Gastrointestinal Disorders
Embryonic Development
Failure to fuse = cleft lip and palate
Failure to differentiate = duodenal stenosis
Atresia or abnormal closing of structure:
Esophogeal atresia
Anal-rectal malformation
Biliary atresia
Fetal Development
Fistula is an abnormal connection
Tracheal esophageal fistula
Anal-rectal malformations with fistula
Incomplete or abnormal placement
Mal-rotation
Diaphragmatic hernia
Prenatal History
Birth weight
Prematurity
History of maternal infection
Polyhydramnios
Down Syndrome
Health History
Congenital anomalies
Growth or feeding problems
Travel
Economic status
Food preparation
General hygiene
Family history of allergies
Present Illness
Onset and duration of symptoms
Weight loss or gain
Recent changes in diet
Vomiting
Reflexive = infection or allergy
Central = central nervous system
head trauma
meningitis
CNS tumor
Nursing Assessment
Abdominal distention
Abdominal circumference
Abdominal pain
Acute / diffuse / localized
Abdominal assessment
Inspect / auscultation / palpation / measure
Measuring Abdominal Girth
Diagnostic Tests
Flat plate of abdomen
Fluid
Gas
Structural changes
Barium swallow or UGI
Strictures
Foreign body
Motility disorder
Diagnostic Tests
Ultrasound
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
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
Organic
Physical cause identified: heart defect, GER, renal insufficiency,
malabsorption, endocrine disease, cystic fibrosis, AIDS.
Non-organic
Inadequate intake of calories
Disturbed mother-infant bonding
Idiopathic: unexplained
Cleft Lip and Palate
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
Close the defect
Symmetrical appearance of face
Post Surgery Care
Airway management
Pain control
Position in infant seat – upright position
Elbow restraints
Wound care as ordered by MD
Minimizing crying
Feeding techniques
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 Repair
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
Pre-surgery feeding
Alternate nipple design
Breast feeding consultant
ESSR
Enlarge / stimulate / swallow / rest
Post Surgery Repair
Position on side
NPO for 48 hours
Suction with bulb syringe only
Avoid injury to palate with syringes, straws, cups etc.
Long Term Referrals
Hearing
Speech
Dental
Psychological
Team approach to care
Esophageal Atresia
Esophagus ends in a blind pouch.
Infant has a lot of mucous at birth.
The rationale for giving sterile water for the first feed.
E.A. Tracheo- esophageal Fistula
Clinical Manifestations
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
NPO
Up in infant seat or HOB elevated
Continuous suction
G-tube to decompress stomach
Post Operative Care
Respiratory support
Gastric decompression
Chest Tube
Gentle suctioning
TPN until taking PO’s
Antibiotics
Long Term Complications
5 to 15% experience leaking at operative site.
Aspiration
Dysphagia / difficulty swallowing
Stricture of esophagus
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 : Clinical Manifestations
Projectile vomiting
Visible peristaltic waves
Olive shape mass in the upper abdomen to right of the midline
Electrolyte imbalance
Management Pre-surgery
NPO / document any emesis
IV therapy / Correct electrolyte imbalance
Comfort infant and caretakers
Feeding Post-operatively
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
A hernia is a protrusion of an organ or
part of an organ through the wall of the
cavity in which it is containe
Inguinal Hernia
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.
Hydrocele
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
Diaphragmatic Hernia
Congenital diaphragmatic hernia is the protrusion of abdominal contents
into the chest cavity through a defect in the diaphragm.
1 in 5,000 births
Mortality rate is 40 to 50%
Diaphragmatic Hernia:Clinical Manifestations
Chest appears barrel-like
Abdomen is sunken
Bowel sounds in chest
Breath sound decreased
Severe respiratory distress
Treatment
ECMO
Ventilator support
Chest tube
Umbilical artery catheter
NG tube
Surgical correction when stable
Long Term Problems
Gastro Esophogeal Reflux
Respiratory infections
Obstructions
Abdominal Defects
Omphalocele
Gastroschisis
Omphalocele
Congenital malformation in which abdominal contents protrude into the base
of the umbilical cord.
Gastroschisis
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:
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
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
Long term complications:
Obstruction
Weak abdominal wall
Prune Belly
Intussusception
Clinical Manifestation
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
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
Definition
Lack of ganglion cells in colon prevents
bowel from transmitting peristaltic
waves needed to move fecal material.
Clinical Manifestations
No meconium in the first 24 hours.
History of constipation or fecal mass.
Distended abdomen.
Diagnosis and Treatment
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
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
Clinical Manifestations
Abdominal pain
Generalized to localized
Mc Burney’s point
Rebound tenderness
Loss of appetite
Vomiting
Low grade fever
Appendectomy
Ruptured Appendix
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
Post Operative Care
Nursing Interventions
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
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.
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.
Clinical Manifestations
Diarrhea
Rectal bleeding
Abdominal pain
Weight loss
Anemia
Diagnostic Tests
Erythrocyte sedimentation rate ESR
Stool for gross or occult blood
Colonoscopy evaluation and biopsy
Genetic marker / family history
Drug 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
Gastro-esophageal Reflux
GER
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
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
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
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
Surgical Management: GERD
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
Management
NPO
Nasogastric tube to decompress gas
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 permanent intolerance to dietary gluten.
1 in 3000 in USA
1 in 300 in European countries
Genetic predisposition
Celiac Disease: Assessment
FTT after gluten products introduced into diet
Chronic diarrhea
Foul smelling, greasy stools
Abdominal distention
Anemia
Muscle wasting
Management
Gluten free diet
Limit the intake of wheat, barley, rye containing foods
Dietary Restrictions
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.
