Gastrointestinal Elisa A. Mancuso, RNC-NIC,MS,FNS Professor of Nursing Anatomy and Physiology of GI Tract • • • • • Process and absorb nutrients Maintain metabolic process Support growth and development Detoxification Maintain fluid.
Download ReportTranscript Gastrointestinal Elisa A. Mancuso, RNC-NIC,MS,FNS Professor of Nursing Anatomy and Physiology of GI Tract • • • • • Process and absorb nutrients Maintain metabolic process Support growth and development Detoxification Maintain fluid.
Gastrointestinal
Elisa A. Mancuso, RNC-NIC,MS,FNS Professor of Nursing
Anatomy and Physiology of GI Tract • Process and absorb nutrients • Maintain metabolic process • Support growth and development • Detoxification • Maintain fluid and electrolyte balance
Gastroesophageal Reflux GER/GERD
• Passive regurgitation into esophagus
– Relaxation of the cardiac sphincter or – (LES) lower esophageal sphincter • Gastroesophageal Reflux Disease (GERD) – when GER causes symptoms – clinical problems – complications- Esophageal Strictures
Clinical Signs
Infants
• Regurgitation / “Spitting Up” • Apnea/Bradycardia • •
↑↑ Risk of Aspiration PN
• Irritability &
↑↑ Crying
• Esophagitis RT HCL irritation • Poor weight gain
Heme+ stools & Anemia
Clinical Signs
Young child
• Heartburn/Chest pain • Abdominal pain • Dysphagia • Hoarseness/Wheezing/Stridor • Chronic Cough & Sinusitis
• Disturbed Sleep
Diagnosis
Upper GI Barium Swallow
• Check patency of sphincter via fluroscopy • Evaluates anatomy but will not give # of
times reflux occurs
• Barium – Contrast medium & shows-up as “bright white” – Not absorbed & can harden & cause constipation – √
bowels sounds
– √
stools for passage of white barium
– May need laxative
Diagnosis
Esophageal PH monitor-probe
• •
Detects episodes of reflux over 24 H.
– Frequency of Reflux – Time & Duration of acid reflux episodes – √ Feedings – √ Positioning – √ Sleeping – √ Apnea & Bradycardia
Upper Endoscopy
Identifies esophageal strictures • Biopsy reveals extent of damage
• • •
Therapy Goals
Eliminate Symptoms Heal Esophagus Prevent complications
• –
Positioning ↑↑ HOB @ 30 0 < after feedings.
– Side or prone is best position. – AAP recommends back to sleep to
↓ SIDS.
– Car seats can
↑ risk for GER
• •
Nutrition
Infant Feedings
– Small, frequent feedings (30cc q 3H) – Thicken formula • 5cc rice cereal/30cc of formula – Provide quiet times after meals
Older child
– – Avoid skipping meals. –
↓ caffeine, soda & chocolate. No NSAIDS, Steroids, cigarette or alcohol
Medications
H2 Blockers (Histamine receptor antagonists) ↓ HCL content.
• Ranitidine (Zantac) >1 month
– Give 2 H pc
• Famotidine (Pepcid) >1 year
• Nizatidine (Axid) >12 years
• Cimetidine (Tagamet)>16 years
Medications
Proton Pump Inhibitors (PPI) ↑ Gastric emptying time Block acid secretion
• Lansoprazole (Prevacid) > 1 year • Omeprazole (Prilosec) > 2 years • Nexium use 30 minutes pc
• • •
Medications
Prokinetic
Resting sphincter pressure ↑ Contractility of esophagus ↓ Efficacy & children ↑ adverse side effects for
– –
Bethanechol (Urecholine)
– May exacerbate respiratory symptoms
Cisapride (Propulsid)
–
NA due to cardiac arrhythmias and death Metoclopramide (Reglan) Restlessness, drowsiness and irreversible CNS (EPS)
Gastroenteritis
• 500 deaths /year • $ 600 million/year for hospitalization & lost
job time
• Inflammation of stomach and intestine • Enterotoxins •
loss of H2O and electrolytes
• severe dehydration and hypovolemic shock • Intestinal mucosa of infants is more H2O
permeable
• ECF > ICF • Lose more fluid and electrolytes than older
child
Diarrhea
↟
# of stools &
↓
consistency Severe electrolyte imbalances
↟↟
↓ H20 loss NA, ↓ K+, ↓ HCO3
Metabolic acidosis
Etiology
• Food irritants, lactose intolerant • Contaminated food products • Stress • Malnutrition • Antibiotics – Ampicillin, EES & Tetracycline can induce C-Diff • Infections – Bacterial – E Coli, Salmonella & Shigella – Parasitic- Giardia – Viral –
Rotovirus
• 200,000 hospitalizations annually with 20-40 deaths/year
Signs and Symptoms
• Depends on pathogen • Diarrhea – Bloody or non-bloody – Acute or chronic • Vomiting • Fever • Dehydration – √
dry mucous membranes, sunken fontanels,
– –
↑ HR, ↓ Output
• •
↓ # diapers,
↡
tears tenting
Diagnosis
• Stool culture • C & S • Guaiac – Positive = inflammation of lining of intestine
or E-coli
• O & P (Ova & Parasites) – store in a warm place • Pale yellow, foul smelling stools = Rota • Greenish stools = Giardia or C-Diff
Therapy
Enteric Precautions!
– Gown, gloves & separate linen/garbage bag • Fluid Replacement (IV + NPO x 24H) – Replace fluids lost with aggressive IV hydration – Monitor electrolytes and correct imbalances – NPO – rest the bowel • Rehydration - start with pedialyte – ORT 1:1 basis 10ml/kg or ½ cup to 1 cup fluid
for every stool
– No juice or high sugar drinks; acts as laxative • BRAT diet – Bananas, Rice, Applesauce & Toast • Advance to regular as tolerated –
Vit/mineral supplements
– –
↑ calories & ↑ protein to promote healing ↓ fat and fiber
Medications
• Anticholingerics – Atropine (Donnatal) – Relaxes GI tract & – • Antibiotics •
↓ ↓peristalsis
• Antispasmotics – Diazepam (Valium)
↓ Diarrhea & cramping
– Broad Spectrum: Penicillin or Cephalothin (Keflin) – Localized: Sulfasalazine (Azulfidine) • Antiseptic & Anti-inflammatory
bacterial count in bowel
• 1/3 dose sm intestines & 2/3 dose lg intestine • Interferes with absorption of folic Acid – Need Folic acid supplements • – –
Antidiarrheal Paragoric (Tincture of opium) ↓ Frequency of stools & delays transit in intestines Not recommended in infectious diarrhea
Constipation
• Altered consistency
(Not ↓ frequency)
– Dry, hard stools, pebble like – Blood streaked due to rectal fissures • Abdominal distension
• Pain • Bloating N/V
• Encopresis – Leakage of stool around hard mass –
soiling of underwear
Etiology
• • Poor elimination pattern • Retention of stool – excessive H2O reabsorption in colon •
Dry, hard stool ↓ A ctivity Level
• Drug SE (Narcotics) •
↓ R
–
oughage in diet
• Change in formula or switch to whole milk • R/O medical conditions (Obstruction)
Hypothyroidism, CF, Hirschsprung
–
√ Abdominal X-ray, Lower GI series
Therapy
•
↑↑ Fluid & ↑ Fiber intake
– Fresh fruits and vegetables •
↑ Carbohydrate & Fructose foods
•
↑ Activity
• Bowel training – Develop routine &
√ regular habits
– Glycerin suppository or enema. • Medications – MOM and miralax safest. –
Lactulose, Sorbitol, Colace
–
Gylcerin suppositories
Hirschprung’s Disease
• Congenital Aganglionic Megacolon – Absence of ganglion cells in distal area of colon – No innervation
→ no peristalsis → ↑ distention = megacolon
– Mechanical obstruction RT
↓ Motility
– No relaxation of internal rectal sphincter – No evacuation of stool, liquids or flatus! • 25% of all cases of neonatal intestinal
obstruction
•
Males 4x > females
Signs and Symptoms Infants
• Do not pass meconium in 1
st
• Abdominal distension • Bilious vomiting
• Not tolerating feedings
• Failure to Thrive
• Palpable fecal mass
24 hours.
Signs and Symptoms
Older children
• Chronic constipation
• Recurrent distension
• Diarrhea alternates with constipation –
↑ # of episodes = ↑ mortality
• Visible peristalsis
• Ribbon-like & foul smelling stools
•
Malnourished & anemic
Diagnosis
• Anorectal Exam – Tight internal sphincter & no stool – Sudden release of gas and stool • Barium enema – Distinct change in distal portion of colon – Very distended to saw toothed appearance – Won’t pass barium • Full Thickness Rectal Biopsy – Definitive diagnosis shows absence of –
ganglionic cells
Therapy
• NGT- decompression • √ – –
Abdominal girth and bowel sounds q 1H
• Cleansing NS enemas till clear a surgery • IV therapy – Hydration & electrolyte replacement • Meds • Sulfasuxidine, Neomycin and Kanamycin SO4 – Local antibiotics
↑ ↓↓ Flora of colon
– Prevent infection and sterilize bowel • Watch for Necrotizing Enterocolitis (NEC)!
Abd. distention, Ruddy undertone & + Guiac stools/emesis/ NG drainage
Treatment
• Mild: Rare – Treat chronic constipation with stool softeners
and cleansing enemas
• Moderate:Surgery – Remove aganglionic portions of bowel – Temporary colostomy • Proximal stoma = functional stoma (Stool) • Distal stoma = mucous or H2O drainage – NPO until positive bowel sounds – Diet •
↑ Protein ↑ Calories
• Gradually
↑ Volume & consistency
– Reverse Colostomy @ 2-3 months or 8-10 kg –
Re-anastomose both ends
Pyloric Stenosis
• Abnormal severe narrowing @ pylorus • Hypertrophy & Hyperplasia of pylorus muscle • Not present @ birth = Not Congenital • Muscle becomes cartilaginous & thickens • Twice the size! • Males 5x > females • Sonogram shows solid mass •
Barium swallow
–
Delayed gastric emptying
Clinical signs
• 2-4 weeks p birth • Visible L • Visible or palpable mass (olive shaped) • Feeding residuals – Entire contents never emptied –
↑ → R peristalsis waves residual q feeding
• Projectile vomiting – As early as one week and as late as 5 months – Moderate/severe up to 3‘ due to
↑ Pressure & ↑ Volume
– Metabolic Alkalosis & Failure to Thrive (
↓ Weight)
• Irritable and hungry –
Eager for next feeding
Therapy
• •
Surgery-Pyloromyotomy Pre-op
•
NGT & replace drainage with 1/2 NS added to IV
•
NPO, strict I & O, IV, daily weight, and Post-op
•
Position on R side with HOB elevated
•
Assess incision site
– – – – – – – √
Steri strips over mid upper abd.
DSD change PRN √ abd girth Continue assessment of I & O, girth and daily weights Feedings Slowly introduce when BS present 15cc D5W q 3H x 3 feedings then 15cc ½ ↑ in volume then ▲ to full strength formula Any vomiting – hold feed and return to previous volume tolerated strength formula
Intussusception
• Telescoping of bowel into itself •
↑ Risk between 3-12 months old
• Males 3 x > risk than females • Pushes bowel inward = obstruction – Stops peristalsis completely – No bowel sounds distal to obstruction •
↑ Incidence @ ileocecal valve
Signs and Symptoms
• Palpable sausage mass in RUQ • Sudden acute abdominal pain – Colicky, wavelike intermittent pain – Draw-up knees in pain with guarding • Hyperactive BS proximal to obstruction – –
↑ ↑ Peristalsis before obstruction
• Distended abdomen and • Jelly stools
↑ tender with palpation
• Constipation no feces or flatus passed
pressure on bowel walls, ischemia and blood
• Fecal vomiting and dehydration (
↓ H2O ↓ Na ↓ Cl)
• – –
Lethargy & Shock Initially then ↓ ↑ HR ↓ HR ↑ BP ↓ BP, Temp & clammy
Therapy
• Barium Enema – Diagnostic and curative 85% – Forces bowel out – Do not do if you suspect ischemia or
strangulated /infarction of bowel
• Surgery – Resect all affected areas & re-anastomose – No colostomy needed –
Same care as for Hirschprungs
Appendicitis
• Inflammation of vermiform appendix @ cecum • Peak incidence at 10-12 years • Obstruction
→
Pathophysiology
• Feces trapped in appendix (fecalith) or food
Ischemia → Infection → Inflammation
–
P → Perforation
– Rupture of appendix and contents – Medical emergency!
eritonitis – Life threatening
Signs and Symptoms
• Children describe pain as general or vague • Abdominal pain starts @ peri-umbilical
then localizes @ RLQ McBurney’s point
• Anorexia N/V/D, • Low grade temp 100-101 •
WBC > 12 - 15,000
• Hypoactive BS over affected area • Constipation RT paralytic ileus • Rebound tenderness after palpation – Positive Hop test – CT scan with oral and IV contrast
Therapy
Pre-op
• NPO, IV antibiotics & no pain meds! • No enema! • √
Abdomen
– Distention via girth – Bowel sounds – Stool pattern
Post-op
• • • • √
s/s infection, obstruction/ileus
• Pain management ATC x 1
Early ambulation st
• Splinting, cough and deep breathing
NPO until positive bowel sounds & passing flatus 24 H
Perforation
• • • • • •
Medical Emergency!
High temp 104 Rigid (board like) abdomen ↑ Abd. distention Diffuse pain or sudden relief of RLQ pain Very sick appearing STAT OR!
– Need 7-10 days triple antibiotics post op
Malabsorption Syndromes
• Impaired digestion/absorption – Fluids & Electrolytes • Chronic diarrhea
Etiology
• CF Lactase deficiency – Decreased/ absent digestive enzymes • Celiac Ulcerative Colitis – Absorptive defects • Short bowel syndrome – Extensive resection of bowel RT NEC
Celiac Disease
Gluten Induced Enteropathy
• 2
nd to CF & possible genetic component
• • •
↓ incidence when solids are delayed until 6 months
• Inability to digest gliadin or protein part of • wheat, barley, rye and oats –
↑ accumulation of toxic substance
– Glutamine damages mucosal cells
→ villi
–
atrophy ↓↓ absorptive surface of small intestine Lifelong Dietary modification needed to prevent chronic symptoms
Clinical signs
• Usually @ 9 months
– Need 3-6 months after introduction of
grains
• Drop on growth chart <25 %
• Steatorrhea • Abdominal distention/pain
• Anorexia
• Irritability & Uncooperative
•
Muscle wasting in legs & buttocks
•
↓ Vitamin A, D, E & K = Anemia
Therapy
• Serum Antiglidian Antibody (AGA) • Newer test - Tissue Transglutaminase (tTG) • Jejunal biopsy – Flat surface and
↓↓ # of villi
–
↓ ↓ Absorption
• Fecal collection 72 hours – √
stetorrhea Gluten free Diet
–
– Lifelong Therapy
• No Wheat, Barley, Rye or Oats – No prepared foods, pizza, pasta, – hot dogs, cold cuts, bread • Only Corn or Rice
In 1 week Rapid improvement
–
↑ appetitite and ↑ weight
– Symptoms are gone, this is diagnostic
• • • •
Complications
Anemia Growth retardation Osteoporosis = ↓ Failure to Thrive bone mass and softening
• • • • • • • •
Celiac Crisis Infection, hidden source of gluten food or binging Abdominal distension Profuse watery foul smelling stools Metabolic Acidosis Vomiting → Therapy Dehydration → Electrolyte imbalances IV fluids & albumin for shock Steroids for mucosal inflammation
Short Bowel Syndrome
• •
↓↓ Mucosal surface area RT resection
– Gastroschisis, Bowel Atresia, NEC, Chrons •
↓↓ Ability to digest & absorb nutrients
• Severity of symptoms RT amount and
location of resected intestines
– >60 % =
↓↓ absorption
• Diarrhea • Food intolerance •
Abdominal distention ↓↓ weight
Therapy
• Maintain nutritional status via IV & TPN
therapy
– √
Growth & development
– √
Broviac – S/S infection
– √
Renal & hepatic function
– √
Labs
• Parental Anticipatory Guidance • Bowel & Liver Transplant
Biliary Atresia
• Female > Male • Congenital obstruction or absence of a
portion of bile ducts.
• Irreversible obliteration of extrahepatic bile
ducts.
• Impaired flow of bile from liver – to small intestine and gallbladder. • Back-up of bile into liver.
Clinical signs
• Jaundice > 2 weeks • Hepatosplenomegaly • Abdominal distention • Ascites RT portal • Poor weight gain • Failure to Thrive • Irritability RT
↑↑ ↑ BP
• Clay colored (Acholic) stools RT lack of bile
toxins
Therapy
• Surgery only for extrahepatic atresia – Provides drainage for bile. – 80-90% will still require liver transplant • Phototherapy • Diet -
↓↓ Na+
• Meds – Cholestyramine - Bile acid binding – Phenobarbital -
↓ Irritability & ↓ Bilirubin
– Lasix - • Plan care during awake periods –
↑↑ ↓ Ascites Toxic products accumulate
–
↑↑ Irritability & restlessness