Prothrombin according to Quick: what kind of analysis is it? If prothrombin according to Quick is increased, what does this mean for an adult?

Indicators below normal are a reason to prescribe coagulants.

A decrease in PC during pregnancy threatens a woman with thrombosis, blockage of blood vessels and related complications. In such situations, doctors usually prescribe anticoagulants - thinning drugs (warfarin).

The prothrombin test is part of the blood clotting test - coagulogram. In addition to the activity of this protein, indicators such as PI (prothrombin index, or PTI) and PT (prothrombin time) are also determined, allowing one to evaluate the rate of coagulation. The normal values ​​of prothrombin in women, men and children, as well as the reasons for their deviation from the norm, are described in detail below.

Prothrombin - what is it?

Prothrombin is a high molecular weight protein compound involved in blood clotting. Its production occurs in the liver in the presence of many substances. In particular, vitamin K, deficiency of which leads to the synthesis of incorrect prothrombin molecules - they form blood clots that disrupt blood flow and can be fatal.

A prothrombin test is needed to assess blood clotting, and the most accurate and universal method research is PC - prothrombin according to Quick. What it is? This test detects the activity of prothrombin in the patient's blood compared to that in a control portion of plasma. This is the ratio of the patient's plasma clotting time to the time of this process in the sample.

The analysis is named after the scientist A. Quick, who proposed this method. In the results of the Quick prothrombin test, it is expressed as a percentage. In international nomenclature it is given the number II, since it was discovered second after fibrinogen.

Quick analysis is used not only to assess the activity of blood clotting elements, but also to study the functioning gastrointestinal tract and liver. The PC test is more universal compared to the prothrombin time and prothrombin index tests.

List of indications to carry out the prothrombin analysis according to Quick:

• impaired blood clotting;
• liver diseases;
• antiphospholipid syndrome - increased thrombus formation due to autoimmune causes;
• blood cancer;
• pathologies in which the production of vitamin K is impaired (blockage biliary tract, poor digestibility of food in the intestines, etc.).

Help: Vitamin K is produced by bacteria in the intestines and is actively involved in the formation of prothrombin. Both its deficiency and its excess negatively affect the rate of blood clotting.

The PC test is necessary to monitor the hemocoagulation system during the use of anticoagulants - Heparin, Warfarin and others. The structure of the blood and its composition also change with the onset of menopause in women (after 45 years), which is a risk factor for the development cancer diseases. Therefore, at this age it is especially important to regularly get tested for prothrombin.

Prothrombin time - what is it?

Depending on the causes of bleeding, blood can begin to clot along two routes - internal or external. The first is activated if the vessels are damaged externally - as a result of a bruise, cut, scratch, bite, or abrasion. The internal pathway works when the integrity of the blood vessel wall has been damaged from the inside - under the influence of toxins, pathogenic microorganisms, antibodies.

Prothrombin time is an indicator that reflects the work of the internal pathway in the hemocoagulation system.

It reflects the effectiveness of “repairing” vessels that have been damaged by compounds circulating through the bloodstream. In test results, prothrombin time may be referred to as PT, ecombipl RT or RT.

Prothrombin time is increased, compared to the norm, in the following conditions:

• lack of vitamin K;
• initial stage of DIC syndrome;
• liver pathologies;
• taking drugs from the group of anticoagulants - Thromboassa, Aggregal, Warfarin, Heparin and others;
• hemorrhagic diathesis of newborns;
• inflammation and blockage of the biliary tract;
• Zollinger-Ellison syndrome;
• impaired absorption of fats in the intestines;
• deficiency of coagulation factors - prothrombin, AC globulin, proconvertin and Stewart-Prower factor.

The lower the concentration of prothrombin in the blood, the higher the prothrombin time, because the blood clotting process occurs more slowly.

Prothrombin time is decreased, if the following conditions occur:

• pregnancy;
• DIC syndrome;
• high levels of antithrombin-III and other anticoagulants produced by the body;
• deviation from the norm of hematocrit - the ratio of the volume of blood cells to the volume of plasma.

Low prothrombin time during the test may be due to long storage plasma before the study and irregularities during blood collection.

The prothrombin index is an indicator that reflects the rate at which blood clotting starts. inner path. It is calculated on the basis of prothrombin time, so its increase is observed with the same disorders in the body as an increase in PT, as well as a decrease.

To determine the PTI, the patient's plasma clotting time is divided by this value in the control sample. Normally, the result should be 95-105%.

The accuracy of the prothrombin index test depends on the sensitivity of the drugs used in the laboratory. Therefore, it cannot be called universal, unlike the Quick prothrombin test.

Increased prothrombin

If the Quick prothrombin test is elevated and shows high values ​​(up to 150% or more), the reason for this may be:

• DIC syndrome;
• cholestasis and other diseases that reduce the activity of vitamin K;
• diseases that impair the functioning of fibrin;
• hereditary and acquired pathologies leading to a deficiency of coagulation factors (liver disease, nephrotic syndrome).

Increased prothrombin also appears with long-term use of drugs:

• antibiotics;
• diuretics;
• Aspirin;
• indirect anticoagulants;
• anabolic steroids;
• Methotrexate;
• laxatives;
• nicotinic acid;
• Heparin and other clotting inhibitors.

Prothrombin norm, table

The extreme values ​​of PC are figures below 78 and above 142%. Prothrombin standards according to Quick are presented in the table.

Norms of prothrombin in men and women of the same age group do not differ. Normal prothrombin time values ​​for both sexes are 9-12 seconds. The rate of prothrombin in the blood of women expecting a child is slightly higher than normal values.

Low prothrombin

Low prothrombin according to Quick always indicates excessive rapid education blood clots and can be triggered by conditions such as:

• pregnancy and postpartum period;
• vein thrombosis;
• penetration of thromboplastin into blood vessels due to tissue damage;
• high blood viscosity (polycythemia).

The decrease in PC can be explained by this dependence - the activity of the prothrombin protein is high, the blood clots faster compared to the control plasma sample, therefore the Quick test for prothrombin is lower than normal.

Low Quick prothrombin can also be caused by taking Mercaptopurine, hormonal contraceptives and other drugs that increase blood density.

Prothrombin during pregnancy

A coagulogram is a mandatory part of the tests for pregnant women. Evaluation of this study, including prothrombin tests, allows for the timely identification of conditions dangerous to the health of the child and the expectant mother.

Prothrombin according to Quick during pregnancy is normally slightly reduced, that is, the activity of the coagulation system increases. This is due to the emergence of a new blood circulation and the body’s preparation for the upcoming birth and possible blood loss.

A very low PC can provoke the development of thrombosis, and its increase in pregnant women can cause severe bleeding during childbirth, including internal bleeding.

Severe bleeding can cause hemolytic shock due to the mixing of the blood of mother and child. This is one of common reasons postpartum mortality. To avoid this, in this situation, not only monitor and control the state of the coagulation system, but also introduce immunoglobulins at 28 weeks of pregnancy, which destroy potentially dangerous antibodies.

• The normal prothrombin index for women carrying a child is 80-100%. With him high values To avoid thrombosis and other complications, drugs that reduce increased activity coagulability.
• Low PI, on the contrary, carries a risk of bleeding. Normal value prothrombin time for pregnant women - 11-18 seconds. During pregnancy, any deviation from the norm in the coagulogram is a reason for a thorough examination and, in most cases, hospitalization.

Prothrombin is a complex protein produced in the liver. Based on its quantity, a conclusion is made about the blood coagulation system. For the analysis result to be informative, fasting blood, better in the morning, between eight and eleven o'clock.

Before blood sampling, at least eight and no more than fourteen hours must pass after the last meal. During this time, you can only drink water. The day before the analysis, you need to limit fried and fatty foods, do not drink alcohol, it is necessary to exclude heavy physical exercise. Psycho-emotional and physical stress should be eliminated within half an hour before the test. You can’t do it for half an hour before taking blood.

Blood sampling should be carried out before taking medications and no earlier than one to two weeks after taking them. If their use cannot be stopped, in the referral for the study the doctor must indicate which drugs the patient is taking and in what doses.

High level fibrinogen indicates acute inflammatory processes and about tissue death, it may be associated with increased risk hypertension, heart attack, stroke, diabetes and even cancer. Increased fibrinogen causes inflammatory damage to arterial walls in the body, preparing the ground for atherosclerotic plaque and blood clot formation. A blood clot blocking one of the arteries in the brain can cause a stroke, and thrombosis coronary artery provokes the development of myocardial infarction.

Too much low level fibrinogen may cause heavy bleeding that are difficult to stop. As a rule, it is the result of a donor, large blood loss, when using drugs. A decrease in its concentration is also observed in congenital hypofibrinogenemia and afibrinogenemia, secondary disorders of fibrinogen formation in the liver, as well as in coagulopathies of various origins. For normal clot formation, the minimum required level of plasma fibrinogen should be 0.5 g/l.

During pregnancy, the membranes of the embryo form. The membrane cells of the embryo, that is, the chorion cells, synthesize the hormone human chorionic gonadotropin (hCG) into the woman’s blood. All studies for diagnosing pregnancy are based on the determination of this hormone.

You will need

• - referral to a gynecologist.

Instructions

To diagnose pregnancy, a blood test for human chorionic gonadotropin (hCG or hCG) is performed.

A blood test for hCG is carried out in specialized laboratories on the direction of a gynecologist.

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What it is? Prothrombin is a protein involved in the blood clotting mechanism; its synthesis occurs in the liver with the participation of vitamin K. Clotting involves the transition of blood from a liquid to a thick state.

To function comfortably in the body, blood must have a liquid consistency. When blood vessels are damaged, a process of coagulation—thickening—must occur. The body cannot lose a large volume of blood and clog the vessels with numerous blood clots.

• Laboratory analysis for prothrombin allows you to assess the quality of the coagulation mechanism.

Like any analysis, a prothrombin test is taken on an empty stomach. Patient who cannot perform this condition for health reasons, eats 4-5 hours before the procedure. Drugs that affect blood clotting cannot be taken before the test - the results will be far from the truth. If you refuse medicine If it doesn’t work, notify your doctor about taking it.

An analysis of the quality of blood clotting is necessary for the following diseases and suspicion of their presence:

• Antiphospholipid syndrome in pregnant women (it is manifested by miscarriages, frozen pregnancies, placental insufficiency and other obstetric complications);
• Liver pathologies;
• Atherosclerosis, varicose veins;
• Imbalance of vitamin K in the body;
• Presence of autoimmune diseases;
• Long-term use of indirect anticoagulants.

The prothrommin test may also be prescribed for other diseases to screen for coagulation. Under a microscope, the natural mechanism of blood clotting is recreated.

Potassium ions and thromboplastin are added to recalcified plasma. The prothrombin complex has several coagulation factors - the analysis allows us to identify a deficiency or surplus of such factors.

Prothrombin time - what is it? (norm)

Prothrombin time is the period of blood clotting from the moment a mixture of potassium and thromboplastin is added to the plasma. Thromboplastin, used in laboratories, has a certain level of sensitivity to factors II, V, VII and X.

The normal prothrombin time is from 11 to 16 seconds, but the activity of the substance may vary depending on the sample. Accordingly, draw conclusions by comparing general meaning The result in seconds is incorrect. A relative assessment is required.

Prothrombin index - what is it? (norm)

Prothrombin index is the ratio of the fixed normal blood clotting time to individual indicator patient. The prothrombin index can be determined more accurately using the INR (international normalized ratio) analysis.

The prothrombin index mathematically corrects the prothrombin time. Individual result in seconds divided by a fixed rate healthy person and multiplied by the sensitivity coefficient of the taken thromboplastin. The number of the latter is from 1 to 3; it can be found in the universal international classification.

Remember, when determining the prothrombin index: the norm for women and men is the same - from 0.8 to 1.3. But the rate may vary depending on age and health status.

The results of the preoperative study should not go beyond 0.85 - 1.25. An indicator of 3.0 - 4.0 is observed in a patient who has suffered a myocardial infarction or suffers from serious cardiovascular diseases.

The normal prothrombin index is 2.0 – 3.0 in the case of:

• Heart valve defects;
• Chronic atrial fibrillation and taking Warfarin against its background;
• Treatment of venous thrombosis and prevention of deep vessel thrombosis after surgery;
• Implantation of mitral and aortic valve prosthesis;
• Treatment of thromboembolism in the pulmonary artery area.

A prothrombin index according to INR above 6.0 requires urgent hospitalization of the patient. This coefficient indicates high risk internal bleeding in various locations.

The situation becomes more complicated if the person has already had ulcerative lesions gastrointestinal tract, renal failure, hypertension and blood flow disorders in the brain. In this case, the potential risk of hemorrhagic (bleeding-related) infarctions in organs increases.

If unsatisfactory results of the analysis using the INR system are obtained, a repeat study is not required (the result is very sensitive and reliable). The index values ​​do not differ depending on the type of laboratory material taken (capillary, venous blood).

• The prothrombin index is calculated taking into account the sensitivity of thromboplastin to blood clotting factors.

Prothrombin according to Quick - what is it? (decreased, increased and normal)

For several decades, prothrombin has been calculated using the Quick method in laboratory conditions. What it is? This is the percentage expression of prothrombin activity. The scientist proposed comparing the patient’s prothrombin time with the indicator of the dependence of this period of time on the number of prothrombin complex factors in the taken plasma. The result is a percentage.

The construction of the dependence allows you to very accurately estimate the coagulation index, but the sensitivity coefficient of thromboplastin is not taken into account.

This feature of the test affects the quality of the result in the area of ​​critical values ​​below and above the norm. In standard results and minor deviations from them, the INR and Quick index are directly proportional.

• The test results card in any laboratory will contain prothrombin according to Quick. The norm is in the range of 78% - 142%. The indicator may be slightly higher than the average, but it should be within normal percentages.

In a healthy body, blood clotting is often increased - hypercoagulation is observed. This process is considered normal until a person develops any vascular diseases or chronic tissue damage. Their presence becomes a risk of blood clots.

Regular screening is necessary after blood thinning medications are prescribed. In some cases, a depot (the stage of accumulation of a substance) can form in the body from these drugs, which will lead to a state of hypocoagulation with increased bleeding.

In addition, the analysis results may also show the opposite process - hypercoagulation (increased coagulation activity). Indicators of insufficient blood density are observed much less frequently than excess blood density.

• However, any pathology of prothrombin factors requires control or even treatment.

Increased prothrombin in men and women

Prothrombin in men and women over 45-50 years of age is often increased - more than 142% according to Quick. Hypercoagulation can be caused both by the presence of vascular diseases and by temporary factors. The latter include:

• Imbalance of vitamin K, which interferes with the proper synthesis of prothrombin in the liver, where it is normally formed;
• Chronic liver diseases and disorders of its functioning, which also interfere with the normal synthesis of prothrombin;
• Congenital anomalies: deficiency of blood coagulation factors II, V, VII, X;
• The presence of a heparin inhibitor in the coagulation mechanism;
• Nephrotic syndrome, amyloidosis (deposition of a special pathological protein in organs);
• Taking antiseptic, laxatives, anabolic drugs, hormonal drugs, nicotine and acetylsalicylic acid, quinine, quinidine.

Increased prothrombin not due to the above factors indicates the presence of serious illnesses. Thus, the diagnostic search is based on the following nosologies:

• Thromboembolism (blockage of blood vessels with blood clots);
• Polycythemia (increased number of red blood cells in the blood, including in connection with oncological processes);
• Oncological diseases: leukemia, cancerous tumors various localizations;
• Pre-infarction state of the body;
• Myocardial infarction.

Prothrombin in women may be increased due to long-term use hormonal contraceptives, especially with increased dosage estrogenic component (from 30 to 50 mcg in 1 tablet).

If the patient has serious vascular disease, birth control pills needs to be cancelled. Possible transition to hormonal drugs local effects (suppositories, vaginal ring).

Diet does not significantly affect blood clotting. You can reduce the Kwik score by several percent by adding daily menu"oxidizing" products. Increased result causes lack of diet fermented milk products, red and black berries, citrus fruits, fatty varieties fish and the amount of water drunk.

Low prothrombin - what does it mean?

Low prothrombin is observed during hypocoagulation. This result indicates the body’s tendency to internal bleeding. A deficiency of coagulation factors occurs in the following situations:

• Vitamin K deficiency is a violation of prothrombin synthesis;
• Congenital deficiency of certain factors regulating processes in the blood;
• Pathologies of the liver that interfere with the normal synthesis of coagulation factors;
• Lack of fibrinogen in the blood (congenital and acquired);
• Taking medications that reduce the blood's ability to clot.

A low prothrombin level indicates the following diseases:

• Dysbacteriosis;
• Pathologies of the gastrointestinal tract;
• Prothrombin deficiency;
• Hypovitaminosis.

Adjust slightly reduced rate prothrombin can be achieved with the help of foods containing vitamin K. Cabbage, carrots, bananas, apples, pears, spinach and lettuce will be useful.

The reason for poor results in diet concerns men more often than women. It is the male gender that prefers meat products vegetables. As a result of such addictions, a deficiency of vitamins appears in the body.

Prothrombin during pregnancy

For pregnant women, a test for the prothrombin index is mandatory. During childbirth, a low reading can lead to heavy bleeding, and high - to premature contractions and even late miscarriage.

Therefore, it is very important to evaluate this indicator during gestation, especially if there are various complications both during this pregnancy and during the previous one.

During gestation, a blood test for the prothrombin index is taken at least 3 times (once per trimester). If expectant mother significant deviations are diagnosed, it is necessary to do a coagulation test more often. The rate of prothrombin in the blood of women during pregnancy is lower than usual - from 70% to 120%.

Disturbances in the blood clotting mechanism of pregnant women are indicated by:

• Varicose veins on the limbs;
• Bleeding and noticeable bruising after minor injuries;
• Improper liver function;
• A long period of lack of results when trying to conceive;
• Conception through the IVF procedure;
• Multiple pregnancy;
• Fetal development lags behind norms;
• Drinking alcohol, smoking by the expectant mother;
• Long-term treatment with anticoagulants;
• Multiple miscarriages.

Since prothrombin according to Quick decreases during pregnancy, the INR index also decreases. Changes are especially noticeable in the second trimester of gestation. Until the 13th week, the coefficient should correspond to the norm: from 0.8 to 1.3. Then the indicator decreases:

1. From the 14th to the 20th week, the prothrombin index according to INR ranges from 0.55 to 1.1;
2. From the 21st to the 28th week, the indicator can decrease to 0.5, but cannot exceed 1.15;
3. From the 29th to the 35th week the result is 0.6 – 1.17;
4. From the 36th to the 42nd week the index is from 0.55 to 1.15.

In the case of pregnant women, the INR indexing method is preferred. The indicators are quite low, and the Quick method produces errors at critical values.

IN human body There is a constant movement of blood - a life-giving fluid that provides nutrition to all cells of the body and metabolism. The length of the vessels is thousands of kilometers, and their area is more than half a hectare. It is impossible to imagine how all this fits in the body of an adult.

But the amount of life-giving fluid is small: for men - a little more than five liters, and for women - about four. Therefore, when injuries or cuts compromise the integrity of circulatory system, its contents can spill out quite quickly, threatening a person with death.
If blood loss is not prevented, the main transport link that nourishes the entire body will cease to exist.

To prevent this from happening, nature has created a system responsible for blood clotting. She is the one who can launch defense mechanisms, closing the wound and preventing blood from leaving the vessels.

The value of prothrombin in the body

Part of this system are special plasma proteins called blood clotting factors. They are designated by Roman numerals from I to XIII. Prothrombin is one of the main components. This protein is blood clotting factor II.

The name “prothrombin” suggests that it is a precursor to thrombin, an active enzyme. With its assistance, a clot (thrombus) is formed, closing the wound and stopping blood loss.

A normal level of prothrombin indicates that the blood clotting process is working efficiently and the body will be able to stop the loss of this life-giving fluid in time.

Protein testing is not performed as often as clinical blood testing. This procedure is not easy and is prescribed only in cases of extreme necessity, for example in case of blood diseases or problems with blood clotting.

Determination of prothrombin level – the most important test as part of a hemostasiogram.

Norm of prothrombin

Prothrombin molecules disintegrate very easily and quickly. It is difficult to separate them from other proteins, which makes determining its level much more difficult. For qualitative analysis Several methods are used.

• Prothrombin according to Quick. Today this method is generally accepted and widespread. This technique involves calculating the level of a substance as a percentage of the permissible amount. The following values ​​(%) are considered optimal:
  • minimum – 70;
  • maximum – 120.

  The indicator allows you to determine the activity of the thrombosed plasma complex in comparison with various dilutions of the patient’s plasma. A graph of changes in prothrombin is drawn up, which is based on data on blood clotting time.

  Experts consider the Quick analysis to be the most accurate when low prothrombin levels are recorded.

• Prothrombin index– also determined as a percentage. Normal indicator is within the following limits (%):
  • minimum – 95;
  • maximum – 105.

  The results of the two tests above may be the same if prothrombin is normal. But when its value is lower than optimal, they diverge significantly. The index is very dependent on sensitivity chemical reagents, used in testing.

• Prothrombin time– shows how many seconds it takes the plasma to coagulate after adding a special mixture to it.

  The final test data depends on age. In newborn babies, blood clotting time can range from 14 to 18 seconds. And these indicators are normal. In adults, a period of 10 to 15 seconds is considered optimal.

• International normalized ratio - INR. This method is additional and is used to monitor the results of the prothrombin test.

  The INR method is recommended by WHO experts and others international organizations and committees that study thrombosis and deal with standardization in hematology. The results of such a test allow the doctor to monitor the effectiveness of treatment with anticoagulants - synthetic substances that reduce the level of prothrombin in the blood and slow down its clotting. These drugs are used in the treatment of thrombophlebitis, thrombosis, that is, diseases that form dangerous blood clots in the venous vessels.

  The normal INR is 0.85–1.15.

  When is therapy carried out for diseases such as pulmonary embolism, venous thrombosis, or pathologies of the heart valves are present, the permissible limits increase to 3.0.

Indications for prothrombin test

A blood test for prothrombin may be prescribed by a doctor in the following cases:

• the patient has bleeding that does not stop for too long (this clearly indicates that blood clotting is below normal levels);
• the performance of liver enzymes and the liver in general decreases;
• to monitor clotting during long-term use anticoagulants;
• at antiphospholipid syndrome in order to clarify the cause of the disease;
• if there are diseases that are accompanied by a lack of vitamin K in the body.

Some indirect reasons requiring a prothrombin test are purely individual in nature. Most often, the study is prescribed to representatives of the fair sex between the ages of 50 and 60. It is at this time that the hormonal changes, causing change in the composition and structure of blood.

The following doctors can prescribe an analysis:

• therapist;
• traumatologist;
• surgeon;
• cardiologist;
• anesthesiologist-resuscitator;
• pulmonologist;
• pediatrician.

Blood from a vein is used for the study. To ensure that the results are as correct as possible, you must follow the standard rules before the study:

• dinner no later than eight o'clock in the evening, at least 12 hours before testing;
• Before the study, be sure to get your nerves in order and not overexert yourself physically;
• Do not smoke on the day of the test and do not drink strong drinks.

As usual, blood is donated in the morning on an empty stomach. Need to inform medical staff about everyone medicines, which were taken in the last 24 hours.

Prothrombin is increased

An increased level of prothrombin in the blood indicates that blood clotting is greater than normal. This means that it becomes too viscous, which impedes blood circulation and leads to blockage of blood vessels.

The following ailments can provoke an increase in prothrombin levels, and therefore blood clotting:

• malignant neoplasms;
• liver pathologies;
• thromboembolism;
• polycythemia;
• progressive angina.

An increase in the amount of protein can also be caused by the following factors:

• an excess of vitamin K in the body, with the help of which prothrombin is produced;
• use in therapy of anticoagulants, antibiotics, nicotinic acid, hormonal contraception. Excessive use aspirin, anabolic steroids, laxatives can also affect the growth of prothrombin.

Quite often, the protein content increases during pregnancy. Most often it appears in the last trimester and does not require treatment.

Prothrombin is reduced: reasons

A reduced level of prothrombin is dangerous because even a minor injury that damages blood vessel, can result in significant blood loss. After all, the formation of a blood clot occurs more slowly than it should.

A decrease in prothrombin levels is provoked by the following reasons:

• Certain liver pathologies, although most of them are accompanied by an increase in protein. The prothrombin content decreases during acute and chronic forms hepatitis A. Liver cirrhosis has a similar effect.
• Insufficient synthesis of vitamin K by the body. This process develops most often due to gastrointestinal ailments and dysbiosis.
• Deficiency of fibrinogen, a protein that is produced in the liver and then converted into fibrin, which is the basis of the clot during blood clotting. Such a deficiency can be either congenital or acquired.
• Admission to medicinal purposes drugs that promote blood clotting.

It is possible to bring the prothrombin level back to normal, but anything should be done only after consulting a specialist.

Therapy is aimed at eliminating the ailments that caused the problem. Quite often the basis of treatment is special mode nutrition.