1. Alteration in Gastrointestinal Function
Lecture 6
Part Two

2. Omphalocele
The bowel protrudes outside of the body through a defect in the umbilical cord. 
A membrane covers the bowel and  protects it from damage and germs.
Omphalocele occurs early in the baby’s development.
It may be detected on an ultrasound before the baby is born.

3. Omphalocele

4. omphalocele Prevalence of omphalocele is 2.5 in 10000 births.
May associated with other congenital anomalies
Treatment involves:
Protecting the site from injury.
Providing fluids and warmth.
Surgical repair to replace the abdominal content

5. Gastroschisis
The bowel comes out of the abdomen through a defect (abnormal opening) in the abdominal wall.
There is no membrane covering to protect these organs. So, they’re more likely to become damaged or infected.
If doctor sees gastroschisis on an ulstrasound, he or she will probably deliver your baby by cesarean section. This helps lessen damage to the bowel.

6. Gastroschisis
Abdominal organs may include small intestine and ascending colon.
1: births
Survival rate: 92%

7. Gastroschisis

8. Collaborative care:
Elevated Maternal serum alpha fetoprotien MSAFP and ultrasonography lead to early diagnosis .
Intensive care is needed to manage fluid status and Temperature regulation and infection control.
Surgical care.
Prosthetic silo around a gastroschisis.

9. Treatment
Vital sign
IV is placed and a naso-gastric (NG) tube (a tube is placed to decompress the intestine.
Repair of gastroschisis involves returning the extra-abdominal contents back into the abdominal cavity, followed by abdominal wall closure
This can either be performed with an immediate primary gastroschisis repair or, more commonly, a repair done in a series of steps (staged), depending upon postnatal assessment

10. Nursing Management Following the physician protocol:
Sterile guaze soaked in warm normal saline.
Monitor vital sign especially temprature.
The child sould be in warmer.
Inspect of infection
NPO.

11. Post operative Control pain. Prevent infection
Fluid and electrolyte balance.
first feedings are provided through an intravenous (IV) line. Once intestinal function returns, oral feedings or feedings via an NG tube are slowly started while IV feeds continue.
Parants care.

12. Intussusception
Intussusception is a serious disorder in which part of the intestine slides into an adjacent part of the intestine.
This "telescoping" often blocks food or fluid from passing through.
Intussusceptions also cuts off the blood supply to the part of the intestine that's affected. Intussusception can lead to a tear in the bowel (perforation), infection and death of bowel tissue.

13. Symptoms Stool mixed with blood and mucus Vomiting
A lump in the abdomen
Lethargy
Diarrhea
Fever
Constipation

14. Etiology Idiopathic cause Viral infection Use of medication.
The body inflammatory mediators
The most common site of intussusception is iliosecal valve

15. Diagnosis Radiograph Ultrasound
Contrast enema can be diagnostic and therapeutic
Surgical intervention

16. Nursing management
Fluid & electrolytes, monitoring, NG to suction , pain meds, antibiotics, barium/air enema
Vital sign
Check abdominal distention.
Listen bowel movement q 4 hrs.
Feeding are advanced to milk if tolerated.

17. Hyperbilirubinemia
The term refers to an excessive level of accumulated bilirubin in the blood.
Characterized by jaundice, or icterus, a yellowish discoloration of the skin, sclera, and nails.
It is a common finding in the newborn.

18. Pathophysiology
Normally the body is able to maintain a balance between the destruction of RBC and the use or excretion of products
Destruction of RBC= heme+ globin.
Globin (protein) portion is used by the body.
Heme portion is converted to unconjugated bilirubin: an insoluble substance bound to albumin.
In the liver: the unconjugated bilirubin with the presence of the enzyme glucuronyl transferase is conjugated produce a highly soluble substance, conjugated bilirubin. Which is then excreted into the bile.
In the intestine , bacterial action reduces the conjugated bilirubin to urobilinogen, the pigment that gives stool its characteristic color.
Most of reduced bilirubin is excreted through the feces; a small amount is eliminated in the urine

19. Causes of Hyperbilirubinemia in the newborns
Physiologic factors (prematurity).
Excess production of bilirubin (hemolytic disease, bruises).
Disturbed capacity of the liver to secrete conjugated bilirubin (enzyme deficiency, bile duct obstruction).
Combined overproduction and under secretion (sepsis).
Some disease states (hypothyroidism)

20. Hyperbilirubinemia Types of Unconjugated Hyperbilirubinemia:
Physiological jaundice.
Breast-feeding associated jaundice (early onset).
Breast milk jaundice( late onset).
Hemolytic disease.

21. Diagnostic evaluation
The degree of jaundice is determined by serum bilirubin measurements. (invasive method)
Normal values of unconjugated bilirubin are 0.2 to 1.4 mg/dl.

22. Complication Bilirubin encephalopathy: Kernicterus
a syndrome of sever brain damage resulting from the deposition of unconjugated bilirubin in brain cells called:
Factors that enhance the development of bilirubin encephalopathy include:
Metabolic acidosis.
Lowered serum albumin levels.
Intracranial infection as meningitis.
Increase in blood pressure.
Signs: CNS depression. or excitation .decrease activity, lethargy; irritability, hypotonia, and seizures.
Later signs: cerebral palsy, mental retardation, deafness.

23. Therapeutic management
The main form of treatment involves:
1. the use of phototherapy.
2. Pharmacologic management with Phenobarbital has centered primarily on the infant with hemolytic disease.

24. Nursing consideration
Nursing diagnoses:
Body temperature, risk for imbalanced related to use of phototherapy.
Fluid volume, risk for deficient related to phototherapy.
Family processes, interrupted, related to situational crisis, prolonged hospitalization of infant, or rehospitalization for therapy injury, risk for, related for phototherapy.

25. Nursing consideration
Planning: the goals:
Infant will receive appropriate therapy needed to reduce serum bilirubin levels.
Infant will experience no complications from therapy.
Family will receive emotional support.
Family will be prepared for home phototherapy (if prescribed).

26. Nursing consideration
Implementation:
Nursing care for infant under Phototherapy:
Repositioned frequently to expose all body surface areas to the light.
Frequent serum bilirubin levels every 4-12 hours are necessary.
The infant's eyes are shielded
The infant's eyelids are closed
On each nursing shift the eyes are checked
Eye shield are removed during feeding.
Temperature is closely monitored

27. Nursing consideration
Accurate charting is important nursing responsibility and includes:
Times that phototherapy is started and stopped.
Proper shielding of the eyes.
Distance between surface of lamps and infant (should be no less than 18 inches.
Use of phototherapy in combination with an incubator or open bassinet.
Oily lubricant or lotions are not used on the skin in order to prevent increased heat
Additional fluid volume needed.

28. Hirschsprung Disease
“Megacolon”, aganglionic cells in parts of the bowel
M>F, associated with congenital heart defects
At birth, fail to pass meconium, anorexia, abdominal distension and emesis
Diagnosed: clinical hx, bowel patterns, lower GI series, rectal biopsy
> birth (<5cm affected), ribbon-like, foul-smelling stools; intestinal obstruction, abd discomfort/distension, bloating, distention, constipation, (fever, GI bleeding & diarrhea = enterocolitis, life-threatening)
Fluids & electrolytes, monitoring, NG to sux, pain meds, antibiotics, barium/air enema, rectal irrigation (bowel prep), surgery

29. Hernias
A hernia is an opening or weakness in the wall of a muscle, tissue, or membrane that normally holds an organ in place.

30. Hernias

31. Umbilical Hernias
Umbilical hernias are common in newborns and infants younger than 6 months. They occur when part of the intestines bulge through the abdominal wall next to the belly button.
In babies with umbilical hernias, parents may see bulging around area when the baby cries.
Unlike other types of hernias, umbilical hernias may heal on their own, usually by the time a baby is 1 year old. If not, surgery can repair the hernia.

32. Appendicitis Infected, inflamed appendix (teens – young adults)
Abdominal pain, but this may be vague and poorly localized in the periumbilical area. The pain gradually migrates to the RLQ.
Anorexia and nausea with or without vomiting may occur but usually begin after the abdominal pain.
Constipation or diarrhea may be present, and the child’s temperature may be normal or slightly elevated.
Emesis, low-grade fever, inc WBC, rebound tenderness LR quad (McBurney’s point), rigid abd, dec/absent bowel sounds

33. Appendicitis
Immediate bowel rest, then appendectomy (24-48 hrs of first symptoms)
Rupture – fever rises sharply, peritonitis, sudden pain relief (diffuse pain), inc abd distention, tachycardia, shallow tachypnea
IV antibiotics, fluids, electrolytes
Appendicitis is difficult in children because the clinical manifestations are atypical. This increases the incidence of perforation.

34. Diverticulum
Out-pouching of ileum that secretes acid – irritation and ulceration
1-3% of general population
Symptoms appear by 2 yo, M>F
Painless rectal bleeding, abdominal pain rare, severe case will perforate &/or cause peritonitis (many may be asymptomatic)
Surgery – very good prognosis

35. Inflammatory Bowel Disease
Crohn’s
Chronic, inflammation of random segments of GI tract, and move around – through the wall involvement
Often develop enteric fistulas between loops of bowel &/or nearby organs
Often develops between years of age
Subtle onset, crampy abd pain, diarrhea, fever, anorexia, wt loss, malaise, joint pain, greatly inc rate of cancer
Anemia common, inc ESR, hypoalbuminemia

37. Inflammatory Bowel Disease
Ulcerative colitis
Chronic, recurrent disease of colon & rectal mucosa
Inflammation, ulceration, hemorrhage, edema – localized in a portion of the GI tract (may be removed)
Peak onset at 12 years of age
Diarrhea, lower abd pain with passage of stool and gas, blood & mucous in stool, anorexia, weight loss
Treatment same for both Crohn’s and UC
Antibiotics, anti-inflammatory, immunosuppressive, antidiarrheal, nutrition counseling (high protein/carb with low fiber diet), surgery

38. Ulcerative colitis

39. Celiac Disease Genetic disorder – inability to digest gluten
9-12 mo, diarrhea, abd distention, emesis, anemia, malnutrition, steatorrhea, pale, watery and foul smelling stools; muscle wasting, edema, low serum albumin, wt loss, anorexia
Fluids & electrolytes, monitoring, pain & antiemetic meds, dietary instructions
which is primarily found in bread, pasta, cookies, pizza crust and many other foods containing wheat, or rye.

41. Teaching plan for child with celiac disease and the child’s family.
Important to a teaching plan for the child with celiac disease and the child’s family is to provide dietary education and adequate supervision of the dietary treatment.
It is important for the nurse to explain the disease process, the signs and symptoms, and the rationale for the gluten-free diet.

42. Lactose Intolerance
Inability to digest lactose (insufficiency of lactase)
>3 yo, watery diarrhea, bloating, flatulence, crampy abdominal pain after ingestion of lactose
Fluid/elec replacement, monitoring, pain meds, dietary instructions