Congenital Anomalies of G.I.T Prepared by Dr. Hoda Abed El Azim

Objectives: State common types of congenital anomalies in GIT. Compare and contrast between cleft lip and palate (CL/CP). Discus pre and postoperative care of CL/CP. Compare and contrast between the types of hernias. Identify the clinical manifestation of esophageal artesia (EA). Discus pre and postoperative care of esophageal artesia (EA). Identify Anorectal malformations.

Congenital Anomalies in GIT The most common anomalies are: 1. Cleft Lip or Cleft Palate 2. Hernias 3. Esophageal Atresia 4. Anorectal malformations

1. Cleft Lip (CL) or Cleft Palate (CP) CL and CP are facial malformations that occur during embryonic development and they are the most common congenital deformity of the head and neck. They may appear separately or more often , together.

Definitions: CL : is a congenital fissure in the upper lip. CP: is a midline fissure of the palate that results from failure of the two sides to fuse.

CL and palate

CL may be: Small notch Extending into the base of the nose. Unilateral or bilateral. CL/CP may be involve the soft and hard palate. One or both sides. Unilateral clefts are nine times more common than bilateral clefts. 60% to 80% of children born with cleft lip and palate are male.

Diagnostic evaluations Apparent at birth. Examining the palate. Prenatal diagnosis after 13-14 weeks when the soft tissue of the fetal face can be visualized.

Why CP more serious than CL? It interferes more with feeding and breathing, more difficult to repair.

Therapeutic Management The management of CL involves the cooperative efforts of a multidisciplinary health care team. Pediatrics Plastic surgery Speech/ language pathology Audiology Nursing and social work

Management is directed toward: Closure of the clefts. Prevention of complications. Facilitation of normal growth and development in the child.

Prognosis Even with good anatomic closure most children have: Some degree of speech impairment . Inefficient functioning of the muscles of the soft palate and nasopharynx. Improper tooth alignment. Varying degree of hear loss. Improper drainage of the middle ear. Recurrent Otitis media with scarring of the tympanic membrane.

Nursing consideration It is important for nurse to emphasis not only the infant’s physical needs but also on the parents emotional needs. CL or CP reduces the infant’s ability to suck, interferes with compression of the areola. Feeding is best with the infant’s head in upper right position. Large , soft nipple with large holes have been advised and used. Large syringe with soft rubber tubing can used.

With some infant spoon feeding works best Breast pump may be useful to stimulate the let down reflex.

Postoperative care for CL Elbow restrains are used to prevent the infant from rubbing or disturbing the suture line. Older infants who roll over will require a jacket restraint to prevent rolling on the abdomen and rubbing the face on the sheet. Adequate analgesia is required to relieve pain.

Postoperative care for CL cont. Clear liquids are offered when the infant has fully recovered from anesthesia. The suture site are is carefully cleansed of formula. A thin layer of antibiotic ointment. Genital aspiration of mouth and nasopharyngeal secretions. An upright or infant set position.

Postoperative care for CP Lie on the abdomen. Feeding by bottle, breast or cup. Oral packing, it is usually removed after 2 to3 days. Elbow restrains. Instruct the parents to keep the restrained at home until palate is healed (2 to 6 weeks). Opioids may be prescribed. Soft food in discharge plan until the surgeon directs them otherwise.

2. Hernias The diaphragm, The abdominal wall, or The inguinal canal. Is a protrusion of a portion of an organ or organs through an abnormal opening. through The diaphragm, The abdominal wall, or The inguinal canal.

1. Diaphragmatic Hernias Protrusion of abdominal organs through opening in diaphragm. Symptoms Mild to severe respiratory distress Tachypnea , cyanosis, dyspnea Absent breath sound. shock

Diagnosis Therapeutic Symptoms Radiographic study. Prenatally as early as 25 week of gestation. Therapeutic Supportive treatment of respiratory distress (Use of end tracheal intubation, oxygenation). Prophylactic antibiotics. Surgical reduction of hernia and repair of defect.

Nursing role Preoperative Post operative Resuscitation, maintain suction, oxygen. IV fluids Positioning head up. Administer medication Post operative Carry out routine postoperative care and observation.

2. Hiatal Hernia Protrusion of stomach through esophageal hiatus. Symptoms Dysphagia, vomiting, Bleeding (hematemesis)

Hiatal Hernia

3.Umbilical Hernia Symptoms Weakness in abdominal wall around umbilicus, incomplete closure of abdominal wall allowing intestinal contents to protrude through opening. Symptoms Noted by inspection and palpation of the abdomen. High incidence in premature.

3. Esophageal Atresia The esophagus instead of being an open tube from the throat to the stomach is closed at some point. A fistula is common between the trachea and esophagus. Clinical manifestation Excessive salivation. Coughing, choking, cyanosis, Apnea Abdominal distention.

Types of TEF

Nursing alert Any infant who has an excessive amount of frothy saliva in the mouth or difficulty with secretions and unexplained episodes of cyanosis should be suspected of having an EA/TEF and referred immediately for medical evaluation

Therapeutic Management Maintenance of a patent airway. Prevention of pneumonia. Surgical repair of the anomaly. Avoid oral intake, started IV fluids. Removal mouth secretion by suction. Broad spectrum antibiotic therapy. Gastrostomy AND ligation of the TEF.

Nursing role `Nursing responsibility for detection of this malformation immediately after birth. If feed the infant and swallows but suddenly coughs, and the fluid return through the nose or mouth, reported immediately. The infant placed in incubator, oxygen is administer. Intermittent or continuous suction of nose. Oral fluid are withheld, the infant fluid met by IV fluid or gastrostomy.

Postoperative care The infant is returned to radiant heater or incubator. The gastrostomy tube is connected to gravity drainage until the infant can tolerate feeding. Tracheal suction with extreme caution to avoid injury to the suture line.

Postoperative care cont. The initial attempt at oral feeding to make sure that the infant can swallow without choking. Oral feedings are begun with sterile water, followed by frequent small feeding of formula. Infants are usually not discharged until they are taking oral fluids well and the gastrostomy tube is removed.

4. Anorectal malformations The rectum and urinary tract separate completely by the seventh week of gestation. Abnormal development of genitourinary and pelvic organs.

1. Imperforate anus Is the most common congenital anomaly of GIT in newborn. Diagnosis There is no anal opening. The nurse is unable to insert the thermometer. No passage of meconium. Later on abdominal distention and pain occur.

Imperforate anus

Postoperative care The anal area should be kept dry and clean. If a colostomy has been done the skin around the wound must be clean and apply colostomy clean dressing.

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