Gastrointestinal surgical disorder in children

Gastrointestinal surgical disorder in children

Presented by:-Prerna sharmaM.Sc Nursing, 3rd semesterIntroduction

The digestive system is an intricate system that can be disrupted by disease, diet and emotional stress. While some digestive problems can be remedied with medicine and lifestyle changes, others require surgery. Gastrointestinal ultrasound provides more detailed images of the digestive system than other imaging studies. It allows physicians to examine your esophageal and stomach linings, as well as your upper and lower digestive tract.The primary role of the digestive system is to help the body break down and absorb food. Also known as the gastrointestinal (GI) tract, it includes the mouth, esophagus, stomach, small intestine, large intestine also called the colon rectum, and anus. Tiny glands in the mouth, stomach, and small intestine produce juices to help digest food. The digestive system also contains a layer of smooth muscle that moves food along the tract.

common surgical disorders in children are:-

Cleft lip and cleft palate

These are congenital malformation resulting from the failure of fusion fusion of the maxillary and premaxillary process occurs between 5th and 8th intrauterine week. Failure of fusion result in cleft lip and cleft palate.The complete formations of lips occur by 5-12 week; whereas formation of palate occurs only by 12-14 week of gestational age.Cleft lip is due to incomplete fusion of the central process with one or both of the external processes from which the area around upper jaw lip and nose are formed. Defect is in the upper lip of the baby, this is referred as the hare lip. The defect may be unilateral or bilateral (below the centre or one of the nostrils and bilateral beneath both nostrils.)

Fig 1 cleft palateTypes of cleft lip

Group 1- pre-alveolar; it includes only cleft lip in right or left side or bilateral and rarely in mid line.Group 2-post alveolar; it includes only cleft palate.Group 3-combine;it includes both cleft lip and cleft palate in midline may be bilateral and unilateral.:-Cleft lip 25% Cleft palate25%Combined 50%The incomplete c left may be little more than of the vermilion border of the lip and extends to the nostrils.ContdThe complete cleft involves alveolar process of some degree and alanosi(the flap of flash forming the side of nostrils is displaced towards the right). The floor of nares and gum in which upper teeth are set may also be deformed. Infant cannot create vaccum with in the oral cavity and cant such properly.

Cleft palate:

Defect in the roof of mouth and the oral cavity communicates with the nasal passage. Cleft palate may involve only the soft palate or it may extend into the hard palate and also the nose.

Fig 2 comparison of normal, cleft lip and cleft palateCharacteristics:-

Characteristics:-It may be unilateral or bilateral. It may involve the whole palate which can be confined to the posterior part i.e. soft palate. The cleft forms the passage between the nasal pharynx and nose.This passageway causes part of difficulty in feeding and it is the factor leading to infection.Infant is unable to suck if at all he tries to suck feeds are expelled through nose.

Clinical features:-

Fedding-As it is difficult to create negative pressure in the oral cavity unable to suck and take breast feed.Especially designed bottle and nipple or dental plates may be applied in cleft palate patient to prevent nasal regurgitation. Speech:-It can be in the form of nasal tone in speech or articulation of the speech. Child is unable to produce the sound of certain vowels properly. This can be prevented by early surgery for the cleft palate.Hearing:-Recurrent infection in the form of ottis media occurs in cleft palate. This children are at increased risk of sensorineural deafness(all children with cleft lip and cleft palate should undergo test for hearing)Dental problem:-Many children with cleft lip and cleft palate need the advice of orthodontist for alveolar, graft and alignment of a permanent teeth.Airway problem:-Sometime tongue may fall back and affect respiration-perirobin syndrome.

Treatment:-Treatment for these conditions is early surgery.

Cleft lip is treated at 3 month of age.Millards rule says that child should be operated when he has haemoglobin of 10gm/dl and weight of 10 pound and age of 10 weeks. This favour adequate wound healing and safe anaesthesiaCleft palate is required at above 9-18 month depend upon the surgeons choice further delay can leads to speech defect.Orthodontic treatment for alveolar defect is done about 5-8 years of age.

Surgical management:-

If both cleft lip and palate is present , lip is repaired first. For lip repair some surgeon prepare to do at birth and infant will be more acceptable to parents.Palatoplasty; cleft palate repair; a mouth gag is used through out surgery in order to permit access to palate without obstructing airway. Apply soothing antibiotic ointment to keep lip soothing.A lip adhesions procedure a palliative meaure is done by suturing the edges of defective end.When lip is healed palate repair is done by 6 month-5 years of age.If ;lip repair is delayed after 3 yrs a countered speech bulb can be fitted into the malformation so that there is occlusion of the nasopharynx.

Preoperative care:-

Written consent to be taken.Feed should be given before 6 hours only.Premedication order by surgeons should be given.

Postoperative care:-

Keep airway patent. Removal of all secretion to prevent atelectasis and pneumonia.Observe the tissue of mouth and nostrils for edema.Emergency equipment should be kept ready.Indication of bleeding and repeated swallowing, restlessness and vitals monitoring should be done.Restrain arm to prevent rubbing from the area.release the restrain 2-3 hourlyMild sedation to prevent infant from crying and prevent stress on suture.clean the suture lip gently with cotton thick and gauze tipped swab dipped in saline solution or hydrogen peroxide and dry carefully to prevent any infection.After removal of adhesive breast feed can be started.

Contd. Cheiloplasty(lip repair) this is a cosmetic repair Z shape suture are used these technique minimize notching of the lip because of retraction of scar tissue. This should be explained to parentsAfter surgery the incision is secured by adhesive butterfly or logans bow which is an arched wire bow over the incision attached to both cheeks with strips of adhesive this is to prevent tension in the suture line caused by facial movement especially by crying.

Nursing management

Assisting parents to adjustment to malformation:-Help the parents to relieve distress over the birth of a malformed child through complete acceptance of infant with deformity.Emotional support should be given.Provision of adequate nutrition:-Baby should be fed in upright position to minimize regurgitation through nose.Burping should be done frequently because more airswallowing than normal infant feeding.Prevention of infection:-Observe the child for sign of aspiration and respiratory distress.Infant breathe through mouth and mucous membrane become dry prevent fissure through which infection can occur.Give water after each feed to rince the mouth.Parental education:-Routine care must be tought to parents at the time of discharge.Adequate fluid intake to prevent dehydration.

Esophageal atresia

Esophageal atresia; congenital absence or closure of normal baby orifice or tubular organ. It is a malformation that results from the failure of esophagus to develop as a continuous tube during the 4th and 5th week of gestation.Fistula is an abnormal examination or passage generally between two internal organs or leading from internal organ to body surface. trahageal fistula usually associated with anomalies of vertebra anorectum, heart, kidney and skeletal.

Contd..Agenesis; absence of an organ.Hernia; protrusion of loop or part of an organ or tissue through an abnormal opening.Stenosis; narrowing or constriction of passage duct or opening.Evisceration; removal of internal opening.

Symptoms

Excessive salivation,GrullingChockingThree Cs - Coughing, choking, and cyanosis when fed, overflow may be aspiratedFood may be expelled through the nose immediately following the feeding Rattling respirations and frequent respiratory problems such as aspiration pneumonia

ContdGastric distention, if fistulaHistory of polyhydramnios during pregnancy can suggest a high gastrointestinal obstructionCoughing and sneezingDuring feeding the infants return fluid through the nose and mouth. Depending on the type of defect abdomen may defect because of air trapping.

Pathophysiology

During the embryonic development the gut and respiratory tract originates as a single tube. During the 4th and 5th week of gestation this tube lengthens and separates longitudinally.Two parallel tubes are formed. Both of which are joined at the pharynx atresia occurs because of the defective growth of endodermal cells.When there is in complete fusion of the lateral walls of the forgut there is incomplete closure of the laryngotracheal tube and a fistula is formed generally at the level of tracheal bifurcation.Developmental anomalies may affect and interconnect both tracks owing to defective separation.When atresia is present there is a thin noncolonized cord with on upper blind pouch connected to the pharynx and a lower pouch leading to stomach.Diagnosis

Prenatal diagnosis:-By ultrasound examination; mother has polyhydraminos.Small or absent gastric bubble in fetal abdomen.

After birth :-TEF suspect child has continuous drooling and froathing of saliva from the mouth. New born develop chocking and coughing on feed and may regurgitate.This may be associated with cyanosis, respiratory distress and inability to accept feed.Abdomen distended if there is no fistula confirm the diagnose by inserting on NG tube in the upper pouch and taking a radiography that demonstrate coiling the tube in the upper pouch.Echocardiogram and abdominal ultrasound.

Types

Contd.Distal trachio esophagealfistula with esophageal atresia:-The upper part of esophagus ends blindly and the lower part is connected to the trachea by fistula.Esophageal atresia without fistulaTEF without atresia Proximal TEF with esophageal atresia.Proximal and distal fistula with esophageal atresia.Surgical management

A gastrostomy is done to decompress the stomach. Preoperatively and to feed infant postoperatively. Tube is left open so that air entering the stomach through the fistula can escape by gravity drainage and prevent stomach content to reach the trachea.Place the infant either in prone position or propped up an angel of 30 degree to 45 degree in a supine position to avoid gastric content reaching lungs through the distal segment of the esophagus.

ContdDepending on the type of atresia either a thoractomy with ligation of fistula and end to end anastomosis of the upper and lower segments of the esophagus or on intestinal transplant may bed one to form on esophageal pouch is brought out to the skin of the neck to establish a salivary fistula if complete repair of the defect cannot be done early in life

Fig 4 end to end anastomosisPre op care

Shift the child to NICU, maintenance temperature and start IV fluids.Position the child slightly head up.Insert a sump catheter in the upper pouch and connect to continuous slow suction apparatus to prevent aspiration of saliva.if not available perform intermittent suctioning.Give broad spectrum antibiotics

Postoperative Care

Take care of the temperature, fluid resuscitation and administration antibiotics.Maintain the child in slightly upright position to prevent aspiration.Perform chest aspiration.Feeding through the Trans anastomotic tube is started after 48 to 72 hrs of repair. Expressed breast milk of the mother is breast feed. In case of accidental removal of feed. In case of accidental removal of the feeding tube, do not attempt to reinsert it. Inform the surgeons who shall take decision for further management.Pacifier is given to satisfy to infant need for sucking.Keep the infant in propped up positionPost operative gastrostomy feeding

Gastrostomy feeding is continued after oral feeding of small amount of glucose water than milk. When oral feeds are given make sure that infant is able to swallow without chocking. Until the infant is taking sufficiently from mouth.If infant is taking sufficiently from mouth remove gastrostomy tube and child should be planned for discharge.Parents should be taught for gastrostomy feeding Keep the skin clean and dry to reduce infection.

Fig 5 infants position during gastrostomy feedingCongenital diaphragmatic herniaIt is defined as the protrusion of a loop, part of an organ, tissue through an abnormal opening.It is a congenital anomaly of children in which protrusion of abdominal organ like, stomach, spleen, intestine and liver into the thoracic cavity through diaphragmatic hernia detect. Exact cause is unknown.

ContdNormally a strong muscle diaphragm prevents the abdominal organ from entering the chest cavity if abnormal embryonic development occurs hernia result.

Fig 6 congenital diaphragmatic herniaPathophysiology

The diaphragm which separates the thoracic from the abdominal cavity is normally formed from the four embryonic structure that fuses together foramina in the diaphragm permit the esophagus and great vessel to pass through.If formation of diaphragm does not progress normally abnormal opening may result.A diaphragmatic hernia occurs when there is a failure of the pleural peritoneal canal in the posterior lateral segment of the diaphragm to close completely at about 8th week of embryonic development.In mild cases a slight herniation of abdominal organs. In severe malformations the intestine and stomach, liver, spleen and kidneys may press the lungs and heart from their normal position.

Fig 7 pathological changes in congenital diaphragmatic herniaDiagnosis

Prenatal- antenatal period ultrasonography.Neonatal-Mild development of respiratory distress after birth.Abdomen appear swallowBowel sound can be heard in chestXray chest shows filled loops of intestine on the side of defect.

Clinical Manifestation

New born have severe respiratory distress, tachypnea, dyspnea,retraction and cyanosis.Affected side of chest does not expand as compared with unaffected side.Small abdomen and scaphoid in contour.Chest appear large.Herniated bowel fills with gas as the result of crying.Shock and hypoxia may occur.If no symptoms at birth they appear next several days and later after birth.Uncomfortable after feeding and may vomit.Become constipated.When percussion is done over the thorax the sound may be more tympanic and dull than normal.Breath sound may be absent, increased or decreased.Peristalsis sound may be heard on auscultation of chest.

ManagementAs long as lung cannot expand normally the neonate requires resuscitation. It should be done carefully by using a mask or endotrachial tube(no bag and mask ventilation with ambu bag)Surgical management consist of laprotomy reduction of the thoracic contents and repair of the diaphragm with non absorbable sutures for the left side hernia.For the right side defects, thoractomy and repair of defect is done.Chest tube is inserted on the unaffected side(usually right side since most diaphragmatic hernia occurs on the left side to prevent pneumothorax)

Fig 7 management of congenital diaphragmatic herniaNursing management

Preoperative-Explanation about the surgical procedure need to be given to parents.Infant need to be placed in affected side to allow for expansion of lungs and in semi fowlers position.Metabolic disturbance need to be corrected.IV fluid administration should be done.Give antibiotics after doing culture and sensitivity.Postoperative:-Provide general nursing care including vital signs charting.Frequent change in position.Gastrostomy drain should be drains by gravityCare of intercostals drainage need to be done.water seal connected to the chest tube should not raise above the level of patient to prevent backflow of fluid.Feeding can be given once the general condition is improves.

Prognosis

It depends upon the condition of the lungs on the affected and unaffected size of defect.

Omphalocele

An omphalocele or herniation of intestine into the umbilical cord or it is a herniation of abdominal organ into the umbilical cord and appears sac like structure. The protruding organs may be covered by amniotic content and peritoneal wall. Omphalocele is a defect of the abdominal wall through umbilical ring in which the protruding abdominal viscera are covered by a thin membrane made up of amnion.Gastroschisis is an abdominal wall defect just to the right of the normally inserted umbilical cord through which intestine protrude out of the abdominal cavity. Not covered

Fig 8 omphalocelePathophysiology

Between 6th and 10th week of life when the mid gut becomes too large for the abdomen and therefore projects into the umbilical cord.If the intestine do not return to abdominal cavity during the 10th wk of gestation an omphaocele results.The abdomen is proportional small because it is the presence of abdominal contents that cause it to grow in size.

Screening

An omphalocele is often detected throughAFP screeningor a detailed fetalultrasound.Genetic counselingGenetic testingsuch asamniocentesisis usually offered during the pregnancy.

Causes

Caused by malrotation of the bowels while returning to the abdomen during development. Some cases of omphalocele are believed to be due to an underlying genetic disorder, such asEdward's syndrome(Trisomy 18)orPatau Syndrome(Trisomy 13).Beckwith-Wiedemann syndromeis also associated with omphalocelesManagement

Nursing Management

The new born is placed in nursery in an incubator or under overhead warmer.Cover the defect with sterile saline dressings.No pressure or torsion on the toe. Dressing should be moist gauze covered with day sterile towels and plastic wrap to keep the area warm and moist to prevent contamination.Pass a NG tube to decompress the stomach and prevent aspiration.

Surgical management

Surgery is done to replace the viscera into the abdomen and closure of abdominal wall. If defect is small sac is excised the intestine are placed in the abdominal cavity and abdominal wall is closed.

Fig 9 incision closed after repairContd..If the defect is large treatment is carried out in stages.-Ist defect is placed into a sac made of silastic, mersilene or other synthetic material. The sac is sutured to the fascia or full thickness of the abdominal wall around the defect and tried with tape at the top to form a pouch.Protect the area where the sac is in contact with the skin from infection with an antiseptic solution.The top of the sac is in supported from the top of the incubator so that it does not rest on the defect.Then the sac is gradually reduced in size by tying new tapes at lower level closure to the abdominal wall. As a result the abdominal wall is gradually stretched as the content of the omphalocele are slowly and gentle pushed into the abdominal cavity without excess pressure being placed on the diaphragm or inferior vena cava

Fig 9 Repair of the Defect In StagesPostoperative care

Feed the child with IV fluid and gastrostomy feed increase the amount with day increasing.Observe the area for any sign of infection or any dehiscence.Change the position frequently to prevent atelectasisWhen omphalocele reduced completely abdominal wall is closed gradually start fedding.Good parental support to deal with reality and loving care to their infant should be given.

Home care management

keep the child warmAdequate rest.Keep child free from infectionMaintain nutritional statusContinue medication and regular follow up.

Imperforated anus

This is a birth defect in which child does not have any anal opening or anus does not develop properly.

Fig 10 Anorectal MalformationPathophysiology

During the 7th or 8th weak of life the membranes which separates the rectum from the anus breaks to form the continuous patent communication between the anus and remaining gut.If this membrane separating rectum from anus is not absorbed and union does not take place anorectal anomaly result. If not separated anus will remain closed.

Types

Anal stenosis(stenosis of the anus, stricture may be at the anus 1-4 cm above the anus)Anal membrane atresia(anal membrane produces the onbstruction)Anal agenesis(anus is not formed on imperforate anus seen as a dimple with a rectal pouch ending blindly) this distance between blind pouch of rectum and on anal dimple is less than 1.5 cm the rectum has decended below.pubococcygeal line low in perforated anus.Rectal atresia- absence of rectum (normal anus and anal pouch with rectal pouch ending blindly in hallow of the sacrum.High imperforate anus (the distance between the blind rectal pouch of rectum and anal dimple is more than 1.5 cm; the rectal pouch is at or above the pubococcygeal line.

Clinical manifestationNo anal opening found on nursery examination of neonates.A gloved finger or thermometer cannot be inserted into the infants rectum. There is no muconium or stool.Abdominal distention may occur later.Rectal fistula is diagnosed by observing presence of muconium in urine.

Diagnostic investigation

Xray revelas the extension and location of the rectal pouch inrelation to the anal dimple (swallowed air ascending into the rectum will outline the pouch.Abdominal ultrasound.

Management

Stenosis can be managed by anal dilatation. Anoplasty may be done in simple cases(surgery depends upon the level at which rectum end anoplasty temporary colostomy etc are surgical management)Keep child NPO start on IV fluids.In low imperforate anus (if the distance between the anal dimple the blind end of the colon is not more than 1.5 cm) the abdominal pull through and anoplasty may be done during neonatal period or in early in infancy period.

Fig 11 anoplastyContd..In high type (if the distance greater than 1.5 cm the anal dimple and the blind end of the colon) a colostomy is done during neonatal period with further intestinal repair and closure planned is 6-12 months. The colon can be brought down through the anal dimple by an abdominoperineal procedure. The anus is positioned in the area of external spints and the fistula is removed.

Post operative care

NPO, IV fluidsNG suction to prevent abdominal distension.Breast milk or formula feeding when peristalsis is return.No tension should be placed on the perineal sutures places the child in supine position and legs suspended 90 degree angle from the trunk or on sidelying with hips raised.Heat lamp may be used to facilitate healing.General postanesthetic care must be given.Meticulous skin care must be given.Keep anal area clean and dry.Continue medication as orderedRegular follow up.

Hirschsprungs disease (Megacolon)

This is also known as congenital megacolon. This is caused by absence of ganglionic cells in the bowel wall. It extends from variable distance. Proximally from anus congenital aganglionic megacolon is a most common disease/ cause of intestinal obstruction.

Fig 11 comparison of normal and megacolon structureEtiologyLack of ganglionic cells in submucosal and mynetric plexuses of the distal intestine.

Pathophysiology:-

Congenital mega colon is caused by a congenital absence of autonomic parasympathetic ganglionic cells in the sub mucosal and intramuscular, neural plexus of the wall of intestine.The term aganglionic is used in the description of the condition. This condition affects the distal rectum and extends proximally for varying distance.This cause may be either failure of migration of cells of the embryonic neural chest into the walls of the intestine or the failure of the plexus to progress in a craniocaudal direction with in the intestinal wall.The result is functional obstruction of the colon due to lack of peristalsis, leading to accumulation of faeces and gas proximal to the defect.Since the colon enlarges or become distended the condition is called mega colon (large colon). Some infants it is limited to the recto sigmoid colon although the length of the aganglionic bowel varies.

Fig 12 Pathological changes in megacolonClinical features

Failure to pass muconium or passed delay.Acute intestinal obstruction with or without infection.Abdominal distention during first and second day of life.After a rectal examination explosive lekage of accumulated faeces and gases.Bile stained vomiting due to intestinal obstruction.Weight lossDehydrationEpisodes of constipation and diarrhea during infancy.If not treated early shock can developDiarrhea may lead to enterocolitis(severe febrile illness, watery diarrhea, abdominal distension and hypovolumeia)Dehydration and sepsis cause death of infant within 24 hr.In older children this may be present with chronic constipation and abdominal distension due to mass of faeces and gas.Fecal mass can be palpated in left lower position of abdomen.Rectum is empty on examinationStools are expelled in pellet or ribbon like form or may be liquid.Children are malnourished anemia with protruding abdomen thin waisted extremities.Hyponetremia and hypoprotenimea due to malabsorption of nutrients.

Diagnostic evaluation

History and physical examination.Rectal examination reveals absence of fecal matter.Plain Xray of abdomen-reveals bowel distension with multiple air fluid level and paucity of air in pelvis.Barium enema- difference in between ganglionic and aganglionic bowelRectal biopsy- to show absent ganglionic cells in the submucosa and intermuscular nerve plexus with or without decreased numbers of nerve fibre and child has mega colonAnorectal manometery shows absence of relaxation reflex of intestinal sphincter-An invasive procedure by inserting ballons attached to an electromyography (EMG) into the rectal ampulla. The reflex responses of the internal and external sphincter are recorded as the balloons are distended.A fall of pressure in the internal and sphincter and a contraction of the external sphincter in normal individual. If the child is having mega colon the pressure in the internal sphincter increases while the external sphincter contracts normally. The test is uncomfortable when perforated but it is reliable.

Medical management

Mild and chronic symptoms of mega colon:Isotonic enemasStool softenerResidual diet (infant and children who are malnourished and manifestation of more severe disease can get enough to do with stoma surgery.

Surgical management

Goal-To remove ganglionic bowel and improve functioning of internal sphincter.A temporary colostomy is done first above the transition zone of aganglionic and ganglionic bowel with sigmoid or transverse colon.(A temporary colostomy creates a stoma or opening in the colon) this helps the normal distal bowel to return to its original tone and size. Resection of aganglioinc bowels, pull through and anastomosis of normally innervated ganglionic bowel close to anal margin.

Colostomy:-

Loop colostomyDouble barrrled colostomyLoop colostomy

A loop of bowel is brought out through an abdominal incision sutured to the abdominal wall and held in place by a glass road slipped under the loop to hold it in position on the abdomen. A length of rubber or silicone tubing is slipped over each end of the road to prevent it from sliding out. A slit mode on the anterior wall of the colon permits fecal drainage.

Fig 13 Loop ColostomyDouble barreled colostomy

Two distinct stomas are created usually side by side(actually a doubled barrled colostomy can result when the surgeon opens a loop colostomy)Depending on the location of the colostomy the active proximal stoma from which fecal material drains is usually located higher in the abdomen or towards the childs right side and inactive distal stoma from which mass mucoid secretions drain is below the proximal stoma or near to childs left side.The three different corrective procedure are(or bring down the ganglionic gut)Swensons procedureModified duhamels procedureSoaves procedureProcedure is resecting the abnormal aganglionic colon and pulling the end of the normal ganglionic bowel down to a position at or near the rectum or anus. The need both abdominal and perineal incision temporary colostomy is done and closed within a year.

Fig 14 double barrled colostomyNursing management

Care depends upon severity:-Observe the passage of of muconium, abdominal distension, vomiting and record the time of first passage of stool.Take complete history about bowel habits.Once mega colon is diagnosed teach the parents the procedure for isotonic enema under supervision until they feel comfortable about giving enemas.A low residue diet to keep stool soft.

Preoperative care

If congenital mega colon is diagnosed transfer the child to high facility centre.Parents should be informed about disease condition, management and prognosis.Vitals signs should be recorded.Daily rectal wash should be given to children who are planned for primary pull through or there is delay in colostomy.Rectal wash is given by plain normal saline.Antibiotics and fluid should be given as per instruction.Abdominal circumference is taken to know the progress of increased abdominal distension and record it. Semi fowler's position to facilitate lung expansion.Intake output chart to be maintained.Observe strict vital signs.Observe early sign of complication like increased pulse rate, tachypnea, fever, vomiting, abdominal distension and absence of bowel sound.Prepare the child for surgery.

Postoperative

Regular vital signs monitoringObserve for early sign of infection.IV fluid should be monitored as no oral feeding till bowel sound are heard.Good mouth care.Before any painful procedure like dressing analgesic should be given.Observe complication like; excoriation, prolapsed, bleeding from colostomy.A serious complication is leakage at the time of anastomosis, leading to a pelvic abscess(abdominal distension, fever 40 degree Celsius, extreme irritability)Explain the frequent movement and handling can help to prevent pulmonary complication and encourage peristaltic activity.

Discharge teaching

Care of wound and colostomyDietary management small frequent feeds.Administration of medicationEducate the parents to care stoma.If stoma get irritated bleeding or prolapsed, if no flatus or stool becomes ribbon like or excessive diarrhea inform surgeons.

Intestinal obstruction

Intestinal obstruction is a condition in which normal flora of intestinal content through the intestinal tract. This occurs in small intestine or in large intestine. It may be due to mechanical cause or paralytic ileus.

Fig 15 Intestinal ObstructionEtiological factors

Atresia and stenosis:-Commonly occur in ileum, may also occur in duodenum, jejunum and colon.

Muconium ileus:The neonate lacks an enzyme supplied by pancrease and discharge into intestinal tract. When fetus is in utero this deficiency causes the muconium to be stickier. The muconium adheres to the mucosa of the intestinal wall and obstruction occurs.Mega colon:This occurs due to absence of ganglionic cells in bowel wall.

ContdMalrotation:In 10th wk of embryonic structure Ileo-Caecal structure normally rotates,so that caecum lines in the lower quadrant of abdomen and is fixed there by mesentery if the process does not occur colon remains in right upper quadrant. Here an abnormal membrane may obstruct duodenum. This obstructive band is one of the significant findings in malrotation from the lack of normal mesenteric attachment volvulus(pristein) occur loop of small intestine twist on themselves produce obstruction and may go onto necrosis due to lack of blood supply.Intra abdominal hernia:-This is caused by a loop of bowel slipping out of its. A normal position and caught in a defective area of mesentry or becoming compressed between bands of peritoneum.

Fig 16 causes of intestinal obstructionTypes of obstructions

Mechanical obstruction-It can occur due to congenital Artesia or stenosis of the intestine, malrotation of the colon with the volvulus of the mid gut, peritoneal band, hernia, intussusceptions, tumor or polyp etc.Paralytic ileius-Paralysis can occur due to toxic or traumatic disturbance of the autonomic nervous system.Strangulation-Obstruction affecting the blood supply which lead to gangrene of the intestine.

Pathophysiology

Due to obstruction there is increased peristalsisDistension by the fluids and gas and increased bacterial growth proximal to obstruction.Intestinal secretions are increased and bowels absorptive capacity is decreased.

Diagnostic evaluation

HistoryPhysical examinationAbdominal XrayBarium enemaClinical manifestation

The three main symptoms include:-Absence of faecesVomitsAbdominal distensionThe higher the obstruction earlier the symptoms appear and earlier diagnose can be made and treatment can be started.Obstruction lower intestinal tract causes generalized distention and vomiting.

ContdAbsence of passing of flatus and stools.Patient becomes drowsy.A bile stained gastric fluid suggest a high intestinal obstructionPainFeverTreatment

Surgical removal of mechanismResection of affected part and anastomosis of healthy part.

Fig 18 anastomosisPreoperative care

Written consent should be taken.Maintain fluid and electrolytes.Cross matching of blood.Broad spectrum antibiotics are given if there is perforation or sepsis.

Postoperative care

Surgical correction is resection of the involved portion of the bowel and end to end anastomosis with an ostomy is done. Gastrostomy done to prevent vomiting and to decompree stomachMaintain intake output chart.Continue antibiotics.Replace IV fluid.Daily albumin infusion to replace protein loss.

Contd..Oral fluid can be started laterObserve indication of complication like aspiration, pneumonia, sepsis and recurrent obstruction.Feeding can be started when infant passes stool(gastrostomy feed)Record consistency and number of stool

Nursing management

NG tube insertion, aspiration and on continuous drainage (to avoid aspiration due to vomiting and avoid respiratory embolism due to abdominal distension.)Check the patency of tube and prevent blockage.Maintain IV fluids to prevent dehydration.Keep the child NPO as they have to go for surgery.

Malrotation

Rotational abnormalities developing during the maturation of the gut cause recurrent obstruction, occurring as either the ladds band or volvulus of the gut over the narrow mesenteric pedicle.

Fig 19 comparison of normal and malrotation anatomyClinical manifestation

Abdominal pain with bilious vomiting suggest small bowel obstructionAbdominal distension may not be prominent findings.

Diagnostic evaluation

Barium meal which shows duodenojejunal junction on the right of the spine(rather than to the left of midline at the level of pylorus)An abnormally positioned caecum and small bowel loops on the right side of abdomen.Volvulus is also present.

Management

After resuscitation , emergency laprotomy is required for correction of the defect usually by ladds procedure which include derotation of volvulus, division of the ladds band, widening of the base of the mesentry, placement of bowel in a state of non rotation and appendicectomy.

Fig 20 surgical repair of malrotationSummary

Most of the disease of gastrointestinal tract present with a few symptoms , such as vomiting, dysphagia, gastrointestinal bleeding and failure to thrive. Additionally other diseases may present with symptoms attributed to GItract. Appropriate diagnostic evaluation, sign and symptoms and management can be helpful in better outcome.The digestive system is an intricate system that can be disrupted by disease, diet and emotional stress. While some digestive problems can be remedied with medicine and lifestyle changes, others require surgery.

Conclusion

The digestive system is an intricate system that can be disrupted by disease, diet and emotional stress. While some digestive problems can be remedied with medicine and lifestyle changes, others require surgery. Gastrointestinal ultrasound provides more detailed images of the digestive system than other imaging studies. It allows physicians to examine your esophageal and stomach linings, as well as your upper and lower digestive tract.proper treatment at proper time will provide better outcome.