1. Gastrointestinal Disorders in Pediatric Patients
Revised, Summer 2009

2. Cleft Lip and Cleft Palate
Etiology- Failure of maxillary and median nasal processes to fuse during embryonic development
Remember the psycho-social implications for these children and families

3. Assessment
Unilateral, bilateral, midline

4. Treatment Surgical repair done ASAP
Rule of 10 > 10#, 10 weeks, 10 HGB
Multidisciplinary team
Homecare by the family prior to surgery
E-enlarge opening in nipple
S-stimulate suck reflex
S-swallow fluids appropriately
R-rest when infant signals
Home care: breastfeeding may be possible if yor child has a small cleft; compressible bottle will prevent your child from having to suck, longer nipple may allow the milk to be swallowed without entering the nose. A syringe with a rubber tip may also be used, esp. after surgery, keep your child in an upright position during feedings; burp frequently
Feed slowly, bubble often, hold and position upright, SUCTION (bulb or electric) handy!!!

5. Pre-op Teaching
Remind parents that defect is operable- show photographs of corrected clefts
Introduce cup, spoon feeding devices (see your book for feeding tips)
Explain restraints
Elbow restraints may be used so that the child cannot touch the stitiches. They should be removed every 2 hours for minutes, and play games with the child that encourage movement of the elbows. Remove only one restrainst at a time..

6. Post-Op Prevent trauma to suture line – Do not allow to suck!
Facilitate breathing
Maintain nutrition
Reduce pain to minimize crying
Prevent infection
Cleanse suture lines as ordered
Referrals to appropriate team members
Do not brush teeth for 1-2 weeks after surgery, feeding a small amt of water after meals will help keep the teeth clearn.

7. Esophageal Atresia/ Tracheoesophageal fistula
Failure of the esophagus to totally differentiate – 4-5th wk gestation
Both are malformations of ESOPHAGUS
Cause is unknown
Esophageal atresia and tracheoesophageal fistula (TEF) are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural commection with the trachea.

8. Assessment 3C’s -coughing, choking, cyanosis when feeding
Respiratory difficulties
Drooling
Inability to pass suction catheter, birth
Abdominal distention if fistula present
Mom may have a history of polyhydramnios (thought that the fetus is not swallowing amniotic fluid as normally does and therefore there is a larger than normal amount present), prematurity and low birth weight are also frequent problems that may have an impact

9. Management Early diagnosis Surgical repair- thoracotomy
Ultra sound
Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray
Surgical repair- thoracotomy
Anastomose ends of esophagus if possible (may need 2 stage repair)
Ligate fistula

10. Pre-Op Maintain airway Prevent aspiration pneumonia
Keep NPO- administer IV fluids
Elevate HOB 30 degrees
Suction PRN
Gastrostomy for feedings
Prevent aspiration pneumonia
Suction
HOB 30 degrees
Prophylactic antibiotics

11. Post-Op Maintain airway Maintain nutrition Prevent trauma
Monitor growth and development

12. Gastroesophageal Reflux Disease (GERD)
The cardiac/lower esophageal sphincter (AKA LES) and lower portion of the esophagus are weak, allowing regurgitation of gastric contents back into the esophagus.
The pedi book calls it the cardiac sphincter but Lewis and other M/S texts as well as Corwin call it the LES, lower esophageal sphincter. It is not actually a sphincter but an area of increased muscle tone.

13. Assessment: Infant
Regurgitation almost immediately after each feeding when the infant is laid down
Excessive crying, irritability
FTH
Risk for:
aspiration (pneumonia)
Apnea
Development of respiratory problems (asthma)

14. Assessment: Child Heartburn Abdominal pain Cough, recurrent pneumonia
Dysphagia

15. Diagnosis Ph of secretions in esophagus <7.0=acid
Barium Swallow and visualization of any esophageal abnormalities

16. Management & Nursing Care
Nutritional needs
Positioning – PRONE (supine worsens GERD)
Medications
H2 receptor antaqgonists (-tidine)
Cholinergics – metoclopramide (Reglan)
Proton pump inhibitors – (-prazole)
CPR instruction for parents/caregivers
Possible Nissen Fundoplication

17. Diarrhea/Gastroenteritis Severe
A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents stools/day!!!
Most infectious diarrheas in this country are caused by Rotovirus, but can be c.diff

18. Clinical Manifestations
Increase in peristalsis
Large volume stools (loose, watery, green)
Increase in frequency of stools with cramps, nausea, vomiting
Urge with small stool present
Increased heart & resp. rate, decreased tearing and fever
Complications: dehydration and acidosis (metabolic)

19. Complications Dehydration Metabolic Acidosis
Mucus membranes dried, cracked
Decreased elasticity of skin
Depressed fontanels, eyes sunken
Decreased urinary output, dark
Metabolic Acidosis
pH <7.35
HCO3 =/<22mEq/L

20. Diagnosis Stool culture -causative organism -O&P
ABG’s to diagnose Metabolic Acidosis

21. Treatment & Nursing Care
Contact isolation
Treat cause
Weigh daily
Monitor I&O, assess for dehydration
Skin care
Fluid and electrolyte balance
Oral rehydration
IV rehydration (RL or D5NS)

22. Appendicitis
Inflammation of the lumen of the appendix which becomes quickly obstructed causing edema, necrosis and pain.
Pain begins in the center of the abdomen, and by the 2-3 day, moves down to the LRQ. Accompanied by anorexia, rebound
Diagnosis made by physical exam, hx, labs (WBCs), xrays

23. Clinical Manifestations
Pain
Vague
Periumbilical
Rebound tenderness
No bowels sounds “silent abdomen”
Anorexia with or without vomiting
Diarrhea
Increased temperature
If ruptures/perforates, there is immediate relief of pain followed by high fever and dehydration

24. Diagnosis WBC <15-20,000 Rebound tenderness at McBurney’s point
Abdominal ultrasound or xray - fecalith

25. Management and Nursing Care: Pre-Op
NPO, IV
Comfort measures, knee chest position
Antibiotics
Thermal therapy – Ice pack
No elimination
Patient education for post-op
+/- NG tube
Penrose drain vs open wound bed
Thermal NEVER apply heat…WHY??? May use cold pack to decrease discomfort
NO enemas or laxatives- cathartics cause bowel movements, that can increase the risk of rupture through muscle straining.
Teach patient and family to notify nurse immediately if sudden relief of pain, and if sudden increase in pain. Teach the use of IV’s post op analgesia, and possibility of NG use.

26. Management and Nursing Care: Post-Op
NPO, IVs
Antibiotics
Analgesia
Patient teaching
Wound care
Open vs laproscopic
No contact sports, PE, lifting until released by surgeon
These are becoming more and more, outpatient procedures

27. Pyloric Stenosis Pyloric sphincter Incidence
Possible genetic predisposition

28. Assessment Vomiting: character?? Constant hunger and fussiness
Distended upper abdomen
Visible peristaltic waves
Hypertrophied pylorus
No pain
Weight loss
Dehydration and electrolyte imbalance
Diagnosis made: History and Physical
Ultrasound
Laboratory values
Which electrolytes are lost????
Therefore risk for metabolic alkalosis

29. Diagnosis History and physical Abdominal ultrasound Laboratory data
Decreased Na, K
Metabolic acidosis pH>7.3, HCO3 <22

30. Pre-op care Restore fluid and electrolyte balance Parental support NPO
I & O
Urine specific gravity
Parental support
Guilt – think they are “bad parents”
Emphasize structural problem not parental feeding technique

31. Management and Nursing Care
Pylorotomy via laproscopy
I & O
Feeding
Position – HOB elevated slightly
Surgical site infection free
Patient teaching – s/s recurrence

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

33. Intussuception Most commonly seen in infants 3-12 months but can
occur in older child
Bowel “telescopes”
within itself usually
at ileocecal valve
Telescoping causes obstruction and mesenteric vessels become trapped between the walls of the two layers and ischemia occurs
Cause actually unknown, but may follow a viral infection

34. Assessment Pain – colicky, knee chest position
Vomiting – can contain stool
Stools – “currant jelly”
Dehydration
Serious complications
Stools resemble currant jelly.
Diagnosis is made by xray or abd ultrasound

35. Diagnosis
Abdominal xray = intraperitoneal AIR
Abdominal ultrasound

36. Therapeutic Intervention
Hydrostatic reduction
Surgery
Barium or air enema until free flow of barium into the terminal ileum is evident. This can be done in approximately 80% of all cases
If unsuccessful, continue to monitor for return of normal bowel function because spontaneous resolution could occur, eliminating the need for surgery
IV fluids, NG suction, and frequent vial signs

37. Post-op care NPO with NG tube
Monitor bowel sounds and passage of stool
Gradual introduction of fluids and solids

38. Hirschsprung’s Disease
Congenital disorder of nerve cells in lower colon
Also known as megacolon. It is the result of a congenital absence of parasympathetic nerve ganglion cells in the rectum and, to varying degrees, upward in the colon. This accounts for 20-25% of all neonatal GI obstructions.

39. Assessment Failure to pass meconium Vomiting with reluctance to feed
Bowel assessment
Breath
Ribbon like stools that are foul smelling

40. If in older child: Constipation Offensive ribbon-like stools
History of REGULAR laxative use
Palpable fecal mass

41. Diagnosis History & Physical Barium enema (X-ray)
Rectal biopsy- absence of ganglionic cells in bowel mucosa

42. Surgical intervention
Management
Surgical intervention
One stage = resection
Two stage
Temporary diverting colostomy with resection
Re-anastomosis and take-down of colostomy
If diagnosis is made early enough before the bowel becomes severely dilated a one-stage pull-through procedure may be used that eliminates the necessity of a temporary colostomy.
If the child is acutely ill on presentation, enterocolitis must be suspected. This is a life-threatening complication and, if it is suspected, must be reported immendiately!

43. Nursing Care: Pre-op Cleanse bowel Neomycin per rectum
Patient/parent teaching re: ostomy
Post-op
NPO – N/G tube, IV fluids
No rectal thermometers, monitor VS
Monitor bowel sounds and abdominal girth
Patient/parent teaching
Incision care, s/s infection
Pain management
?colostomy teaching

44. Volvulus & Malrotation
Assessment- pain, bilious vomiting, S & S bowel obstruction
Treatment- surgery to prevent ischemia
Nursing Care- same as Intussuception and Hirschsprung’s
Twisting of the bowel caused by a malrotation and results in obstruction. Result of a defect in fetal development in which the midgut, which normally rotate 270 degrees around the superior mesenteric artery, fails to rotate and fixes itself to the abdominal wall.

45. Failure to Thrive (FTH)
Assessment- low growth for age, developmental delays, apathy
Diagnosis- History to determine organic- vs- non-organic
Nursing Care- Teaching on nutrition feeding techniques, feeding cues, praise
Community resources

46. Celiac Disease Assessment- Growth pattern, GI pattern
Treatment- Dietary restrictions
Nursing Care- monitor for dehydration, encourage compliance with dietary restrictions, provide support groups for patient and caregiver
No gluten!

47. Diagnosis
Measure fetal fat
Duodenal biopsy
Screen IgA

48. Complications
Hypocalcemia
Osteomalacia
Osteoporosis
Depression