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