What is Giardia in children, symptoms and treatment, Dr. Komarovsky

If a child is diagnosed with Giardia, many parents have no idea who these creatures are and how they can be dangerous. Doctors and the Internet frighten moms and dads with monstrous consequences, but often this is precisely the case when the word itself is worse than what lies behind it. Authoritative children's doctor Evgeniy Komarovsky talks about how to perceive such a diagnosis as giardiasis, what to do and how to treat a child.

What it is?

Doctors call giardiasis a disease that is caused by single-celled organisms - the simplest Giardia. They live in the small intestine. The parasites themselves are divided into two types: active and living, with flagella tentacles, which they deftly wield and stick to the wall of the small intestine, and motionless and inactive, which are called Giardia cysts.

Getting infected with Giardia is as easy as shelling pears; all you have to do is not wash vegetables and fruits bought at the market, or even wash your hands less often, especially after playing outside, traveling on public transport, or shopping.

Protozoan parasites enter through the mouth and enter the small intestine.

There they live, reproduce (sometimes very actively), and sometimes cause irritation of the mucous membrane of this part of the intestine.

If live and vigorous Giardia enters the large intestine, they die because the habitat there is not suitable for them. These individuals, which become cysts, are excreted in the feces.

This disease is most widespread among children, in a certain age group - from 1 to 4 years. However, it is children who tolerate the disease more easily than adults.

What kind of parasites are these?

Giardia are not microbes or worms, they are among the simplest single-celled creatures that were discovered by the inventor of the microscope, Leeuwenhoek, almost 4 centuries ago.

It is believed that only children suffer from giardiasis, this is not entirely correct; adults get sick in the clinical form much less often, but they suffer the disease more severely.

The source of infection is people and animals, from whose bodies these parasites are released into the external environment with feces. In the form of cysts, they are preserved in the ground or sand for a long time due to the presence of a durable chitinous shell. The peak of infection usually occurs in the warm season. Komarovsky calls giardiasis in children a classic disease of dirty hands.

You can become infected in the following cases:

• drinking untreated water or foods contaminated with cysts (fruits, vegetables);
• swimming in small ponds or sunbathing on the coastal sand;
• contact with an infected person or common objects - on the street, at home or in children's groups;
• communication with domestic or stray animals.

Ingestion of 10-15 cysts is sufficient for the development of the disease. In the small intestine of humans, they transform into a motile flagellated form, cover the entire mucous membrane of the duodenum and feed at the expense of the host, gradually poisoning him with the products of their vital activity. Over time, the immune system begins to react to the invasion - antibodies are produced, the secretion of bile increases, which kills Giardia, stimulates peristalsis and promotes their removal from the body in feces. However, after self-healing, re-infections are not uncommon, since immunity is unstable and does not protect against dirty hands.

Symptoms

Quite often there are no symptoms at all. It is possible to detect Giardia cysts completely by accident, when a child takes tests to obtain admission to kindergarten or after another illness, when it is necessary to examine stool. Sometimes giardiasis can manifest itself with the following clinical picture:

• Frequent pain in the upper abdomen, around the navel.
• Increased flatulence, bloating, gas formation.
• Frequent attacks of nausea and vomiting in a child.
• Stool disorders - diarrhea alternates with constipation and vice versa.
• Atopic dermatitis (popularly called diathesis).
• Fatigue, slow weight gain, restless and unhealthy sleep, headaches, irritability and tearfulness.

You can verify the absence or presence of Giardia only on the basis of laboratory tests of the child’s stool.

However, it is not always possible to find cysts in it, and then, if characteristic symptoms are present, the doctor prescribes an unpleasant procedure - inserting a one and a half meter probe through the mouth to examine the duodenal contents. In addition, a blood test is prescribed to check for the presence of antibodies to Giardia; such antibodies, according to medical reference books, usually appear about a month after infection.

Symptoms of the disease

Symptoms of giardiasis in children can manifest themselves in different ways, some of them may be absent altogether:

• abdominal pain;
• digestive disorders: diarrhea occurs more often, sometimes diarrhea is replaced by constipation;
• constant nausea;
• bloating;
• poor appetite;
• irritability, restless sleep, weakness;
• weight loss.

The main symptom of giardiasis is prolonged (more than 10 days) diarrhea. At the same time, there are no typical symptoms of OCI - no vomiting, no temperature, and giardia was detected in the stool analysis. In this case, treatment must be prescribed. If the diarrhea goes away after three days, this means that the child’s body has coped with the problem on its own. In this case, treatment is not necessary.

Doctor Komarovsky's opinion

About 30% of the world's population is infected with the simplest Giardia, says Komarovsky, and most of them are children. Despite the fact that humanity has known about Giardia for several centuries (they were discovered in 1861), these single-celled organisms are shrouded in a veil of secrets and myths.

The first of these is excessive danger. Evgeny Komarovsky says that many patients, and doctors, also tend to exaggerate the harm caused to the body by Giardia.

The second is habitat. If a doctor tells you that Giardia lives in the liver or gall bladder, and therefore causes cirrhosis and biliary dyskinesia, you need to run away from such a doctor as soon as possible and as far as possible. Giardia cannot survive anywhere except the small intestine.

Not everything is simple with the diagnosis of the disease.

Komarovsky calls stool analysis for Giardia cysts the only reliable analysis. Other methods, including blood tests, will not show a reliable picture.

Evgeniy Olegovich urges parents not to become victims of scammers if someone promises that, using the latest computer diagnostics, they will find Giardia and other parasites in their child for a small fee. These protozoa cannot be detected either on x-ray or ultrasound.

If cysts are found in a child’s stool, then this is not a reason to sound the alarm, says Evgeny Komarovsky.

According to unofficial data, about 18% of kindergarteners in Russia have lamblia in their bodies, but at the same time they feel great and do not complain about anything.

Treatment

In a healthy child, the immune defense is able to create such unbearable conditions for a simple organism such as Giardia that the parasite will leave the body on its own, without pills, ultrasound waves, folk remedies and other methods that traditional and alternative medicine offer today.

Giardiasis does not have a big impact on children's immunity.

Doctors discovered this when they observed how the disease progressed in children with severe congenital immunodeficiency (HIV). Their condition was no different from that of their healthy peers.

This does not mean that giardiasis does not need to be treated at all. There are particularly difficult situations in which a specific treatment regimen is needed.

When and how to treat

If a child has diarrhea with diagnosed Giardia for more than 10 days, if all other symptoms are present, including weight loss and pathological loss of appetite, and if the child also suffers from atopic dermatitis, treatment may be necessary. Komarovsky emphasizes that in reality such a need arises extremely rarely.

The World Health Organization establishes the only indication for the treatment of giardiasis - prolonged diarrhea. If this symptom is not present, there is no need for medication or other treatment.

If treatment is still indicated, then there is no need to commit to long-term therapy. Today, according to Komarovsky, there are very effective medications that can get rid of parasites in the shortest possible time - from 1 to 3 days. They must be prescribed by a doctor.

Treating giardiasis with folk remedies, according to Evgeniy Komarovsky, is ineffective, takes a long time and is completely unnecessary. The same applies to treatment with various expensive dietary supplements (dietary supplements). It also makes no sense to treat the problem with antibiotics, since Giardia is not a bacteria.

Antihistamines and enterosorbents can be added to them.

Almost all young patients are recommended a special diet that has a positive effect on intestinal motility (porridge, applesauce, fermented milk products).

Komarovsky's opinion on the disease

On his forum, in a topic about the treatment of giardiasis, Komarovsky is of the following opinion:

“Parents should think about starting active therapy when severe symptoms develop: diarrhea, weight loss, rash. When there are no symptoms of intoxication, you should not immediately resort to antiparasitic drugs. Naturally, giardiasis can be completely cured by resorting to complex therapy and taking numerous medications.”

Dr. Komarovsky strongly recommends that before starting treatment, you read the instructions for the medications Trichopolum or Furazolidone and determine for yourself whether taking them would be advisable.

By

Prevention

Hand washing is a useful habit, but it practically does not protect against Giardia, says Evgeny Komarovsky. The fact is that these protozoa are found not only in people, but also in animals, and if a dog or cat went to the toilet in the yard where a child is walking, then with a high probability he will bring home Giardia cysts on his shoes, which, if they fall into a favorable environment, the environment of the small intestine will come to life and begin to show activity.

The best prevention is prevention by the entire country, says Komarovsky, when owners begin to clean up excrement after their pets. But this will most likely still take many decades.

In addition, Giardia spreads well in water, including drinking water. But today the situation with the quality of drinking water in most Russian cities is quite deplorable. Moreover, standard chlorination of water does not kill Giardia cysts.

A few words about prevention

After a course of antiparasitic therapy, the child should be under specialized supervision for the next six months. Treatment should also be provided to all family members to reduce the likelihood of relapse. The good news is that remission of the pathology occurs in approximately 90% of cases. Remission of the disease can be achieved in more than 90% of cases.

Compliance with preventive measures will help to eliminate subsequent relapses:

• introduction of basic hygiene standards, for example, hand washing, personal hygiene, washing fruits and vegetables;
• using exclusively boiled water for drinking;
• protecting the child from contact with domestic and, especially, stray animals.

It is also very important to avoid swimming in open, potentially polluted bodies of water. All this will prevent the child from becoming infected with giardiasis.

Adviсe

The doctor emphasizes that washing your hands correctly means washing them for at least 20-30 seconds with baby soap.

Teaching a child to wash their hands is not enough. It will be good if parents activate all their pedagogical skills and show maximum ingenuity and teach the child not to lick his hands. For this purpose, all methods are good - from heart-to-heart conversations to smearing hands with viburnum juice or mustard.

Fight flies mercilessly.

They are 100% carriers of cysts and therefore must be destroyed.

If you have been treating your child for gall bladder problems for a long time and without success, and the doctor says that the cause is Giardia, you should refuse to visit such a doctor.

If a doctor says that skin diseases in a child are aggravated due to Giardia, and they, these same protozoa, are to blame for frequent illnesses from acute respiratory viral infections, acute respiratory infections and other viral ailments, do not believe them. Giardia cannot do this.

If, after all the arguments, parents still have a persistent desire to deal with these parasites by hook or by crook, Komarovsky warns that the relief may be short-lived: some protozoa can be destroyed, others will settle in the child’s body in a few days, perhaps even hours.

You will learn more about Dr. Komarovsky’s recommendations in the following video.

medical reviewer, psychosomatics specialist, mother of 4 children

Giardia is a parasite that often affects the body of young children, mainly preschool age. At the same time, Dr. Komarovsky says that the symptoms of Giardia in children do not appear immediately, so treatment is often prescribed at a late stage of infection. It is impossible to detect these helminths with the naked eye; it is necessary to undergo an analysis so that the material can be examined under a microscope in the laboratory; this is the only way to determine the presence of helminths. According to statistics, about 30% of all people in the world are affected by Giardia.

Most often, infection occurs through dirty hands, that is, a child, after playing in the sandbox or with a pet, begins to put his hands in his mouth, and Giardia cysts enter the body. An equally common source of infection is water, since chlorination does not destroy cysts; they can only be gotten rid of by boiling. You can become infected with giardiasis by eating contaminated fruit or vegetables.

Main symptoms of infection

Dr. Komarovsky talks a lot about the symptoms and treatment of Giardia in children, and at this point it is worth talking in more detail about those signs that may indicate the presence of parasites.

Giardia life cycle

It is for this reason that doctors strongly recommend paying attention to certain signs of infection, these include:

• an increase in body temperature in the evening, while such a symptom is not associated with extraneous causes, and the readings on the thermometer do not exceed 37.5 degrees;
• the child develops chronic diarrhea;
• during night sleep, the infected person grinds his teeth;
• the child becomes more tired, his concentration decreases, he wants to lie down and rest more;
• nagging pain occurs in the abdominal area, young children cannot explain where the source of pain is located, but older children will be able to explain that the pain is localized at the navel or under the right rib;
• the child does not gain weight, or loses a lot of kilograms;
• there are attacks of suffocating cough, which can occur several times a day;
• the number of eosinophils in the blood increases;
• There may be an increase in the size of the spleen, lymph nodes and liver gland.

If we talk about the last two points, then these symptoms can only be determined after the child is examined by a doctor. The rest of the symptoms are noticeable, and anyone can identify them, just watch the baby.

According to Dr. Komarovsky, in order to treat Giardia in children, it is necessary to identify additional symptoms that develop with helminthiasis, these should include the development of acute dermatitis of an allergic nature. Popularly, this disease is called diathesis; it is this disease that may indicate infection of the body by parasites.

The doctor emphasizes that in some cases giardiasis does not manifest itself with certain symptoms, that is, it occurs in a latent form. Infection is detected during testing, which is why you should be tested for helminths at least once every six months. This will help avoid certain complications.

Giardiasis Clinic

Due to the high prevalence of Giardia in children, Komarovsky and other pediatricians can detect symptoms in many patients, and there are often no complaints. Acute new-onset giardiasis is rarely diagnosed correctly; it is most often mistaken for an intestinal infection and treated accordingly. Chronic infection can be suspected based on certain signs that parents pay attention to when visiting their doctor or are discovered by the doctor himself during an examination. For example:

• weight loss and stunting;
• lack of fat under the skin;
• the presence of pronounced transverse folds on the abdomen;
• decreased appetite;
• increased nutritional need for sweets;
• pain of an uncertain nature around the navel, most often occurring on an empty stomach;
• bloating after eating;

• prolonged or frequently recurring diarrhea, alternating with constipation;
• rough “parchment” skin in the elbow and knee joints, increased dryness and flaking throughout the body;
• recurrent urticaria, persistent allergic dermatitis;
• “geographical” pattern on the tongue;
• symptoms of general intoxication in the body - malaise, headaches, apathy, absent-mindedness, memory impairment, restless behavior.

These symptoms and treatment of giardiasis are not related to each other; they are only a reason to conduct further examination of the child, for example, to prescribe a stool test for giardia. Laboratory methods make it possible to detect the presence of cysts (less often live parasites) provided that the material is quickly delivered to a medical institution, so most often at least 3 tests are required. A blood test for Giardia has no practical significance, since the result is reliable only within 20 days after infection, if the date of entry of the cysts into the body is known.

How is diagnostics carried out?

According to the famous doctor Komarovsky, identifying the symptoms of Giardia in children in order to prescribe treatment is not so simple, for this reason it is important to conduct a full diagnosis of the body.

To do this, the doctor may prescribe:

• carrying out scatological examination of feces; duodenal contents are checked;
• Additionally, blood is donated for serological analysis; it is more effective at 3-4 weeks of infection.

Only after this can the doctor review the finished results and select the most appropriate treatment method. You should not refuse a full course of examination, since these helminths do not always show up in stool and blood tests. If no helminths were detected in the first examination, this does not mean that there is no Giardia in the child’s body.

Diagnostics and tests

Laboratory diagnostics are mainly used. The child will need to have their blood tested for the presence of Giardia antibodies.

Experts evaluate this analysis as the most accurate method for identifying parasite infection in the first four weeks from the moment of infection.

In addition, diagnosis before treatment necessarily includes:

1. Examination of feces to determine the presence of either pathogenic microflora or dysbacteriosis. However, cysts of these parasites are rarely found in feces.
2. A clinical blood test that will indicate general changes in the functioning of the body corresponding to pathology. At the same time, the presence of Giardia in a child is not diagnosed in this way.
3. Duodenal intubation with further examination of the contents, which almost always identifies cysts. However, such probing can only be used for children over 10 years of age; at a younger age, appropriate diagnostics are not carried out.

This scheme of testing a child makes it possible to detect giardiasis and prescribe appropriate treatment. After completion of the rehabilitation course, repeated checks may be required, which will indicate the effectiveness of therapy and the likelihood of complications.

How is the treatment carried out?

Unfortunately, giardiasis has a large number of symptoms that may indicate other diseases, and doctors do not always make the correct diagnosis. Because of this, the disease develops, Giardia continues to affect the body, which ultimately leads to serious health problems. To make a diagnosis, you should consult an experienced doctor and conduct a full course of examination.

The treatment process should include several important stages at once, these include:

1. Preparatory stage. At this time, parents should prepare the child for a long course of treatment, since it is very difficult to remove Giardia from the body even at the initial stage of infection. During the preparatory period, it is necessary to establish nutrition in order to restore the normal flow of bile. The duration of preparation will depend on what the results of the ultrasound examination show.
2. Treatment stage. The treatment process includes the use of drugs to kill helminths, as well as the use of homeopathic medicines and the use of herbal medicine. The most effective medications include Tiberal, Furazolidone and Metranidazole. But it is worth considering that these drugs can only be prescribed by the attending physician, since the child needs to select the correct dosage. Among the homeopathic medicines, Lycopodium and Mercurium solubilis should be highlighted. During the treatment period, the doctor must constantly monitor the child’s condition, adjust his diet, dosage of medications and vitamin complexes.
3. Rehabilitation stage. At this stage, the doctor prescribes medications to the child that will help restore intestinal function and normalize the microflora. Complex vitamins may also be needed, but they should be prescribed by your doctor. Parents are obliged to carefully monitor the child’s nutrition, as well as his hygiene and contacts with stray animals.

Complex treatment of lamblia in children

Dr. Komarovsky argues that the infection should be treated only after an accurate diagnosis has been made, since characteristic symptoms may indicate other internal diseases.

In general, treating giardiasis is not difficult if you follow the recommendations of your doctor and completely give up sweets. Scientists have proven that those with a sweet tooth are more susceptible to infection, since for parasites a sweet environment is the most favorable for reproduction.

1. The preparatory stage consists of strengthening the immune system, eliminating intoxication and suppressing the active activity of parasites. Enzyme and choleretic drugs are prescribed, taking into account the severity of the disease and the individual characteristics of the child’s body. The duration of the stage is 2-3 weeks.
2. Intensive drug therapy is aimed at destroying weakened parasites. Treatment lasts 7-10 days. Since almost all medications are toxic, drugs such as Phosphalugel, Enterosgel, and activated carbon are prescribed in combination.
3. The rehabilitation period may take a couple of months. At this stage, medications are taken to restore the gastrointestinal tract, intestinal microflora and vitamin complexes.

For treatment of giardiasis in children, Komarovsky recommends starting with a strict diet, completely eliminating sweets, and filling the baby’s diet with acidified foods and citrus fruits.

The thing is that parasites cannot actively reproduce in an acidic environment, unlike a sweet one.

When starting treatment for giardiasis, it is necessary to completely exclude the following dishes and foods:

• whole milk and sweet cheeses;
• any sausages;
• fresh bread, especially sweet yeast buns and pies;
• fried foods and fatty meats;
• sweet soda.

The patient's diet should be filled only with boiled and low-fat foods. The first courses are prepared in lean broth, porridges are cooked only in water, and lean meats are boiled or baked. Dietary nutrition must be followed for at least four months after complete completion of the course of treatment.

Parents should be prepared for the fact that after starting drug treatment the child may feel worse, but this is not a reason to refuse therapy. The reason for the deterioration in health is the strong release of toxins due to the destruction of parasites. Within a week after starting treatment, the baby will feel relief and painful symptoms will decrease.

Giardiasis is a serious parasitic disease that affects about 50% of active children visiting public institutions

In order to reduce the risk of infection, it is important to adhere to certain precautions, thoroughly wash your hands and food, avoid contact with stray animals, stop children from biting their nails, and begin to instill basic hygiene skills from early childhood.

2016–2017 – Encyclopedia of diseases from parasites and bacteria: symptoms and treatment methods

Dietary food for the treatment of helminthiasis

As Dr. Komarovsky says, the symptoms of Giardia in children are quite clear, so treatment must begin immediately, and at the preparatory stage the nutrition of the little patient should be adjusted. There is an opinion among doctors who are confident that at the initial stage of the disease it is possible not to use drug treatment, but to get by only with dietary nutrition.

But it is very important to strictly follow the basic rules of the diet, these include:

1. Products that have an antiparasitic effect should be included in the child’s diet; such ingredients should be present on the menu daily. Such products include pumpkin seeds, various types of cereals, sunflower oil, raw vegetables and dried fruits.
2. Sour fruits and vegetables are no less beneficial; they contain an antioxidant, which has a positive effect on the body and also reduces the level of intoxication.
3. Fish and meat should be consumed in small quantities, and these products must undergo long-term heat treatment.
4. Fermented milk products will be useful, as they have a beneficial effect on the digestive system and also restore intestinal microflora.
5. All foods that contain fast carbohydrates are removed from the child’s diet, because they are the main food for helminths.

While the child is on a diet, he must eat according to a fractional system, that is, he must feed the baby at least six times per day, and the portions must be small. All cooked dishes should be warm and pureed to facilitate the work of the gall and stomach.

Important tips from Dr. Komarovsky

As Dr. Komarovsky says, if symptoms of Giardia are detected in children, then treatment should begin as soon as possible, and in addition, parents should carefully monitor the child’s hygiene. There are other tips for treating helminthiasis from the famous children's doctor:

A blood test cannot always accurately detect the presence of Giardia in the body, for this reason it is important to donate stool and blood several times to confirm the diagnosis. You should not buy medications that are sold in online stores and have an exclusively herbal composition; such supplements do not help remove helminths.

Products for proper nutrition

It is best to consult a doctor who will prescribe your child complete treatment with medications. Today there are modern drugs that can eliminate parasites in just two days of treatment. You should not self-medicate; only the attending physician can prescribe medicine to a child, as he will be able to take into account all the nuances of health, allergic reactions and the patient’s age in order to select the dosage.

The doctor assures that today there are no such biological additives or special teas that will help cure the disease.

Parents should teach their child to wash their hands thoroughly with soap after playing with animals or going for a walk. The doctor also strongly recommends washing your child after going to the toilet.

It is equally important to monitor the condition of the apartment; there should be no cockroaches, flies and other insects in it, and you should also clean the toilet and potty in a timely manner. If there are animals in the house, you should constantly monitor its health and also clean the litter box on time.

Most often, this type of helminthiasis is transmitted from an infected person to a healthy person. If the child has a fairly strong immune system, then the parents may not even know that Giardia infection has occurred, since the body will not show any symptoms.

Often the doctor believes that all the symptoms are associated with damage to the body by these helminths, which is why the patient does not receive the necessary treatment. Parents should insist on a comprehensive examination of the baby. During the treatment period, parents should carefully monitor the child’s hygiene, as the baby can easily become infected with other types of helminths, because the body’s immune defense is greatly weakened. With proper treatment, Giardia can be eliminated within a few days.

Parasite under a microscope

Giardiasis is an infection caused by microorganisms from the protozoan family – single-celled Giardia. In the child’s body, they settle in the small intestine and liver, thereby disrupting their normal functioning. Giardia in children and adults is considered the cause of 20% of acute intestinal diseases.

Practical issues of giardiasis infection

• how does infection occur?
• symptoms of Giardia in children according to Komarovsky;
• how to determine whether a child is infected with Giardia;
• treatment of giardiasis in children;
• typical misconceptions about giardiasis in children.

Infection: step by step

Giardia has two life forms:

• The first - mobile - lives in the small intestine, under a microscope it looks like a pear with flagella - with them it is attached to the intestinal wall.
• into the second - immobile - if it finds itself in unsuitable conditions - in the large intestine. This form is called a cyst and is excreted from the body along with feces. Millions of such cysts enter the environment and continue their journey.

Giardiasis in a child, says Dr. Komarovsky, is a classic disease of dirty hands. These protozoa live in the body not only of people, but also of animals - cats, dogs. Even walking from your house to the bus stop, you will see more than one or two “piles” of dogs. All this gets into the soil, and from it onto shoes.

And no matter how much you wash your hands, says the famous pediatrician in his program “Dr. Komarovsky’s School. Giardia and giardiasis,” the likelihood of infection remains high. And all because, as he explains in a video about Giardia in children, there is a concept of sanitary culture not of an individual, but of a country. In Asian countries, where the climate is hot, people are more likely to come into contact with animals and there is poor water quality, the percentage of population infection is 25-30%, and in developed countries it is no more than 2-3%.

Cysts can get into the water, especially where people use untreated water from sources, and from it into our mouths. By the way, regular water chlorination does not kill them. There are cysts in the sandbox, in the ground, and on unwashed fruits and vegetables, toys, dishes, door handles and handrails of public transport. When a child swallows cysts, they enter the intestines and begin their life cycle all over again.

Number of cysts eaten	Probability of infection
10	30-50%
25	100%

An indisputable fact from Dr. Komarovsky . From 17 to 90% of children attending kindergartens are infected with Giardia.

Symptoms

Naming the symptoms of Giardia in children, pediatrician Evgeniy Komarovsky jokes that everyone can be suspected of this. And if a child develops, for example, dermatitis, there may be many other explanations for this, besides Giardia.

Dr. Komarovsky lists the symptoms of Giardia in children as:

• diarrhea lasting more than 3-4 days;
• bloating;
• stomach ache;
• with prolonged diarrhea (more than 10 days), weight gain stops.

An amazing fact from Dr. Komarovsky. The course of giardiasis in adults is much more severe than in children.

How to accurately determine whether a child is infected with Giardia

Today, inexperienced parents are offered a lot of research that promises to find Giardia through a blood test, throat swab, or conduct computer diagnostics in this regard.

Attention ! Detection of cysts or live Giardia in the stool is the only reliable analysis.

Treatment

When discussing the treatment of giardiasis in children, Dr. Komarovsky refers to the position of the World Health Organization: if there are no symptoms, there is no need to treat. The reason for treatment is prolonged diarrhea.

There are a number of drugs that will overcome the disease in a few days. The most common, cheap and effective is the domestic Furazolidone: it is given for 10 days in 3-4 doses at the rate of 10 mg per 1 kg of weight per day. In the first 5 days, no-shpu is also recommended: half a tablet 2-3 times a day.

Misconceptions and fears

Dr. Komarovsky, not without irony, notes that the symptoms and treatment of Giardia in children have given rise to many unfounded fears and myths. And the doctor-TV presenter on the air of his program “Doctor Komarovsky’s School” debunked some of them.

• Everyone has Giardia.

This statement is no more than 30% true.

• Giardia settles in the liver and causes cirrhosis, and also, entering the gallbladder through the bile ducts, causes its inflammation (cholecystitis) and even feeds on bile.

For a long time there was a strong belief that Giardia lives not only in the duodenum. There was even a special diagnosis - “giardiasis cholecystitis”. How does the “life-giving medium” - bile - affect Giardia? Thanks to modern research, it has become clear that they die there instantly, not that they live and reproduce.

Advice to everyone! If you hear such theories from someone, immediately run away from this person, he has nothing to do with medicine. Either his knowledge is based on textbooks published before World War II, or he is simply “medical businessmen” who want to sell you some kind of “miracle potion” for the price of an airplane wing.

• Giardia can be killed with ultrasound.

Various clinics, especially private ones, offer children to undergo treatment courses for all, as they claim, parasites present in the child’s body. Those who offer this act on the principle of “demand creates supply” and satisfy the social order.

• The presence of lamblia is a huge burden on the immune system.

If the body is healthy, it tries to create conditions unbearable for the life of parasites. Individual immunity is developed, and Giardia goes away on its own. But the question is that the child can pick up new cysts, and everything starts all over again.

Interesting fact from Dr. Komarovsky. Studies have shown that even the body of people affected by the immunodeficiency virus is able to independently expel Giardia.

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How is giardiasis transmitted?

The main methods of transmission of Giardia include the following factors:

It is better to bathe children in proven bodies of water

Water. Giardia cysts enter a child's body through contaminated tap water that has not been thoroughly purified. You can become infected with giardiasis by swimming in a pond and swallowing water. The risk of catching Giardia in fresh water is very high. Giardia cysts do not live in the salt sea.

• The fecal-oral route is through the mouth. Infection occurs through contact - from one child to another. Very often, young children become infected with Giardia, whose habit is to chew toys and everything else that comes to hand. Almost all such children have giardiasis.
• The food route of infection is dangerous because by consuming unwashed food (fruits and vegetables), a child can become infected with Giardia. Protozoa can also enter a child’s body through meat and eggs that have not undergone sufficient heat treatment.

What Giardia loves most is wastewater, ponds with wastewater, and sand in children's sandboxes. Particularly dangerous is a sandbox that does not close and cats and dogs can easily enter it. Popular habitats for giardia are the dirty hands of children infected with giardiasis and unwashed fruits and vegetables.

Sandboxes open to street animals are dangerous to children's health

They multiply in the small intestine every 9-12 hours. Cysts are released every 10-20 days. The cyst is in a dense shell, which allows the microbe to withstand the effects of external factors. They are resistant to acid, alkali and active chlorine. Only boiling water makes it possible to completely get rid of them.

As soon as the cysts enter the child’s body, they begin to develop vegetatively: the protozoa develop suckers, with which they cling to the walls of the small intestine.

The body can get rid of Giardia on its own only 6 weeks after infection. But with the condition that the immune system and local intestinal protection are in normal condition. In another case, symptoms of the disease may be completely absent - a person may not know about the presence of Giardia for several years.

How to recognize giardiasis in children

Abdominal pain, nausea, low-grade fever occur with giardiasis

Symptoms of the disease with giardiasis in children are very diverse. Therefore, it is not difficult to confuse them with the manifestation of other diseases.

Giardia in children has the following symptoms:

pain in the right abdomen without its clear localization;

nausea and vomiting;

disruption of normal digestive function (constipation, loose stools);

low-grade fever (no more than 37.5 degrees);

weakness and fatigue;

grinding teeth in sleep;

increase in liver size;

attacks of suffocating cough;

enlarged lymph nodes for no apparent reason;

an increase in the number of eosinophils in the child’s blood.

Due to inflammation in the duodenum and small intestine, the absorption of incoming nutrients is impaired. Children begin to lose weight, become pale and tired quickly. Bile flow and pancreatic dysfunction gradually occur.

Allergic rashes can be caused by parasites

Giardia in children often provokes symptoms such as the appearance of allergic reactions on the skin. These include: urticaria, Quincke's edema, neurodermatitis and even hyperkinesis. Parents complain of frequent blinking, twitching of body parts, and grimacing. As a rule, the main cause is giardiasis. Contributing to the development of Giardia are dyskinesia of the biliary tract and an inflection of the gallbladder.

According to Dr. Komarovsky, giardiasis often occurs as a simple parasite carrier. But forms arise in the form of intestinal dysfunction. The disease begins 1-2 weeks after infection, acutely with loose stools that last up to three days. Sometimes pain appears in the epigastric region. This type of giardiasis usually does not cause complications. The prognosis is generally favorable.

Symptoms of giardiasis and methods of its treatment Dr. Komarovsky

Giardia is a protozoan that lives in the small intestine.
They can only be seen with a microscope, and they look completely different from what worms look like in humans. They affect approximately 30% of people. Infection most often occurs through dirty hands: Giardia cysts are carried into the mouth, from where they enter the stomach and turn into Giardia. Another common source of giardiasis infection is water. Chlorination of water does not kill Giardia cysts; they only die when boiled. You can also easily become infected with giardiasis by eating unwashed vegetables or fruits that have gotten Giardia cysts.

In order for Giardia to settle in the body, it is enough to swallow 10 cysts. In developed countries, where people have highly developed personal hygiene skills, the number of people suffering from giardiasis is small. In third world countries, the vast majority of people are infected with Giardia.

Tip: Dr. Komarovsky advises washing your hands for at least 15 seconds every time.

Diagnosis of giardiasis

In order to confirm whether there is Giardia in the body, you need to take a stool test. With giardiasis, Giardia cysts are found in the stool. When a cyst enters the body, it develops into adult Giardia, which adheres to the wall of the small intestine.

The body, in response to this, begins to produce antibodies, creating conditions that are uncomfortable for the parasite. Thus, the body is able to independently get rid of the protozoa that have entered the body. Even in people with immunodeficiency, giardiasis occurs in the same way as in people with strong immunity.

Tip: According to Dr. Komarovsky, the most effective way to diagnose giardiasis is a stool test.

Symptoms of giardiasis

Symptoms of giardiasis include:

• diarrhea for 10 days at normal body temperature;
• abdominal pain;
• weakness and increased fatigue;
• weight loss.

The symptoms of giardiasis in children differ in severity from the symptoms of this disease in adults (in adults these symptoms are more pronounced). With a strong proliferation of Giardia, if the body cannot cope with the problem on its own, an inflammatory reaction develops in the small intestine. The disease may begin to appear 1-2 weeks after infection with severe prolonged diarrhea, which cannot be explained by any other reasons, such as poisoning or a certain intestinal infection.

Treatment of giardiasis

Treatment of Giardia in adults and children is recommended only if there are symptoms of Giardiasis. Indications for taking drugs that kill all Giardia in the body are prolonged diarrhea and laboratory confirmation of the presence of Giardiasis. With the help of modern drugs, giardiasis can be cured in 1-2 doses.

Advice: Dr. Komarovsky emphasizes that when diagnosing giardiasis, its treatment, unlike the case of identifying skin parasites in humans, should be carried out only if symptoms appear in the form of prolonged diarrhea.

You should not self-medicate giardiasis. When diagnosing giardiasis, the drug and dosage should be prescribed by a doctor. This may be metronidazole, ornidazole, furazolidone and their analogues. Drugs may also be prescribed to eliminate intestinal dysbiosis and lack of vitamins caused by the disease.

Diagnostics

To identify the disease, the following measures should be taken:

Get tested to make a correct diagnosis

scatological examination of stool;

check duodenal contents;

donate blood for a serological test (especially effective in the first three to four weeks after infection);

justify clinical data.

It is advisable to conduct a full range of examinations, as they complement each other. Feces should be examined several times in a row, which is necessary for a more reliable identification of protozoa. Usually this test is taken 3 days in a row with an interval of 10-12 days. The appearance of antibodies to Giardia occurs 2 weeks after infection. To assess the functioning of the biliary system, pancreas and liver, it is also necessary to examine the abdominal organs using ultrasound.

Diagnostic methods

To determine the symptoms and treatment of giardiasis, special diagnostic measures are carried out.

Here they are:

1. A scatological examination involves checking stool. This is a harmless procedure, but it does not guarantee 100% results.
2. Serological diagnosis is a blood test. It is especially effective in the first three weeks after infection. This determines the presence of infection in the blood.
3. Duodenal examination is a probing to examine bile. The procedure is performed only for children over 10 years old.

It is worth considering that the symptoms of giardiasis are varied and parents should pay attention even if at least one of them is detected. In this case, you should immediately consult a doctor

The earlier the problem is diagnosed, the greater the likelihood of a quick recovery. The first symptoms include disruption of normal digestion, as well as the occurrence of persistent constipation and diarrhea. To take the test correctly, you need to take a special container.

In this case, you should immediately consult a doctor. The earlier the problem is diagnosed, the greater the likelihood of a quick recovery. The first symptoms include disruption of normal digestion, as well as the occurrence of persistent constipation and diarrhea. To take the test correctly, you need to take a special container.

It is important that the utensils are sterile and clean. It is recommended to take the analysis several times

Treatment

Giardiasis is a disease that perfectly disguises itself as other diseases. Therefore, a full-fledged diagnosis and an experienced doctor will help to make a correct diagnosis.

For proper treatment, undergo a complete diagnosis

Treatment of giardiasis in children is carried out in several stages:

1. Preparation of the body, the purpose of which is to normalize the secretion of bile. The preparation process will depend on what is revealed during the ultrasound examination;
2. Treatment of giardiasis, which includes pharmacological, homeopathic treatment and herbal medicine. Pharmacological drugs include Ornidazole (Tiberal), Metronidazole, Furazolidone. Drugs are prescribed only by medical specialists, taking into account the characteristics of the child’s body and the tolerability of the components. Homeopathic remedies include Mercurium solubilis, Mercurium dulcis, Chelidonium, Lycopodium and others. During treatment, the immune system is examined and adjusted using special medications, vitamins and nutritional supplements. To achieve treatment effectiveness, it is necessary to provide the child with adequate nutrition and limit sweet foods.
3. A rehabilitation period, which includes correction of vitamin deficiency and intestinal dysbiosis. Preventive measures include compliance with all sanitary and hygienic standards, thorough washing of vegetables and fruits before consumption and less contact with cats and dogs. You should always wash your hands before eating. It is forbidden to drink raw water. While swimming in a pond, a child should not swallow water, as there is a high probability of becoming infected with Giardia.

The child's condition may worsen during treatment

During treatment with antiparasitic drugs, around the fifth day, the child's condition may worsen. But don't be scared, as this is natural and normal. The fact is that, under the influence of potent drugs, a huge number of Giardia dies and their disintegration occurs. Toxic breakdown products located in the intestines are absorbed into the child’s blood. And this leads to a deterioration in his health. To alleviate the condition of children, doctors prescribe them antihistamines and laxatives.

After ten days, the child feels much better. There are fewer and fewer rashes, shortness of breath and cough go away, and the lymph nodes become smaller. To prevent relapse of the disease, you should undergo another diagnostic examination after completing the course of treatment. This is necessary to verify the presence or absence of Giardia in the body.

Treatment regimen

The famous doctor and TV presenter Komarovsky believes that almost 90% of children attending kindergartens are infected with these parasites. Giardia, Komarovsky believes, also affects animals. With their feces, they also enter the external environment and can cause infection in people.

Treatment of Giardia in children involves the use of a number of stages:

1. Stage 1 – preparing the body, diet for giardiasis, taking adsorbents. Enterosorbents help normalize intestinal function. They seem to prepare the body to take antibiotics and other medications. Enterosgel is usually prescribed. The purpose of Smecta and its analogues is shown. These drugs can be safely prescribed to a child, since they do not have side effects and have no restrictions on their use. If liver function is reduced, then hepatoprotectors can be prescribed, although this is extremely rare in childhood.
2. Stage 2 – destruction of parasites. This means the use of various agents that are effective against Giardia. The most commonly prescribed drugs are Trichopolum (Metronidazole), Albendazole (Nemozol), Vermox, Dekaris, Intetrix and other drugs. Furazolidone may be prescribed. Drugs are prescribed according to certain regimens in accordance with the age and body weight of the child. The action of these drugs is based on the fact that they suppress the vital activity of parasites. Usually, correct treatment does not require a repeat course. The intake of enterosorbents is not stopped at this stage.

Stage 3 – restoration of the child’s body. The goal is to help the body regain lost strength. The actions are aimed at strengthening the immune system and normalizing the functioning of the digestive tract. At this stage, it is also expected to combat dysbiosis that has developed against the background of the disease. Replenishing the body's reserves of minerals and vitamins. This link is very important in the treatment of giardiasis. During illness, all these substances are lost to a significant extent, and they are extremely necessary for successful recovery. In this regard, the following prescriptions are indicated: multivitamin complexes, various plant adaptogens, probiotics, enzyme substances in tablet form.

Komarovsky: not everything is so scary

Doctor Evgeniy Komarovsky believes that giardiasis should not always be treated quickly. A little less than a third of all humanity have lamblia in their bodies and this does not cause any problems for their owner. Until, of course, he finds out about it. Some doctors, at the slightest indigestion, refer to these protozoa and immediately begin to eliminate them.

Doctors recommend treatment only for pronounced symptoms: diarrhea, etc.

According to infectious disease specialists and epidemiologists, we should talk about giardiasis if the symptoms are pronounced - when severe diarrhea appears. This is especially true for children with pronounced signs of intoxication and the presence of mucus and blood in the stool.

In the last century, scientists were confused by the question that Giardia can cause diarrhea. Scientists were confused by the fact that there were a huge number of sick people who did not have symptoms of giardiasis and were at the same time carriers of giardia.

Komarovsky believes that if there is a strong desire to remove Giardia from the body, this can be done quickly. But first, before you start cleaning, you should read the annotations of drugs such as trichopolum, furazlidone and tiberal. Parents should think about whether the use of such serious drugs will harm their child’s health.

Giardiasis is getting serious!

Authors : Vasilenko V.V.

If at night you are not allowed to sleep peacefully by a piece of paper with the proud name “form” and almost a lottery inscription “analysis”, which is clearly unwinnable for you, since it says that Giardia is present in the feces passed by your child, and you are afraid of serious treatment this “disease” or you have been unsuccessfully “treating” your child for these protozoa for several years…. First, you must clearly define what in your case is meant by such an “immense medical concept” as “giardiasis.” Does your child have characteristic signs of this disease or is everything limited to the presence of Giardia cysts in his stool? The simple fact is that giardiasis, diagnosed solely by stool analysis, is, paradoxically, another meaningless diagnosis of miracle doctors who read little or philosophize a lot.

1.What is Giardia?

First, a little lie: It is generally accepted that Giardia is a parasite that can cause cholecystitis (inflammation of the gallbladder), and if it starts in the liver, it’s scary to say - cirrhosis; if the intestines are affected, there will be regular pain, plus nausea and vomiting may occur against this background and everything else that can arise in the body.

A little history. This simple creature - a link in the evolution between bacteria and multicellular organisms - was described in 1681. Leeuwenhoek saw it through the microscope he invented and, although he was not a doctor or biologist, he aptly called it an “animacle,” that is, a tiny animal. Dr. F. Lamble from Prague (and not the “Russian scientist D.F. Lambly”, as some believe) named it “Cercomonas intestinalis”, and Steels in 1915 renamed it in honor of F. Lamble and the Parisian professor A. Giard in "Giardia lamblia". Nowadays it is more correct to call this flagellated protozoan “Giardia intestinalis” - Giardia intestinalis (according to the proposal of the International Commission on Zoological Nomenclature).

He looked into the eyepiece of a simple microscope, and an animaculus looked at him from there. A rather small, ghost-like creature, more than twice the size of a red blood cell.

In continuation of the big truth: So, these giardias are small-intestinal, they are, of course, parasites, but they are not particularly destructive, compared, for example, with worms. They do not live at all in the gallbladder and bile ducts, because when they get into the bile they die. Why should they cause cholecystitis? As proof, we can cite a quote from a manual for pediatricians from the “Postgraduate Education” series of 2003: “Currently, most researchers have come to the point of view that Giardia does not live in an intact gallbladder and ducts.” A very careful formulation for the age of molecular biology

Next about the liver. The likelihood of liver cirrhosis in owners of Giardia is equal to the possibility of its occurrence in owners of lice, owners of birthmarks and non-owners in general. Also, Giardia cannot cause severe disorders of the biliary system (cholecystocholangitis). Until now, official medicine has not published any cause-and-effect relationship between the presence of Giardia in humans and serious liver diseases, and assumptions about the existence of this connection by individual people, even those dressed in white coats, are nothing more than their personal opinion. Although, of course, it is extremely interesting to know: if bile is destructive for Giardia, how then do they manage to do such a mess in the liver?

Now, finally, we have reached the only place in which these protozoan flagellates live - the small intestine. Giardiasis usually occurs in the form of simple parasite carriage. But there are also obvious forms, mainly in the form of intestinal dysfunction. In these cases, the disease begins a week or two after infection, acutely, with fatty and loose stools (which can last up to three days) and sometimes pain in the epigastric region. This kind of giardiasis does not cause complications, and as a rule the prognosis is favorable.

2. Is this giardiasis?

It is clear that the source of knowledge about the presence of Giardia in your child, naturally, was stool tests. The only question is what was the reason for the examination. It is quite possible that one of the following points: 1. Your child has periodic abdominal pain, sometimes does not feel well, and spontaneous vomiting occurs. The fact is that most likely, with such symptoms, the child has problems with the digestive tract, or with the nervous system (psychological situation!), In any case, it is very advisable that you be consulted by a good doctor. Which would establish the true cause of the ailments. Instead of explaining everything with Giardia, which was found in feces, and by eradicating which you are unlikely to resolve issues with the child’s health.

2. Your pediatrician advised you to get tested for Giardia, since the child looks “thin”, although he has a good appetite, and you have no other complaints. If every healthy child, thin or, as our grandmothers said, “lean” physique, suspect giardiasis, then with exactly the same reason we should suspect a congenital metabolic disorder in all plump children. Some are thin, others are plump, some are tall, some are short - children simply have different appetites, each of them has a unique gene set, some are athletic and active, others prefer a more measured pace of life, all this is reflected in their constitution. And the main indicator that everything is in order is the child’s well-being and development, and raising suspicions based on the general impression and one’s own ideas about what a healthy child “should” look like is, to say the least, not entirely correct.

3. You decided to get tested yourself, for prevention, since the child has a habit of biting his nails, digging in the ground (sand), sucking a pencil, etc. Prevention is, of course, necessary, if by it we mean hardening the child, good nutrition, sufficient exposure to fresh air and compliance with basic hygiene measures. Instead of the habit of donating blood, urine or feces (as in this case) for tests “just in case”, you look “maybe they will find it.” Because you will do more harm to your child than good if you live in the spirit of “waiting for some illness.”

4. The child has problems with the biliary system, and the doctor, unsuccessfully trying to cope with them, decided that giardiasis was to blame (by the way, the most popular hypothesis). They don’t live in the gallbladder, they don’t! Even with duodenal intubation, when Giardia is removed from the small intestine, they are often in a very poor condition. And there’s nothing to say about the gallbladder. Combine the two simple premises given above and you will come to a simple conclusion that in the gallbladder bile the lamblia are simply dead. Here, too, we can “reinforce ourselves” with a quote from the same manual for pediatricians: “Currently, it is generally accepted, taking into account the achievements of modern methods of studying the biliary tract, that the pathology of the biliary system in children is predominantly functional in nature.” This means that an obvious, objective and therefore easily removable cause cannot be established.

5. The child suffers from frequent acute respiratory viral infections, colds, etc., the doctor recommended this test. It can be assumed that when sending for analysis, a complex scheme was implied in which Giardia harms the intestines and directly or indirectly leads to a weakened immune system. If Giardia had such an effect on the protective processes in the body, immunologists, not pediatricians, would take them seriously. In this situation, there seems to be nothing else to attach Giardia to. The severity of the disease (giardiasis) has nothing to do with immunity: it is known that in patients with AIDS, giardiasis does not worsen and does not transform into threatening forms. Antibodies to Giardia are practically not formed in healthy and weakened people. And this indicates that our immune system is absolutely indifferent to them and does not see Giardia as its enemies. In addition, Giardia does not produce toxins.

6. Attacks of acetonemic vomiting in a child, possible provocateurs of which are Giardia. Not a single serious medical book has covered this issue, so why then invent this dependence for those who do not write or read these books? It is necessary to treat using scientific facts, not shaky assumptions.

7. A child has skin problems, and you are looking for solutions to problems in the digestive tract. The skin is undoubtedly the kingdom of dermatologists, and you can turn to one of them. But not to someone who suggests starting a search for harmless Giardia. Remember, even if you undergo the necessary treatment and eradicate these protozoa from yourself, this will not guarantee a solution to your skin problems. Although it is quite likely that after taking strong antibacterial drugs there will be an improvement, because through the blood these drugs act on pathogens directly in the skin. And Giardia has nothing to do with it. As you can see, none of these 7 points have absolutely nothing to do with lamblia itself.

3. Is it worth fighting flagellar “monsters”?

In the USA, for example, there are only two competing positions on the issue of attitude towards Giardia carriage in children: 1) do not treat if there are no outbreaks of acute gastroenteritis in children's groups and 2) do not treat at all, since this still does not reduce the incidence ( and contamination).

Giardia, in principle, does not cause any particular inconvenience to a person. Almost 30% of the world's inhabitants are their latent carriers, and they cause them virtually no problems. At least until the “owner” knows about their existence and panics at the slight suggestion of a not-so-wise doctor. For reasons that are not entirely clear, some doctors have the habit of “chasing Giardia” for various disorders. Although the only officially recognized disease that occurs when there is an excess of Giardia in the duodenum is “giardiasis enteritis,” and to describe it very briefly, it is diarrhea, which usually goes away on its own within a few days.

According to infectious disease specialists and epidemiologists, one should think about the possibility of giardiasis when diarrhea appears, especially in children, occurring without pronounced manifestations of general intoxication in the absence of mucus and blood in the stool. Until the mid-60s of the past, i.e., the twentieth century, the question that Giardia can cause diarrhea generally remained controversial; researchers were confused by the colossal predominance of asymptomatic Giardia carriers among those examined. To be fair, it should be said that chronic giardiasis “enteritis” also occurs, but the reason for its chronicity has not yet been sufficiently studied. In principle, it cannot be called “enteritis” (inflammation of the intestines), because there is no inflammation. Of course, if you wish, you can remove Giardia from the body. But if you still set yourself this goal, then before you begin the intended “treatment” of the child, take the annotations of such drugs as, for example, trichopolum, tiberal and furazolidone. And if you don’t get the impression that you are “shooting sparrows with a cannon” when using such therapy for simple parasite carriers, then the only good thing is that you are not a doctor and therefore will not recommend this to others.

The conversation was conducted by I. Kovalkova.

Vasilenko V.V., gastroenterologist, candidate of medical sciences, associate professor of the department of internal diseases of the Moscow Medical Academy named after I.M. Sechenov, Moscow.

Please note: in January, a new book by Vasilenko V.V. “Secrets of Digestion”, 2009, went on sale.

Does the digestive system have secrets? It turns out there are a lot of them. Why bad breath and loud belching appear, what causes pain in the side and is it associated with a psycho-emotional state, why does the stomach growl after eating and how to stop sudden hiccups - every person encounters such phenomena, but not everyone knows how to deal with them cope with. What is “fishy odor disease” and the zigzag nutrition system, how to get rid of constipation and stop diarrhea without medications, is a low-calorie diet necessary and how diseases of the digestive system were treated 100 years ago - this is only a small part of what you have to learn.

The secrets of digestion are revealed by Vasilenko Vladimir Vladimirovich - associate professor, candidate of medical sciences, doctor, who has devoted 40 years to medicine.

V. Vasilenko, “Secrets of digestion” - ONLINE STORE : https://www.medknigaservis.ru/catalog/popularscientific/6452

published 05/27/2008 10:37 updated 01/24/2018 - Diseases of the gastrointestinal tract