueza DX, Rosen JM, et al. Prevalence of functional gastrointestinal disorders in Colombian School children. J Pediatr 2014;164:542–545.e1.
4.	Lewis ML, Palsson OS, Whitehead WE, et al. Prevalence of functional gastrointestinal disorders in children and adolescents. J Pediatr 2016; 177:39–43 Tasks.
5.	Van Tilburg MA, Hyman PE, Walker L, et al. Prevalence of functional gastrointestinal disorders in infants and toddlers. J Pediatr 2015; 166:684–689.

Questions
1. Define the regurgitation syndrome, functional dyspepsia and intestinal colic.
2. Prevalence in the pediatric population, the risk factors of the disease.
3. Classification regurgitation syndrome, functional dyspepsia and intestinal colic.
4. The clinical picture of these diseases.

Task
	 1. The child of 3.5 years was admitted to the hospital with complaints of constipation, abdominal pain, poor appetite. These complaints concerned the child about a year. During examination in the hospital no organic pathology of the digestive tract has been detected.
Questions:
1. Place the clinical diagnosis
2. What is the etiology of this disease?
3. The principles of diet therapy
4. Principles of treatment
5. The scheme of follow-up    
   
2. The mother of 3-week-old baby and requested the pediatrician to complain that after feeding the baby and loud screams, there is redness or paleness nasolabial triangle. Belly swollen and tense, legs pulled up to his stomach, feet are cold to the touch, pen pressed against the trunk. Noticeable relief comes immediately after defecation.
Questions:
1. Diagnose
2. What are the causes of this disease development
3. What are the causes of the pain syndrome
4. Principles of treatment
5. Principles of follow-up

b). for next lecture topic «Urinary tract infections in children” 
Literature
1.	Kliegman, R.M., St Geme, J.W., Blum, N.J., Shah, S.S., Tasker, R.C., Willson, K.M., & Behrman, R.E. (Eds.). (2019). Nelson Textbook of Pediatrics (21st ed.). 4264 p.
2.	Karavanaki KA, Soldatou A, Koufadaki AM, et al. Delayed treatment of the first febrile urinary tract infection in early childhood increased the risk of renal scarring. Acta Paediatr 2017;106:149-154. 
3.	Shaikh N, Mattoo TK, Keren R, et al. Early antibiotic treatment for pediatric febrile urinary tract infection and renal scarring. JAMA Pediatr 2016;170:848-854. 
4.	Subcommittee on Urinary Tract Infection. Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2-24 Months of Age. Pediatrics 2016;138(6). pii: e20163026. 
5.	Stein, R., et al. Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol, 2015. 67: 546. 
6.	Shaikh N, Wald ER, Keren R, et al. Predictors of non-Escherichia coli urinary tract infection. Pediatr Infect Dis J 2016;35:1266-1268. 
7.	Schwenger, e.m., et al. Probiotics for preventing urinary tract infections in adults and children. Cochrane database syst rev, 2015: cd008772.

Questions
1. Basic provisions for urinary tract infections in children.
2. Causes of development, the main clinical manifestations of cystitis and asymptomatic bacteriuria in children.
3. Definition, etiology of pyelonephritis in children.
4. The technique of objective examination of a patient with urinary tract infection.
5. Basic laboratory and instrumental methods of examination of a patient with urinary tract infection.
6. Complications of acute and chronic pyelonephritis.
8. Treatment of recurrence of pyelonephritis.

Tasks 
2. An 8-year old girl was received at the hospital with complaints about low back pain, frequent and painful urination. The disease was preceded by swimming in cold sea water. The next day, the girl had headache, adynamia, abdominal ache and low back pain at the left side. The temperature rose up to 39,5o С. Within some days the fever was stable and the urine became turbid. At the reception of the hospital, the state of the girl was of moderate severity, she was pale and had periorbital shadows and a light pastosity of the eyelids. The temperature was 38,5o С. She had a painful symptom in the costovertebral corner leftwards during palpation and percussion, the palpation of the left kidney was painful.  
А. Assumed diagnosis
B. Schedule
C. Diet
D. Etiotropic therapy 
E. Pathogenetic and symptomatic therapy
   
5.  A 5-year old child was received for examination. The anamnesis contained the frequent episodes of “causeless” body temperature rising up to 38-39o С. The general urine analysis showed insignificant leukocyturia and bacteriuria. The spontaneous urination frequency was equal to 2-3 times per 24 hrs. The volume of one-time urine portion was 250  to 270 ml, the urination represented a feeble stream with straining effort. The results of urinary tract echography were: the right side dimensions of the kidneys - 80х42mm, the left side dimensions of the kidneys - 78х40mm, the right side corticomedullary correlation - 1:1, the left side corticomedullary correlation - 2:1, the bladder volume - 160 ml, the residual volume – 70 ml. The urography showed the extension of the bladder and the unevenness of the contours.
A. Enumerate the diagnostic methods of urodynamic tests!
B. Uroflowmetry: designation, test indices.
C. Regulatory indices of the twenty-four-hour rhythm of spontaneous urination for a 5-year old child.
D. Diagnose
   
8. Literature, which was used for the lecture preparation by lector:

1.	Kliegman, R.M., St Geme, J.W., Blum, N.J., Shah, S.S., Tasker, R.C., Willson, K.M., & Behrman, R.E. (Eds.). (2019). Nelson Textbook of Pediatrics (21st ed.). 4264 p.
2.	Drossman, DA, and Hasler, WL (2016). Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 150, 1257-1261.
3.	Rouster AS, Karpinski AC, Silver D, et al. Functional gastrointestinal disorders dominate pediatric gastroenterology outpatient practice. J Pediatr Gastroenterol Nutr 2016; 62:847–851. 
4.	Drossman, DA, Chang, L, Chey, WD, Kellow, J, Tack, J, Whitehead, WE, and The Rome IV Committees (2016). Rome IV functional gastrointestinal disorders – disorders of gut-brain interaction. Raleigh, NC: The Rome Foundation.
5.	Drossman, DA (2016). Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV. Gastroenterology. 150, 1262-1279.
6.	Kuizenga-Wessel S, Heckert SL, Tros W, et al. Reporting on outcome measures of functional constipation in children—a systematic review. J Pediatr Gastroenterol Nutr 2016; 62:840–846.
7.	Korterink, J.J., Diederen, K., Benninga, M.A. et al. Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One. 2015; 10: e0126982.