Gastrointestinal Part III

Jan Bazner-Chandler RN, MSN, CNS, CPNP

Intussusception Telescoping of part of intestine into an adjacent distal portion.

Bowden Text

Intussusception     Common cause of intestinal obstruction in children ages 3 to 25 months Proximal segment of bowel prolapses or telescopes into the lumen of an immediately distal segment of bowel.

The prolapse results in vascular compromise, edema and mechanical obstruction.

Bleeding results in the passage of blood and mucous in the stool.

Assessment       Child appears with intermittent pain which is colicky, severe Child will often draw legs up Episodes occur 2-3 times / hour Vomiting is prominent feature – bile stained vomiting a late sign Bowel movements – bloody / mucous Classic current jelly stool is a late sign

Clinical Manifestation Mucous + blood = classic “currant jelly” stool

Diagnostic X-ray

Reduction of Intussusception

Management    Reduce the obstruction before the bowel becomes necrotic.

Contrast Enema is diagnostic in 95% of cases and therapeutic curative in most cases.

Surgical reduction is radiologic reduction is not achieved.

Surgical Intervention  IV fluids + antibiotics pre-operatively.

 Manual reduction is attempted.

 If bowel perforation is noted during operative procedure a temporary colostomy may be needed.

Hirschsprung Disease

Hirschsprung Disease   Congenital megacolon is a congenital absence of ganglio cells (ganglia). This results in obstructed passage of stools causing the normal bowel to distend.

Assessment      In the newborn No meconium in the first 24 hours Bilious vomiting Abdominal distention Fever     Older infants / children History of chronic constipation or fecal mass Abdominal distention Failure to thrive

Diagnosis and Treatment     Rectal biopsy Removal of the aganglionic portion of the colon.

1 st stage surgery is often a colostomy 2 nd stage is pull-through surgery to connect the working colon to a point near the anus.

Typical X-ray

Colostomy at Birth Goal is to close colostomy and do “pull through” surgery at 6 to 12 months.

Long Term Complications  Anal stricture  Incontinence of stool  Short bowel syndrome

Appendicitis

 Pathophysiology Inflammation of the vermiform appendix.

 Obstruction at base blocks outflow of mucus.

 Pressure builds up  Blood vessels are compressed.

 Perforation and rupture

Assessment        Abdominal pain Generalized to localized Mc Burney’s point Rebound tenderness Loss of appetite Vomiting Low grade fever

Appendectomy Appendectomy

Ruptured Appendix Child develops high fever after a period of feeling better.

Perforation      Alert: With perforation of appendix, abdominal pain is suddenly relieved, but as peritonitis develops, it returns, along with signs of generalized acute abdomen.

Child will guard area of pain Abdominal distension High fever May appear dehydrated

Interventions for Perforation      Extra fluids may be needed – a bolus of normal saline NG may be inserted to decompress the stomach IV antibiotics prior to surgical procedure Fever control Pain control

Post Operative Care Penrose drain acts as a wick to help drain the peroneal cavity after a ruptured appendix.

Interdisciplinary Interventions       Monitor I & O Assess for bowel sounds Dressing change as ordered Ambulate ! Ambulate ! Ambulate !

Cough and deep breath Pain Management

Gastroesophageal Reflux Disease

GER or GERD     Effortless passage of gastric contents into the mouth (regurgitation) or esophagus.

Occurs in 1 in 500 infants Higher incidence of GERD in esophageal atresia, neurologic impairment, cystic fibrosis, s/o omphalocele repair, chronic lung disease, bronchopulmonary dysplasia, asthma By 1 year of age most infants with mild or moderate reflux are symptom free

GERD: Gastro-esophageal Reflux Disease

     Infant older than 6 months, infant / child with congenital or neurological problems.

GER not relieved by simple measures.

  Clinical Manifestations: Regurgitation of feedings with slow growth / poor weight gain Esophagitis = excessive crying Apnea / Respiratory problems Anemia

Diagnostic Tests     Barium swallow or Upper GI series Gastric emptying study Upper GI endoscopy 24 hour pH monitoring

Conservative Management • Thickened formula • Frequent burping • Positioned with head elevated after feeding • In infant with severe GERD positioning prone with head of bed elevated

Surgical Management •

Nissen fundoplication

• Fundoplication creates a one way valve by wrapping the gastric fundus 360 degrees around the lower end of the esophagus • In severe cases may have G-tube for 6-8 weeks after surgery

Inflammatory Bowel Disease    A group of diseases characterized by inflammation of the GI tract.

Crohn’s Disease Ulcerative Colitis

Inflammatory Bowel Disease    Refers to two chronic diseases that cause inflammation of the intestines.

Ulcerative Colitis Crohn’s Disease

Causes     Most likely a genetic link that affects the immune system.

Incidence is increasing in both the pediatric and adult population Prognosis depends on the type, severity and extent of the disease Higher incidence of developing colorectal cancer 

Ulcerative Colitis    Inflammatory disease of the large intestine. The inner lining or mucosa becomes inflamed, swells and ulcers develop.

Affects the lining of the bowel.

Most severe in the rectal area and anus.

Crohn’s Disease    Differs from ulcerative colitis in the areas of the bowel affected.

Most often affects the small intestine and parts of the large intestine. Inflammation that extends deeper into the layers of the intestinal wall than ulcerative colitis.

Crohn’s Disease

Assessment   Ulcerative colitis: Bloody diarrhea with crampy, left-sided lower abdominal pain Crohn’s disease: watery diarrhea with right lower quadrant pain    Both have Weight loss Anemia

Diagnostic Tests  Erythrocyte sedimentation rate ESR  Stool for gross or occult blood  Colonoscopy evaluation and biopsy  Genetic marker / family history

Pharmacologic Therapy     Corticosteroids during acute phase Mesalazine – anti-inflammatory drug for mild to moderate cases. Immunosuppression drugs: Azathioprine, methotrexate, 6 mercaptopurine Remicade has been approved in severe cases

Long Term   Surgical removal of bowel if not managed by medical management.

    Complications: Alteration in body image due to steroids Arthritis Osteoporosis Increase risk of colorectal cancer

Diagnostic Work-up for GERD  Upper GI series  Esophageal pH monitoring  Endoscopic exam

Pharmacologic Therapy    Medications to reduce symptoms including antacids or histamine-2 blocking agents Histamine 2 blocker: cimetadine Reglan or metaclopramide to enhance gastric emptying

Necrotizing Enterocolitis Necrotizing = damage and death of cells Entero = refers to intestines Colitis = inflammation of the colon

NEC      60 to 80% are premature infants Feeding of concentrated formulas Infants who have received blood transfusion Infants with GI infections Infants with polycythemia: congenital heart disease

Clinical Manifestations      History of formula feeding Feedings stay in stomach Abdominal distention / shiny abdomen Bile-green fluid in stomach Bloody bowel movements

Gas filled loops of bowel in NIC.

Interdisciplinary Interventions        NPO Nasogastric tube to decompress stomach IV fluid replacement Antibiotics Extra oxygen Abdominal x-rays to monitor progress Measure abdominal girth every four hours

Complications     Intestinal perforation Surgery to remove dead bowel Colostomy or ileostomy Bowel is reconnected when infection and inflammation have resolved

Celiac Disease  Malabsorption caused by a life long intolerance to dietary gluten.

  1 in 100 children in USA Genetic predisposition

Celiac Disease Celiac.com

Small villi lining the intestine are damaged by the body’s immune system.

Assessment    Nutritional assessment Evaluate patterns of growth    Typical presentation is after gluten products are introduced into the diet Chronic diarrhea Bulky, foul smelling, greasy stools Abdominal distention with muscle wasting and hypotonia

Management   Gluten free diet Limit the intake of wheat, barley, rye containing foods

Lactose Intolerance    Inability to digest significant amounts of lactose.

Lactose that is not broken down can cause abdominal distention and bloating.

Lactose tablets to help breakdown lactose containing foods.