Transcript Disorders of Gastrointestinal Tract

Child with Altered
Gastrointestinal Status
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Developmental and Biologic Variances
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Suck and swallow reflex develops at 34 weeks
Stomach capacity is 10-20 mL in the infant up to
3 liters by adolescence
Coordinated oral pharyngeal movements
necessary to swallow solids develops after age 2
months
Stool frequency is highest in infancy
Control of stool is achieved by 18 months to 4
years
Developmental and Biologic Variances
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Liver edge is palpable 1-2 cm in infants and
young children
Abdominal distension can cause respiratory
distress
Pancreatic amylase secretion does not begin
until age 4 months
Prenatal History
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Birth weight
Prematurity
History of maternal infection
Polyhydramnion
Focused Health History
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Congenital anomalies
Growth or feeding problems
Travel
Economic status
Food preparation
General hygiene
Family history of allergies
Present Illness
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Onset and duration of symptoms
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Weight loss or gain
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Recent changes in diet
Vomiting
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Reflexive = infection or allergy
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Central = central nervous system
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head trauma
meningitis
CNS tumor
Nursing Assessment
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Abdominal distention
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Abdominal pain
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Abdominal circumference
Acute / diffuse / localized
Abdominal assessment
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Inspect / auscultation / palpation / measure
Measuring Abdominal Girth
Bowden Text
Diagnostic Tests
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Flat plate of abdomen
Upper Gastrointestinal series (UGI)
Barium swallow / enema
Gastric emptying study
Abdominal ultrasound
CT scan with or without contrast
MRI
Endoscopy
Abdominal x-ray
5-year-old
s/p MVA
Diagnosis: hematoma
of duodenum
Treatment: NG tube, IV
fluids, electrolyte
maintenance
UGI Series with Barium
Diagnosis of appendicitis, tumors, abscess
CT of liver with metastasis
Endoscopy
Colonoscopy
Stool Sample
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White blood cells
Ova and Parasite
Bacterial cultures
Fecal fat
Stool pH
Rotazyme (rotovirus)
Blood
Blood Values
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Liver function tests: ALT, AST, GGT, ALP,
ammonia levels
Bilirubin direct and indirect
Hepatitis antigens
Total protein, albumin levels
Treatments
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Endoscopy
Surgical interventions
Ostomy
Nutritional therapy
Modified diet
Enteral nutrition
Failure to Thrive
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Inadequate growth resulting from inability to
obtain or use calories required for growth.
FTT is failure to grow at a rate consistent with
standards for infants and toddlers younger
than 3 years of age.
Symptom – not a diagnosis
FTT
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Organic
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Physical cause identified: heart defect, GER, renal
insufficiency, malabsorption, endocrine disease, cystic
fibrosis, AIDS.
Non-organic
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Inadequate intake of calories
Disturbed mother-infant bonding
No associated medical condition
Interdisciplinary Interventions
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If no medical cause is found focus of care is on
environmental / developmental / behavioral
cause
Occupational therapy to determine infant ability
to suck / swallow
Observation of infant / caretaker interaction
Calorie count to determine actual calories
consumed
Monitoring of height / weight / HC
Cleft Lip and Palate
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Most common craniofacial anomaly
Males 3 to 1
Higher in Asians
Familial history
Often diagnosed in utero by ultrasound
Cleft Lip
Incomplete fusion of the primitive oral cavity
• Obvious at birth
• Infant may have problems with sucking
• Surgery in 2 to 3 months
• Goals of surgery
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Close the defect
Symmetrical appearance of face
Feeding
Cleft Lip
Plasticsurgery.org
Cleft Lip Repair
Plasticsurgery.org
Post Surgery Care
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Airway management
Pain control / minimize crying
Position with HOB elevated 30 degrees
Elbow immobilizers
Suture line care as ordered by MD
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Cleanse with saline or dilute hydrogen peroxide to
remove crusts and minimize scarring
Arm Immobilizer
Cleft Lip Repair
Cleft Palate
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Cleft palate occurs when the palatine plates
fail to migrate and fuse between the 7th and
12th week of gestation.
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Diagnosed by looking into infants mouth.
A. Cleft Lip
B. Complex Cleft Lip
C. Cleft Lip
and palate
Note disruption of tooth development in D.
Cleft Palate Repair
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Babies should be weaned from bottle or
breast prior to the surgical procedure.
Done around 1 year of age after teeth have
erupted and before the child is talking to
promote better speech outcomes
Poor speech outcomes if done after 3 years
of age.
Post Surgery Repair
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Position on side
NPO for 48 hours
Suction with bulb syringe only
Avoid injury to palate with syringes, straws,
cups etc.
Long Term Referrals
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Hearing
Speech
Dental
Psychological
Team approach to care
Esophageal Atresia EA
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Congenital anomaly that results from failure
of the esophagus to develop normally.
The proximal esophagus ends in a blind
pouch instead of communicating with the
stomach.
EA is often associated with a tracheal
esophageal fistula (TEF)
Esophageal Atresia
Tracheal Esophageal Fistula
TEF
 TEF results from failure of
the trachea and
esophagus to separate.
Fistula
Assessment- Prenatal
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Clinical manifestations may be noted
prenatally
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History of polyhydramnios
Stomach cannot be easily identified on ultrasound
Assessment at Birth
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CaREminder: Excessive drooling of saliva
may be first symptom of TEF. When fed, the
infant sucks well but then chokes and coughs
as the feeding enters the lungs.
Diagnostic Tests
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Feeding tube is passed into the esophagus
but resistance will be felt.
Diagnosis confirmed by radiographs
Interdisciplinary Interventions
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Pre-surgery Care
Sump catheter in upper esophageal pouch to
provide continuous suction of pooled
secretions
Gastrostomy may be performed to provide
gastric decompression
Respiratory support
Antibiotics for aspiration pneumonia
Interdisciplinary Interventions
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Repair done within 24 to 72 if infants
condition is stable
Done through a thoracotomy or
thoracoscopic repair
Antibiotics
Acid suppression therapy
Chest tube, gastric decompression and
continued respiratory support
TPN
Esophageal Repair
Long Term Complications
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5 to 15% experience leaking at operative site.
Aspiration
Dysphagia / difficulty swallowing
Stricture of esophagus
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Coughing
Regurgitation
Pyloric Stenosis
Most common cause of gastric outlet
obstruction in infants.
 1 in 500
 More common in males
 3 weeks to 2 months of age
 History of regurgitation and non-bilious
vomiting shortly after feeding.
 Vomiting becomes projectile
Hypertrophic Pyloric Stenosis
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Most common cause of gastric outlet
obstruction in infants.
More common in males
2 to 4 per 1,000 births
Pathophysiology
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Hypertrophy and hyperplasia of the circular
smooth muscle of the pylorus of the stomach.
The lumen of the pylorus narrows and
lengthens and the gastric outlet is
progressively obstructed.
Pyloric Stenosis
Assessment
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History of regurgitation and nonbilious
vomiting during or shortly after feeding.
Within a week vomiting becomes projectile
Olive shape mass in the upper abdomen to
right of the midline
Weight loss and FTT
Because of persistent vomiting will often
present with dehydration
Interdisciplinary Interventions
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Initial goal of therapy is to correct any fluid
and electrolyte imbalance
NPO / NG tube insertion to empty and
decompress stomach
Comfort infant and caretakers
Interdisciplinary Interventions
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After fluid and electrolyte balance is reestablished surgery is the definitive treament.
Postoperative care:
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IV fluids
Oral feeding
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Starting with small amounts of pedialyte
Advance to full formula feedings as tolerated
Feeding Post-operatively
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Give 10 ml oral electrolyte solution after
recovered from anesthesia
Start pyloric re-feeding protocol.
Increase feeding volumes from clear fluids to
dilute to full-strength formula.
Keep feeding record
Assess for vomiting
Discharged when taking full-strength formula