Disorders of the Disorders of the Gastrointestinal Gastrointestinal

FunctionFunctionChapter 31Chapter 31

GI Dysfunction• Primary function off the GI tract is

the absorption & metabolism of nutrients necessary to support & promote optimal growth and development

• An alteration in GI function can affect other body systems

Cleft Lip & Palate• Facial malformations that occur

during embryologic development• More common seen in

combination• Incidence is 1 in 1000 live births

Cleft Lip & Palate• Etiology

– Cleft lip• Due to a failure of the medial nasal &

maxillary processes to join• Unilateral or bilateral• Associated with abnormal development

of the external nose, nasal cartilage, & nasal septum

Cleft Lip & Palate• Etiology

– Cleft palate• Failure of the palatal shelves to fuse• Mat be the soft palate or extend into the

hard palate

• Multifactorial inheritance• Folklore

Cleft Lip & Palate• Clinical manifestations

– Feeding may not be difficult if palate intact– Extensive ones

• Feeding difficulties• Ineffective suck• Saliva & feedings may leak into the nasal cavity• Speech can be delayed or hypernasal• Recurrent OM• Psychologic difficulties

Cleft Lip & Palate• Diagnostic tests

– Apparent at birth

• Medical management– Cleft lip

• Z-plasty – performed at 1 or 2 months of age– Cleft palate

• Repaired before 1 year of age

Cleft Lip & Palate• Nursing interventions

– Ensure adequate nutrition– Prevent aspiration– Special feeding devices are used– Frequent burping– Promote bonding

Cleft Lip & Palate• Nursing

– Post op• Protect the integrity of the suture line

– Cleft lip – position on side & back only– SRDs– NPO & then fed with Breck feeder– Suture line gently cleansed with a saline soaked

cotton swab– Infant chair or on right side– Aspiration of oral & nasopharyngeal cavities

Cleft Lip & Palate• Post op

– Cleft palate• Allowed to lie on abdomen• Analgesics• Liquids by cups• Straws, pacifiers, and eating utensils are

avoided• Advanced to a blenderized diet

Cleft Lip & Palate• Patient teaching

– Educate– Refer parents to Cleft Palate Foundation &

March of Dimes

• Prognosis– Some degree of speech impairment– Recurrent OM– Hearing impairment

Dehydration• Body loses more fluid than it absorbs or

when it absorbs less water than it excretes• Total fluid intake is less than the total fluid

output• Mild – 5%• Moderate – 10%• Severe – 15%

Dehydration• Etiology

– Result of a number of disease processes that cause abnormal losses through the skin, respiratory, renal, & (most commonly) GI systems

Dehydration• Clinical

manifestations– Skin – Cold, dry,

gray, loss of turgor– Mucous membranes

- Dry– Eyes – Sunken– Fontanels – Sunken– Behavior - Lethargic

– Pulse – Rapid, weak

– Blood pressure – Low

– Respirations - Rapid

Dehydration• Diagnostic tests

– Observed clinical manifestations– Determine severity

• Serum sodium• Serum glucose • Serum bicarbonate• BUN

– Weighing daily

Dehydration• Medical management

– Same as diarrhea

• Nursing– Clinical assessment– I&O– Vital signs & so forth– Teach parents – more vulnerable to fluid &

electrolyte imbalances

Dehydration• Prognosis

– Shock – severe depletion– Favorable with effective

management

Diarrhea & Gastroenteritis

• One of the most common disorders affecting children

• Can see fluid deficits & electrolyte imbalances• Disturbance in intestinal motility ,

characterized by an increase in frequency, fluid content, & volume of stools

• Acute or chronic• Infectious or non infectious

Diarrhea• Etiology

– Most common – bacterial or viral invasions

– Bacterial • Salmonella• Shigella• Campylobacter jejuni• Yersinia

enterocolitica

• Rotavirus• Giardia lamblia

– Infants have a greater susceptibility

– More serious– More prone

• Malnourished• Debilitated• Immunocompromised

Diarrhea• Etiology

– Poor hygiene– Contaminated food or water– Warm weather– Crowded & substandard living conditions– Large quantities of fruit juices– Food sensitivities– Antibiotics– Formula intolerance

Diarrhea• Pathogen invades the intestinal

mucosa, the resulting enterotoxins stimulate an inflammatory response

• Water & electrolytes are secreted & there is an invasion & destruction of the epithelial cells of the GI mucosa

Diarrhea• Clinical manifestations

– Cool, pale skin– Lethargy– Sunken eyes– Sunken fontanelles– Poor skin turgor– Rapid pulse &

respirations– Low blood pressure

– Normal or elevated temperature

– Irritability progressing to lethargy

– Weight loss– Vomiting– Malodorous stools

• Watch for dehydration

Diarrhea• Medical management

– Restore fluid & electrolyte imbalances– Treat underlying cause– AAP – no longer recommends

withholding food or fluids for 24 hrs or administering the BRAT diet

– Oral rehydration solution – small amounts

Diarrhea• Medical management

– Oral maintenance solution– Number of stools & fluid content have

decreased – advanced to full strength formula

– Rehydration complete offer solid foods• Non irritating foods – bananas, rice, applesauce,

cereal, vegetable juice, crackers, pretzels, & toast (modified BRAT diet)

Diarrhea• Severe diarrhea

– Hospitalization & IV therapy• Saline solution with 5% dextrose• Add potassium as needed - check kidney

function• Continue until diarrhea improves• Detect & treat underlying cause

Diarrhea• Nursing/Patient

teaching– Assessment

• I&O• Promotion of

rehydration• Correction of

electrolyte imbalances• Nutrition• Prevention of the

spread• Support

• Nursing diagnoses– Fluid volume, deficit– Skin integrity, impaired– Anxiety

• Avoid use of anti diarrheals

• Wash hands• Proper

disposal/cleaning of soiled diapers & linens

Diarrhea• Prognosis

– Mild or moderate – managed at home– Severe – hospitalization– Excellent

Constipation• Passage of hardened stools

associated with failure of complete evacuation of the colon with defecation

• Primary disorder or in association with other disorders

Constipation• Etiology

– Any age– Newborn – failure to pass meconium may

indicate – intestinal atresia or stenosis, Hirschprung’s disease, meconium ileus, or meconium plug

– Formula fed infants – high fat or protein content or inadequate fluid in the formula

Constipation• Etiology

– Children – environmental factor (meds) or learned repression of the urge to defecate

– Continuous repression results in dilation of the rectum, reduced sensation of the need to defecate, decreased muscle tone in the lower rectum

Constipation• Clinical manifestations

– Infancy – hard stools & fresh blood in the stools– Children – cramping, abdominal pain, anal

fissures, pain on defecation, loss of appetite, & irritability

• Diagnostic test– Careful history– Examination of anus & rectum

Constipation• Medical management

– Newborn – alleviate the problem• Modifying formula

– Older infants – adding food with bulk– Manually dilate the sphincter– Mild laxatives or enemas – to completely

empty the rectum• Instituting dietary modifications

– Treatment of chronic constipation• Complete evacuation & toilet retraining therapy

Constipation• Nursing/Patient teaching

– Careful history– Educate on diet modifications– Educate on normal stool patterns– Discuss their expectations &

attitudes– Avoid honey & corn syrup in infants

Constipation• Prognosis

– Simple measures ordinarily correct– Successful resolution

• Depends on age & underlying cause• Counseling & bowel retraining

Gastroesophageal Reflux

• Effortless regurgitation of the gastric contents into the esophagus

• Usually begins within 1 week of birth• Immediately after feeding or when

infant is laid down• Most common cause of vomiting in

infancy

GER• Etiology

– Primarily due to an incompetent lower esophageal sphincter

– Gastric contents are allowed to regurgitate into the esophagus

GER• Clinical manifestations

– Vomiting or spitting up– Aspiration can lead to respiratory signs &

aspiration pneumonia– Growth & weight gain are a problem– Continuous irritation of the esophageal

lining – esophageal ulceration• Anemia• Hematemesis• Blood in stools

GER• Diagnostic tests

– History & growth measurements– Barium esophagography– Esophageal probe – measure pH– Upper endoscopy– Esophageal Scintigraphy

GER• Medical management

– Small, frequent feedings thickened with infant cereal

– Positioning– Pharmacologic intervention

• Cimetidine, ranitidine, famotidine• Metoclopramide

– Nissen fundoplication• Wrapping the fundus of the stomach around the

distal esophagus to prevent reflux

GER• Nursing/Patient teaching

– Recognition of these infants– Provide care for infant needing

surgery– Emotional reassurance– Educate parents

GER• Mild GER

– Normal function by 6 to 7 weeks– 90% improve by 1 year of age – require only

medical therapy• Severe

– Unsuccessfully treated• Esophageal strictures• Recurrent respiratory distress with aspiration

pneumonia

Hypertrophic Pyloric Stenosis

• Obstructive disorder in which the gastric outlet is mechanically obstructed by a congenitally hypertrophied pyloric muscle

• Most common reason for an abdominal operation during the first 6 months of life

• Males 3-4 times more likely to be affected

HPS• Etiology

– Cause – unknown– Increased incidence in siblings & offspring

of affected persons– Muscle becomes diffusely enlarged as the

result of hypertrophy & hyperplasia– Difficult for the stomach to empty– 4-6 weeks – vomit almost immediately after

feedings– Grows more forceful & projectile

HPS• Clinical manifestations

– Regurgitation that progresses to projectile vomiting

– Lethargy, weight loss, poor skin turgor, sunken fontanelles, & loss of subcutaneous tissue

– Dehydration

HPS• Diagnostic tests

– Examination of the abdomen• Visible peristaltic waves – move from left

to right across the epigastric region• Palpation of an olive shaped mass - right

of the midline– Upper GI radiographic– Ultrasound

HPS• Medical management

– Surgical relief – done as soon as diagnosed

– Pyloromyotomy – surgically splitting the pylorus muscle down to the submucosa, allowing for a larger lumen

HPS• Nursing Interventions

– Assist with diagnosis– Provide adequate nutrition– Manage preop & postop care

• Correct any metabolic disturbances & dehydration• Prevent complications postop

– Supporting the family• Caused by a structural problem

HPS• Prognosis

– Recover completely & rapidly– Postoperative complications

• Persistent pyloric obstruction• Wound dehiscence • 15% have GER

Intussusception• Most common cause of intestinal

obstruction in children between 3 months and 6 years of age

• Twice as common in males• Generally cause is not known

Intussusception• Etiology

– Result of telescoping one portion of the intestine into another

– Most common site – ileocecal valve– Passage of intestinal contents becomes

obstructed– Hallmark sign – currant jelly stools

• Mucosa of intestinal walls rub against each other, blood & mucus from the mucosa leak into the intestinal lumen

Intussusception• Serious complications

– Peritonitis– Intestinal ischemia– Infarction– Perforation– Shock

• Condition untreated – death can occur within 2 to 5 days

Intussusception• Clinical manifestations

– Sudden onset of severe abdominal pain

– Vomiting & lethargy– Within 12 hours – pass currant jelly

stools

Intussusception• Diagnostic tests

– History & physical signs– Definitive – barium enema – reveal

obstruction to the flow of barium– Digital exam – reveals blood & mucus

Intussusception• Medical management

– Hydrostatic reduction using barium• Force exerted by flowing barium may

successfully force the telescoped portion of bowel into the correct position

– Surgical treatment • Manual reduction of the invagination & if

needed resection of non viable bowel with end to end anastomosis

Intussusception• Nursing intervention

– Obtain a thorough history & observe physical signs

– Educate on diagnostics and if possible surgery

– After watch for the return of normal bowel movements/watched for 24 hours

– Postoperative• VS• Operative site• Assess for return of bowel sounds

Intussusception• Prognosis

– Many patients treated with hydrostatic reduction

– If untreated – 90% will worsen or die – Treated – serious complications &

death are rare

Hirschsprung’s Disease• Megacolon

– Functional intestinal obstruction caused by the absence of parasympathetic ganglion cells in a portion of the colon

– Predominance in males– More common in children with Trisomy

21– Small number follow a familial pattern

Hirschsprung’s• Etiology

– Absence of innervation to a segment of the bowel

– Most cases – lower portion of the sigmoid colon just above the anus affected

– No peristaltic waves in affected portion to propel fecal contents - causes an intestinal obstruction & distention of the bowel proximal to the defect

Hirschsprung’s• Clinical manifestations

– Vary according to age– Neonates

• Diagnosed early with failure to pass meconium

• Partial or complete intestinal obstruction – abdominal distention, vomiting & poor feeding

– Infants• History of constipation or

intermittent constipation & diarrhea

– Infants• Dehydration, failure

to thrive, abdominal distention, & fever

– Older child• Chronic constipation

– abdominal distention, ribbon like, foul smelling stools, poor wt gain, malnourishment, anemia, palpable fecal mass, & visible peristalsis

Hirschsprung’s• Diagnostic tests

– History– Clinical manifestations– Barium enema

Hirschsprung’s• Medical management

– Immediate treatment• Surgical removal of affected portion• Two stages

– 1st - Placement of temporary colostomy – in portion of normal colon just proximal to the defect

– Period of rest – to regain tone– 2nd – excising the affected segment – Pull the normal innervated segment down through

the anus, anastomosing it to the anal canal– Soave endorectal pull through – performed when

child reaches 20 pounds

Hirschsprung’s• Nursing interventions

– Assist parents– Educate– Preoperative

• Restore nutritional status – low fiber, high protein, high calorie diet

• May need daily enemas & stool softeners• Abdominal girths• Prepare & educate parents

Hirschsprung’s• Postoperative

– VS & BS– Passage of flatus & stools– Operative site– NG removed with peristalsis– Regular diet for age– Colostomy care

Hirschsprung’s• Prognosis

– Most require surgery– Stabilize & then do colostomy – very

successful– After closure – able to attain

satisfactory defecatory function