1. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 19 The Child with a Gastrointestinal Alteration

2. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Anatomic and Physiologic Differences in the Gastrointestinal Tract  Swallowing is not under voluntary control until 6 weeks of age  Infants have minimal saliva  Stomach lies transversely and is horizontal in infants’ abdomens  Infants and children have less stomach capacity

3. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Pediatric Gastrointestinal Anatomy

4. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Anatomic and Physiologic Differences in the Gastrointestinal Tract  Gastric secretions are less acidic in the infant than in older children or adults  Hydrochloric acid concentration is low until school age  Human milk has properties that partially compensate for decreased digestive function and optimize nutrition  Formula or milk can increase alkalinity of gastric secretions  Cardiac sphincter of stomach is relaxed at birth, allowing mild, occasional regurgitation of stomach contents

5. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Anatomic and Physiologic Differences in the Gastrointestinal Tract  Peristaltic waves may reverse in infancy, causing regurgitation and vomiting  Peristalsis tends to be faster, with food remaining in the stomach for a shorter period  Conditions such as fever and diarrhea can increase the rate of propulsion and peristalsis

6. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Anatomic and Physiologic Differences in the Gastrointestinal Tract  Infants have a deficiency of the following enzymes: amylase, lipase, and trypsin  Enzymes are not present in sufficient quantities to aid digestion until 4 to 6 months of age  Liver function is immature; gluconeogenesis, plasma protein, ketone formation, vitamin storage, and deamination remain immature during the first year

7. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Nursing Assessment of the Gastrointestinal Tract  History  Vomiting episodes? If so, amount, color, and consistency of emesis  Diarrhea (frequency, amount, color, consistency of stools)  Daily weights (plot progress on growth chart)  Vital signs (including quality of respirations)  Intake and output  Skin integrity (especially in perianal and rectal areas)  Urine specific gravity  Episodes of apnea or respiratory distress?  Pain?  Bowel sounds  Abdominal circumference  Calorie count  Electrolyte status  Hydration status

8. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Diagnostic Tests  Complete blood count, erythrocyte sedimentation rate, electrolytes  Liver enzymes, absorption tests  Stool-reducing substances, pH, fat, trypsin, occult blood  Stool culture, ova and parasites  Upper gastrointestinal tract, colonoscopy, small bowel follow through, barium enema, gastric emptying, pH probe

9. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Malabsorption Syndromes: Celiac Disease  Gluten breaks down into gliadin in the small intestine  Intestine is unable to digest gliadin  Accumulation of glutamine causes toxic effect on the mucosal cells  From here either the villi of the intestine will atrophy, leading to malabsorption of fat calories, carbohydrates, and vitamins, or  The child will go into celiac crisis, which causes severe dehydration and diarrhea

10. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Celiac Disease

11. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Malabsorption Syndromes: Short Bowel Syndrome  Decreased ability to digest and absorb a regular diet because of a shortened intestine  Extent and location of the involved bowel determine the severity of the disorder Causes include:  Necrotizing enterocolitis  Inflammatory disorders  Intestinal malrotation  Atresia  Congenital bowel anomalies

12. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Malabsorption Syndromes: Gastroesophageal Reflux  The return of gastric contents into the esophagus from a relaxation of the lower esophageal sphincter  Occurs at any time and is not necessarily related to having a full stomach  Regurgitation increases in frequency and often results in delayed growth  More common in premature infants and in children with neurologic impairments  Often resolves without surgical intervention by 12 to 18 months of age  Reflux of stomach contents can lead to aspiration, resulting in frequent bouts of pneumonia, respiratory airway disease, color changes during feeding, apnea, or hematemesis

13. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Malabsorption Syndromes: Gastroesophageal Reflux Therapeutic management depends on severity of symptoms:  Diet  Positioning  Medications  Surgery

14. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Nursing Considerations  Frequently monitor the child’s condition  Assess hydration status frequently  Take vital signs often  Monitor intake and output  Monitor urine output (should have a minimum of 1 to 2 mL/kg per hour)  Administer oral and intravenous fluids safely  Monitor child’s weight  Observe infection control procedures

15. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Nursing Considerations  Provide emotional support  Promote rest and comfort  Good handwashing  Good Skin care  Ensure adequate nutrition: oral rehydration therapy, CRAM diet (complex carbohydrates, rice and milk)  Family and child education for home care

16. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Motility Disorders: Congenital Aganglionic Megacolon (Hirschprung Disease)  Congenital anomaly in which inadequate motility causes mechanical obstruction of the intestine.  Caused by absence of autonomic parasympathetic ganglion cells in the colon, which prevents peristalsis at that portion of the intestine  Causes accumulation of intestinal contents and abdominal distention  Occurs more commonly in boys

17. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Obstructive Disorders: Pyloric Stenosis  Occurs when the circular areas of muscle surrounding the pylorus hypertrophy  Results in stenosis of the passage between the stomach and the duodenum, partially obstructing the lumen of the stomach  Lumen becomes inflamed and edematous, which narrows the opening until the obstruction becomes complete  Cause unknown  Affects firstborn children and males most often  Symptoms occur 2 to 4 weeks after birth

18. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Obstructive Disorders: Intussusception  Telescoping of part of the intestine into an adjacent distal portion of the intestine  Usually occurs around 6 months, rare after 3 years  Abrupt onset of acute abdominal pain, vomiting, and passage of brown stool alternating with periods of comfort  Develops “current jelly”–like stools  Palpable mass may be present in right upper quadrant or mid to upper abdomen

19. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Obstructive Disorders: Malrotation and Volvulus  Caused by abnormal rotation of the intestine around the superior mesenteric artery during embryologic development  May present in utero or may be asymptomatic throughout life  Is the most serious type of intestinal obstruction because if the intestine undergoes complete volvulus, compromise of the blood supply will result in intestinal necrosis, peritonitis, perforation, and death

20. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Obstructive Disorders: Necrotizing Enterocolitis  Inflammatory disease of the intestinal tract that primarily occurs in premature infants  Is potentially life threatening and has a 40% mortality rate  Can be caused by several factors:  Intestinal ischemia  Bacterial or viral infection  Immaturity of the gut

21. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Nursing Considerations  Depends on underlying cause  Prevention of dehydration/hydration maintenance  Oral care to prevent effects of hydrochloric acid on teeth  Nothing by mouth order if blockage or obstruction is suspected  Family teaching: see dehydration

22. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Defects in Physical Development that Affect the Gastrointestinal Tract  Cleft lip  Cleft palate  Tracheoesophageal fistula or atresia  Imperforate anus  Umbilical hernia  Diaphragmatic hernia

23. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Tracheoesophageal Fistula or Atresia  Malformation that results from failure of esophagus to develop as a continuous tube during the fourth to fifth weeks of gestation

24. Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Types of Esophageal Atresia and Tracheoesophageal Fistula