Transcript Disorders of Gastrointestinal Tract

Gastrointestinal Disorders
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Embryonic Development
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Failure to fuse = cleft lip and palate
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Failure to differentiate = duodenal stenosis
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Atresia or abnormal closing of structure:
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Esophogeal atresia
Anal-rectal malformation
Biliary atresia
Fetal Development
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Fistula is an abnormal connection
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Tracheal esophageal fistula
Anal-rectal malformations with fistula
Incomplete or abnormal placement
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Mal-rotation
Diaphragmatic hernia
Prenatal History
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Birth weight
Prematurity
History of maternal infection
Polyhydramnios
Down Syndrome
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
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Fluid
Gas
Structural changes
Barium swallow or UGI
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Strictures
Foreign body
Motility disorder
Diagnostic Tests
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Ultrasound
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Visualize organs
Cysts
Abscess
appendicitis
CT scan = tumors, abscess, obstruction
24 hour probe = Gastro esophogeal reflux
Biopsy of liver, esophagus, stomach, intestine
Stool and Blood
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White blood cells
Ova and Parasite
Bacterial cultures
Blood
Failure to Thrive
Inadequate growth resulting from inability
to obtain or use calories required for
growth.
FTT
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Organic
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Non-organic
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Physical cause identified: heart defect, GER, renal
insufficiency, malabsorption, endocrine disease, cystic
fibrosis, AIDS.
Inadequate intake of calories
Disturbed mother-infant bonding
Idiopathic: unexplained
Cleft Lip and Palate
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Most common craniofacial anomaly
1 in 700 births
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
Plasticsurgery.org
Post Surgery Care
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Airway management
Pain control
Position in infant seat – upright position
Elbow restraints
Wound care as ordered by MD
Minimizing crying
Feeding techniques
Cleft Lip Repair
Cleft Palate
Cleft palate occurs when the palatine plates fail
to migrate and fuse between the 7th and 12th
week of gestation.
Diagnosed by looking into infants mouth.
Cleft Palate
Pedisurg.com
Cleft Palate
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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.
Palate Repair
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Pre-surgery feeding
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Alternate nipple design
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Breast feeding consultant
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ESSR
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Enlarge / stimulate / swallow / rest
ESSR
TIP 18-2: Bowden Text
Devices For Feeding
Lamb’s nipple
Flanged nipple
Special nurser
Syringe with rubber
tubing
Whaley & Wong
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
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Esophagus ends in a
blind pouch.
Infant has a lot of
mucous at birth.
The rationale for giving
sterile water for the first
feed.
Bowden Text
E.A. Tracheo- esophageal Fistula
85 to 90% of defects
Failure of the esophagus
to recanalize between
4th and 6th week of
development.
Bowden Text
Clinical Manifestations
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Excessive drooling / frothy mucus
Inability to pass NG tube
Choking and cyanosis with feeding
High risk for aspiration of HCL from stomach
causing a chemical pneumonia.
X-ray Findings
Pre-surgery Care
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NPO
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Up in infant seat or HOB elevated
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Continuous suction
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G-tube to decompress stomach
Post Surgery Care
Ball & Bindler
Post Operative Care
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Respiratory support
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Gastric decompression
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Chest Tube
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Gentle suctioning
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TPN until taking PO’s
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Antibiotics
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
Pyloric Stenosis
Ball & Bindler
Clinical Manifestations
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Projectile vomiting
Visible peristaltic waves
Olive shape mass in the upper abdomen to
right of the midline
Electrolyte imbalance
Management Pre-surgery
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NPO / document any emesis
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IV therapy / Correct electrolyte imbalance
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Comfort infant and caretakers
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
Hernias
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A hernia is a protrusion of an organ or
part of an organ through the wall of the
cavity in which it is contained.
Inguinal Hernia
Bowden & Greenberg
Inguinal Hernia
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Inguinal hernia is the most common
congenital anomaly requiring surgical repair
in infants: 80%
It is a protrusion of peritoneal sac into the
processus vaginalis
Most common in males and pre-term infants.
Inguinal Hernia
Hydrocele
Bowden & Greenberg
Hydrocele
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Caused by peritoneal fluid communication
with the scrotal area through a patent
processus vaginalis.
Often will resolve on its own unless
associated with an inguinal hernia.
Umbilical Hernia
More common in
African
American infants.
Diaphragmatic Hernia
Congenital diaphragmatic hernia is the
protrusion of abdominal contents into the
chest cavity through a defect in the
diaphragm.
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1 in 5,000 births
Mortality rate is 40 to 50%
Diaphragmatic Hernia
Bowden & Greenberg
Clinical Manifestations
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Chest appears barrel-like
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Abdomen is sunken
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Bowel sounds in chest
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Breath sound decreased
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Severe respiratory distress
Diaphragmatic Hernia
Pedsurg.com
X-ray Diaphragmatic Hernia
Treatment
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ECMO
Ventilator support
Chest tube
Umbilical artery catheter
NG tube
Surgical correction when stable
Long Term Problems
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Gastro Esophogeal Reflux
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Respiratory infections
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Obstructions
Abdominal Defects
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Omphalocele
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Gastroschisis
Omphalocele
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Congenital malformation in which abdominal
contents protrude into the base of the
umbilical cord.
Omphalocele
Omphalocele
Gastroschisis
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Defect in the abdominal wall that allows the
abdominal contents to protrude outside the
body.
There is no covering over the bowel or
contents.
Defect does not involve the umbilicus.
Gastroschisis
Immediate Nursing Intervention
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Cover with warm normal saline dressing in
the delivery room.
New standard: put child in small bag to retain
heat and keep intestines warm.
Gastroschisis Repair
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If a small defect can be repaired with one
surgery.
I abnormality is large surgeon may use
Silastic Silo to gradually return the bowel to
the abdominal cavity.
Silastic Silo
Treatment
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Long term complications:
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Obstruction
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Weak abdominal wall
Prune Belly
Intussusception
Telescoping of part of
intestine into an adjacent
distal portion.
Bowden Text
History
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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
Severe abdominal pain
Inconsolable crying
Draw knees up
Currant jelly-like stool is a
late sign
Bowden & Greenberg
Diagnostic X-ray
Management
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Reduce the obstruction before the bowel
becomes necrotic.
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Contrast Enema is diagnostic in 95% of cases and
therapeutic curative in most cases.
Surgical reduction is radiologic reduction is not
achieved.
Surgical Intervention
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IV fluids + antibiotics pre-operatively.
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Manual reduction is attempted.
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If bowel perforation is noted during operative
procedure a temporary colostomy may be
needed.
Hirschsprung Disease
Congenital
abnormality
caused by reduced
motility in colon.
Bowen Text
Definition
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Lack of ganglion cells in colon prevents
bowel from transmitting peristaltic
waves needed to move fecal material.
Clinical Manifestations
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No meconium in the first 24 hours.
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History of constipation or fecal mass.
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Distended abdomen.
Diagnosis and Treatment
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Rectal biopsy
Removal of the aganglionic portion of the
colon.
1st stage surgery is often a colostomy
2nd stage is pull-through surgery to connect
the working colon to a point near the anus.
Typical X-ray
Colostomy at Birth
Pull-through Surgery
Surgery
Surgical repair done between 12 and 18 months
Long Term Complications
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Anal stricture
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Incontinence of stool
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Short bowel syndrome
Appendicitis
Pedisurg.com
Pathophysiology
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Inflammation of the vermiform appendix.
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Obstruction at base blocks outflow of mucus.
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Pressure builds up
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Blood vessels are compressed.
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Perforation and rupture
Clinical Manifestations
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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
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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
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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
Post Operative Care
NPO
IV therapy
IV Antibiotics
Bowden & Greenberg
Nursing Interventions
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Monitor I & O
Assess for bowel sounds
Dressing change as ordered
Ambulate ! Ambulate ! Ambulate !
Cough and deep breath
Pain Management
Inflammatory Bowel Disease
A virus or bacteria interacts with the body’s
immune system to trigger an inflammatory
reaction in the intestinal wall.
Inflammatory Bowel Disease
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Refers to two chronic diseases that cause
inflammation of the intestines.
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Ulcerative Colitis
Crohn’s Disease
Causes
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Most likely a genetic link that affects the
immune system.
Ulcerative Colitis
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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
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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.
Clinical Manifestations
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Diarrhea
Rectal bleeding
Abdominal pain
Weight loss
Anemia
Diagnostic Tests
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Erythrocyte sedimentation rate ESR
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Stool for gross or occult blood
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Colonoscopy evaluation and biopsy
Genetic marker / family history
Drug Therapy
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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
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Surgical removal of bowel if not managed by
medical management.
Complications:
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Alteration in body image due to steroids
Arthritis
Osteoporosis
Increase risk of colorectal cancer
Gastro-esophageal Reflux
GER
Incompetence of
lower esophogeal
sphincter, which
allows return of stomach
contents into esophagus.
Pedisurg.com
GER
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Common condition involving regurgitation, or
“spitting-up” which is the passive return of
gastric contents retrograde into the
esophagus.
Peaks between one to four months.
Usually resolved by 12 months.
Clinical Manifestations GEF
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Regurgitation of formula after feeding
No weight loss
Conservative Management GER
Positioning: upright, semiprone after feeding to
promote gravity resistance to reflux
Dietary: thicken feedings
Feeding modifications: small feedings with
frequent burping to decrease gastric
distention
GERD: Gastro-esophageal Reflux Disease
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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 Work-up for GERD
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Upper GI series
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Esophageal pH monitoring
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Endoscopic exam
Pharmacologic Therapy
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Medications to reduce symptoms including
antacids or histamine-2 blocking agents
Histamine 2 blocker: cimetadine
Reglan or metaclopramide to enhance gastric
emptying
Surgical Management: GERD
Fundoplication
Pedisurg.com
Necrotizing Enterocolitis
Necrotizing = damage and death of cells
Entero = refers to intestines
Colitis = inflammation of the colon
NEC
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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
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History of formula feeding
Feedings stay in stomach
Abdominal distention / shiny abdomen
Bile-green fluid in stomach
Bloody bowel movements
Management
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NPO
Nasogastric tube to decompress gas
IV fluid replacement
Antibiotics
Extra oxygen
Abdominal x-rays to monitor progress
Measure abdominal girth every four hours
Gas filled
loops of
bowel in
NIC.
Complications
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Intestinal perforation
Surgery to remove dead bowel
Colostomy or ileostomy
Bowel is reconnected when infection and
inflammation have resolved
Celiac Disease
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Malabsorption caused by a permanent
intolerance to dietary gluten.
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1 in 3000 in USA
1 in 300 in European countries
Genetic predisposition
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Celiac Disease
Small villi lining
the intestine are
damaged by the
Body’s immune
system.
Celiac.com
Assessment
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FTT after gluten products introduced into diet
Chronic diarrhea
Foul smelling, greasy stools
Abdominal distention
Anemia
Muscle wasting
Management
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Gluten free diet
Limit the intake of wheat, barley, rye
containing foods
Management
Celiac.com
Dietary Restrictions
Celiac.com
Lactose Intolerance
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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.