Gastrointestinal Gastrointestinal Disorders in Pediatric Disorders in Pediatric

PatientsPatientsRevised, Summer 2009Revised, Summer 2009

Cleft Lip and Cleft PalateCleft Lip and Cleft Palate

Etiology- Failure of maxillary and Etiology- Failure of maxillary and median nasal processes to fuse median nasal processes to fuse during embryonic developmentduring embryonic development

Remember the psycho-social Remember the psycho-social implications for these children and implications for these children and

families families

AssessmentAssessment

Unilateral, bilateral, midlineUnilateral, bilateral, midline

TreatmentTreatment

Surgical repair done ASAPSurgical repair done ASAP Rule of 10 > 10#, 10 weeks, 10 HGBRule of 10 > 10#, 10 weeks, 10 HGB Multidisciplinary teamMultidisciplinary team Homecare by the family prior to Homecare by the family prior to

surgerysurgery– E-enlarge opening in nippleE-enlarge opening in nipple– S-stimulate suck reflexS-stimulate suck reflex– S-swallow fluids appropriatelyS-swallow fluids appropriately– R-rest when infant signalsR-rest when infant signals

Pre-op TeachingPre-op Teaching

Remind parents that defect is Remind parents that defect is operable- show photographs of operable- show photographs of corrected cleftscorrected clefts

Introduce cup, spoon feeding devices Introduce cup, spoon feeding devices (see your book for feeding tips)(see your book for feeding tips)

Explain restraints Explain restraints

Post-OpPost-Op

Prevent trauma to suture line – Do not Prevent trauma to suture line – Do not allow to suck!allow to suck!– Facilitate breathingFacilitate breathing– Maintain nutritionMaintain nutrition

Reduce pain to minimize cryingReduce pain to minimize crying Prevent infectionPrevent infection

– Cleanse suture lines as orderedCleanse suture lines as ordered Referrals to appropriate team Referrals to appropriate team

membersmembers

Esophageal Atresia/ Esophageal Atresia/ Tracheoesophageal fistulaTracheoesophageal fistula

Failure of the esophagus to totally Failure of the esophagus to totally differentiate – 4-5differentiate – 4-5thth wk gestation wk gestation

Both are malformations of ESOPHAGUSBoth are malformations of ESOPHAGUS

Cause is unknownCause is unknown

AssessmentAssessment

3C’s -coughing, choking, cyanosis 3C’s -coughing, choking, cyanosis when feedingwhen feeding

Respiratory difficultiesRespiratory difficulties Drooling Drooling Inability to pass suction catheter, NG Inability to pass suction catheter, NG

@ birth@ birth Abdominal distention if fistula Abdominal distention if fistula

presentpresent

Management Management

Early diagnosisEarly diagnosisUltra soundUltra sound

Radiopaque catheter inserted in the Radiopaque catheter inserted in the esophagus to illuminate defect on X-rayesophagus to illuminate defect on X-ray

Surgical repair- thoracotomy Surgical repair- thoracotomy Anastomose ends of esophagus if possible (may Anastomose ends of esophagus if possible (may need 2 stage repair)need 2 stage repair)

Ligate fistulaLigate fistula

Pre-OpPre-Op

Maintain airway Maintain airway – Keep NPO- administer IV fluidsKeep NPO- administer IV fluids– Elevate HOB 30 degreesElevate HOB 30 degrees– Suction PRNSuction PRN– Gastrostomy for feedingsGastrostomy for feedings

Prevent aspiration pneumoniaPrevent aspiration pneumonia– SuctionSuction– HOB 30 degreesHOB 30 degrees– Prophylactic antibioticsProphylactic antibiotics

Post-OpPost-Op

Maintain airwayMaintain airway

Maintain nutritionMaintain nutrition

Prevent trauma Prevent trauma

Monitor growth and developmentMonitor growth and development

Gastroesophageal Reflux Gastroesophageal Reflux DiseaseDisease(GERD)(GERD)

The cardiac/lower esophageal The cardiac/lower esophageal sphincter (AKA LES) and lower sphincter (AKA LES) and lower portion of the esophagus are weak, portion of the esophagus are weak, allowing regurgitation of gastric allowing regurgitation of gastric contents back into the esophagus.contents back into the esophagus.

Assessment: InfantAssessment: Infant

Regurgitation almost immediately after Regurgitation almost immediately after each feeding when the infant is laid downeach feeding when the infant is laid down

Excessive crying, irritability Excessive crying, irritability FTHFTH Risk for:Risk for:

– aspiration (pneumonia)aspiration (pneumonia)– ApneaApnea– Development of respiratory problems Development of respiratory problems

(asthma)(asthma)

Assessment: ChildAssessment: Child

HeartburnHeartburn Abdominal painAbdominal pain Cough, recurrent pneumoniaCough, recurrent pneumonia DysphagiaDysphagia

DiagnosisDiagnosis

Ph of secretions in esophagus Ph of secretions in esophagus <7.0=acid<7.0=acid

Barium Swallow and visualization of Barium Swallow and visualization of any esophageal abnormalities any esophageal abnormalities

Management & Nursing Management & Nursing CareCare

Nutritional needsNutritional needs Positioning – PRONE Positioning – PRONE (supine worsens (supine worsens

GERD)GERD) Medications Medications

– H2 receptor antaqgonists (-tidine)H2 receptor antaqgonists (-tidine)– Cholinergics – metoclopramide (Reglan)Cholinergics – metoclopramide (Reglan)– Proton pump inhibitors – (-prazole)Proton pump inhibitors – (-prazole)

CPR instruction for parents/caregiversCPR instruction for parents/caregivers Possible Nissen Fundoplication Possible Nissen Fundoplication

Diarrhea/GastroenteritisDiarrhea/GastroenteritisSevereSevere

A disturbance of the intestinal tract A disturbance of the intestinal tract that alters motility and absorption that alters motility and absorption and accelerates the excretion of and accelerates the excretion of intestinal contents. 3-30 stools/day!!!intestinal contents. 3-30 stools/day!!!

Most infectious diarrheas in this Most infectious diarrheas in this country are caused by Rotovirus, but country are caused by Rotovirus, but can be c.diffcan be c.diff

Clinical ManifestationsClinical Manifestations

Increase in peristalsisIncrease in peristalsis Large volume stools (loose, watery, Large volume stools (loose, watery,

green)green) Increase in frequency of stools with Increase in frequency of stools with

cramps, nausea, vomitingcramps, nausea, vomiting Urge with small stool presentUrge with small stool present Increased heart & resp. rate, Increased heart & resp. rate,

decreased tearing and fever decreased tearing and fever

ComplicationsComplications

DehydrationDehydration– Mucus membranes dried, crackedMucus membranes dried, cracked– Decreased elasticity of skinDecreased elasticity of skin– Depressed fontanels, eyes sunkenDepressed fontanels, eyes sunken– Decreased urinary output, darkDecreased urinary output, dark

Metabolic AcidosisMetabolic Acidosis– pH <7.35pH <7.35– HCO3 =/<22mEq/LHCO3 =/<22mEq/L

DiagnosisDiagnosis

Stool cultureStool culture

-causative organism-causative organism

-O&P-O&P

ABG’s to diagnose Metabolic AcidosisABG’s to diagnose Metabolic Acidosis

Treatment & Nursing CareTreatment & Nursing Care

Contact isolationContact isolation Treat causeTreat cause Weigh dailyWeigh daily Monitor I&O, assess for dehydrationMonitor I&O, assess for dehydration Skin careSkin care Fluid and electrolyte balanceFluid and electrolyte balance

– Oral rehydrationOral rehydration– IV rehydration (RL or D5NS)IV rehydration (RL or D5NS)

AppendicitisAppendicitis

Inflammation of the lumen of the Inflammation of the lumen of the appendix which becomes quickly appendix which becomes quickly obstructed causing edema, necrosis obstructed causing edema, necrosis and pain. and pain.

Clinical ManifestationsClinical Manifestations

PainPain– VagueVague– PeriumbilicalPeriumbilical– Rebound tendernessRebound tenderness

No bowels sounds No bowels sounds “silent abdomen”“silent abdomen” Anorexia with or without vomitingAnorexia with or without vomiting DiarrheaDiarrhea Increased temperatureIncreased temperature If ruptures/perforates, there is immediate relief of If ruptures/perforates, there is immediate relief of

pain followed by high fever and dehydrationpain followed by high fever and dehydration

DiagnosisDiagnosis

WBC <15-20,000WBC <15-20,000

Rebound tenderness at McBurney’s Rebound tenderness at McBurney’s pointpoint

Abdominal ultrasound or xray - Abdominal ultrasound or xray - fecalithfecalith

Management and Nursing Management and Nursing Care: Pre-OpCare: Pre-Op

NPO, IVNPO, IV Comfort measures, knee chest positionComfort measures, knee chest position AntibioticsAntibiotics Thermal therapy – Ice packThermal therapy – Ice pack No eliminationNo elimination Patient education for post-opPatient education for post-op

– +/- NG tube+/- NG tube– Penrose drain vs open wound bedPenrose drain vs open wound bed

Management and Nursing Management and Nursing Care: Post-OpCare: Post-Op

NPO, IVsNPO, IVs AntibioticsAntibiotics AnalgesiaAnalgesia Patient teachingPatient teaching

– Wound careWound care– Open vs laproscopicOpen vs laproscopic– No contact sports, PE, lifting until No contact sports, PE, lifting until

released by surgeonreleased by surgeon

Pyloric StenosisPyloric Stenosis

Pyloric sphincterPyloric sphincter IncidenceIncidence Possible genetic predispositionPossible genetic predisposition

AssessmentAssessment

Vomiting: character??Vomiting: character?? Constant hunger and fussinessConstant hunger and fussiness Distended upper abdomenDistended upper abdomen Visible peristaltic wavesVisible peristaltic waves Hypertrophied pylorusHypertrophied pylorus No painNo pain Weight lossWeight loss Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance

DiagnosisDiagnosis

History and physicalHistory and physical

Abdominal ultrasoundAbdominal ultrasound

Laboratory dataLaboratory data

Pre-op carePre-op care

Restore fluid and electrolyte balanceRestore fluid and electrolyte balance– NPONPO– I & OI & O– Urine specific gravityUrine specific gravity

Parental supportParental support– Guilt – think they are “bad parents”Guilt – think they are “bad parents”– Emphasize structural problem not Emphasize structural problem not

parental feeding techniqueparental feeding technique

Management and Management and Nursing CareNursing Care

Pylorotomy via laproscopyPylorotomy via laproscopy I & OI & O FeedingFeeding Position – HOB elevated slightlyPosition – HOB elevated slightly Surgical site infection freeSurgical site infection free Patient teaching – s/s recurrencePatient teaching – s/s recurrence

Critical ThinkingCritical Thinking

A 4 week old infant with a history of A 4 week old infant with a history of vomiting after feeding has been vomiting after feeding has been hospitalized with a tentative diagnosis of hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is pyloric stenosis. Which of these actions is priority for the nurse?priority for the nurse?– Begin an intravenous infusionBegin an intravenous infusion– Measure abdominal circumferenceMeasure abdominal circumference– Orient family to unit Orient family to unit – Weigh infantWeigh infant

IntussuceptionIntussuception

Most commonly seen in infants 3-12 Most commonly seen in infants 3-12 months but can months but can

occur in older childoccur in older child Bowel “telescopes”Bowel “telescopes”

within itself usuallywithin itself usually

at at ileocecal valveileocecal valve

AssessmentAssessment

Pain – colicky, knee chest positionPain – colicky, knee chest position Vomiting – can contain stoolVomiting – can contain stool Stools – “currant jelly”Stools – “currant jelly” DehydrationDehydration Serious complicationsSerious complications

DiagnosisDiagnosis

Abdominal xray = intraperitoneal AIRAbdominal xray = intraperitoneal AIR

Abdominal ultrasoundAbdominal ultrasound

Therapeutic InterventionTherapeutic Intervention

Hydrostatic reductionHydrostatic reduction

Surgery Surgery

Post-op carePost-op care

NPO with NG tubeNPO with NG tube Monitor bowel sounds and passage of Monitor bowel sounds and passage of

stoolstool Gradual introduction of fluids and Gradual introduction of fluids and

solidssolids

Hirschsprung’s DiseaseHirschsprung’s Disease

Congenital disorder of nerve cells in lower Congenital disorder of nerve cells in lower coloncolon

AssessmentAssessment Failure to pass meconiumFailure to pass meconium Vomiting with reluctance to feedVomiting with reluctance to feed

Bowel assessmentBowel assessment

BreathBreath

If in older child:If in older child:

ConstipationConstipation

Offensive ribbon-like stoolsOffensive ribbon-like stools

History of REGULAR laxative useHistory of REGULAR laxative use

Palpable fecal massPalpable fecal mass

DiagnosisDiagnosis

History & PhysicalHistory & Physical

Barium enema (X-ray)Barium enema (X-ray)

Rectal biopsy- absence of ganglionic Rectal biopsy- absence of ganglionic cells in bowel mucosacells in bowel mucosa

Management Management

Surgical intervention Surgical intervention –One stage = resectionOne stage = resection–Two stageTwo stage

Temporary diverting Temporary diverting ccolostomy with resectionolostomy with resection

Re-anastomosis and take-Re-anastomosis and take-down of colostomydown of colostomy

Nursing Care:Nursing Care: Pre-opPre-op

– Cleanse bowel Cleanse bowel – Neomycin per rectumNeomycin per rectum– Patient/parent teaching re: ostomyPatient/parent teaching re: ostomy

Post-opPost-op– NPO – N/G tube, IV fluidsNPO – N/G tube, IV fluids– No rectal thermometers, monitor VSNo rectal thermometers, monitor VS– Monitor bowel sounds and abdominal girthMonitor bowel sounds and abdominal girth– Patient/parent teachingPatient/parent teaching

Incision care, s/s infectionIncision care, s/s infection Pain managementPain management ?colostomy teaching?colostomy teaching

Volvulus & MalrotationVolvulus & Malrotation

Assessment- pain, bilious vomiting, S Assessment- pain, bilious vomiting, S & S & S bowel obstructionbowel obstruction

Treatment- surgery to prevent Treatment- surgery to prevent ischemiaischemia

Nursing Care- same as Intussuception Nursing Care- same as Intussuception and and Hirschsprung’sHirschsprung’s

Failure to Thrive (FTH)Failure to Thrive (FTH)

Assessment- low growth for age, Assessment- low growth for age, developmental delays, developmental delays,

apathyapathy Diagnosis- History to determine Diagnosis- History to determine

organic-organic- vs- non-organic vs- non-organic Nursing Care- Teaching on nutrition Nursing Care- Teaching on nutrition

feeding techniques, feeding techniques, feeding feeding cues, cues, praisepraise

Community resourcesCommunity resources

Celiac DiseaseCeliac Disease

Assessment- Growth pattern, GI patternAssessment- Growth pattern, GI pattern

Treatment- Treatment- Dietary restrictions Dietary restrictions Nursing Care- monitor for dehydration, Nursing Care- monitor for dehydration,

encourage compliance with encourage compliance with dietary restrictions, provide dietary restrictions, provide support groups for patient and support groups for patient and

caregivercaregiver

DiagnosisDiagnosis

Measure fetal fatMeasure fetal fat

Duodenal biopsyDuodenal biopsy

Screen IgAScreen IgA

ComplicationsComplications

HypocalcemiaHypocalcemia OsteomalaciaOsteomalacia OsteoporosisOsteoporosis DepressionDepression