Child with gastrointestinal dysfunctions

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Child with gastrointestinal dysfunctions

• Emad Al Khatib, RN,MSN,CNS

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Appendicitis

• The appendix is a small finger-shaped tube that
  branches off the first part of the large
  intestine. The appendix can become inflamed or
  infected causing pain in the lower right part of
  the abdomen.

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• Appendicitis is when the appendix becomes blocked
  and inflamed. The appendix is a small pouch
  attached to the large intestine, whose function
  is not well known.

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Causes, incidence, and risk factors

• Appendicitis is one of the most common causes of
  emergency abdominal surgery in the United States.
  Appendicitis usually occurs when the appendix
  becomes blocked by feces, a foreign object, or
  rarely, a tumor .

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Symptom of Appendicitis

• Appendicitis is the most common surgical
  emergency seen in hospitals. Six of every hundred
  persons will get it at some point in their life.

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• It's use is unknown but sometimes it gets blocked
  by stool passing by. Once this happens bacteria
  in the stool start to multiply and cause an
  infection of the appendix. It's like having a
  river of stool passing by. If it stops it gets
  stagnant just like a real pool of water allowing
  bacteria to grow - which is why stagnant water
  starts to smell bad.

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The symptoms of Appendicitis

• Abdominal pain-Pain may begin in the
  upper-middle abdomen (epigastric), then develop
  to sharp localized pain
• Pain may shift from the epigastric area to become
  most intense in the lower right side of the
  abdomen ("typical" case), tenderness of this area
  is common
• Pain initially may be vague, but becomes
  increasingly more severe

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• Point tenderness, especially over the right
  lower quadrant of the abdomen
• Nausea and vomiting
• Fever usually occurs within several hours
• Abdominal pain may be worse when walking or
  coughing. The patient may prefer to lie still
  sudden jarring motions or bumping can cause pain.

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• Later symptoms
• Fever
• Loss of appetite
• Nausea
• Vomiting
• Constipation
• Rectal tenderness
• Chills and shaking

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• Additional symptoms that may be associated with
  this disease include bloody urine (microscopic
  hematuria).

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Signs and tests

• With appendicitis, pain increases when the
  abdomen is gently pressed and then the pressure
  is suddenly released. Touching the abdomen may
  cause a spasm of the abdominal muscles if
  peritonitis is present. Rectal examination may
  also cause pain, localized on the right side.

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• The health care provider may perform other tests,
  including having the patient lie on his or her
  back with the following
• The right leg is extended straight up.
• The knee and hip are flexed, and then the leg is
  rotated inward and outward.
• The lower left portion of the abdomen is palpated.

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• Each of these actions will cause pain in the
  lower right quadrant of the abdomen of a person
  with appendicitis.
• Appendicitis may be strongly suspected based on
  the following tests
• CBC, often shows an increased white blood cell
  count
• Abdominal sonography
• Abdominal CT scan

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• Appendicitis is diagnosed from a history of the
  above symptoms and by pressing with his/her hand
  on the tummy. If there is pain over the right
  lower abdomen, especially if worse on jerking the
  area, appendicitis is strongly suspected - except
  in females where ovaries and other structures can
  also lead to pain in this area.

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• The surgeon may confirm the diagnosis during an
  exploratory laparotomy. The operation may be done
  as an open procedure or through a laparoscopic
  approach that uses a small camera and requires a
  smaller incision.
• It is important to realize that not all surgical
  explorations for appendicitis reveal an abnormal
  appendix.

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• Approximately 10-15 of operations for suspected
  appendicitis reveal either no obvious
  abnormality, or a disease process other than
  appendicitis. This relatively high rate of
  "negative appendectomies" is tolerated because
  the consequences of not diagnosing appendicitis
  in patients with abdominal pain can be severe and
  sometimes life-threatening.

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• If an operation for suspected appendicitis
  reveals a normal appendix, the surgeon will
  probably remove the appendix anyway, and then
  explore the rest of the abdomen for other
  possible causes of pain. In some cases, this may
  require extension of the surgical incision.

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inflammatory bowel diseases

• These diseases each exhibit very different
  symptoms that make them appear to be completely
  unrelated. However, they all have one
  commonality. They are all autoimmune disorders in
  which the body's immune system has been
  accidentally triggered to attack a specific
  protein tissue of your own body.

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• The original cause is most likely Leaky Gut
  Syndrome. Therefore, autoimmune diseases such as
  arthritis, multiple sclerosis and lupus have a
  very close connection with inflammatory bowel
  diseases. Many people exhibit several of these
  diseases for this reason.

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• Doctors will typically prescribe drugs to treat
  the multitude of possible symptoms which leads
  people to think the diet should be different for
  each. Doctors also prescribe drugs to suppress
  the immune system in an attempt to stop the
  attack. Most of these drugs have very harmful
  side effects.

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• This diet program addresses the root cause by
  eliminating those foods that trigger the immune
  system to attack the body. Eating one bite of a
  "Forbidden Food" as listed below can trigger an
  autoimmune flare that will last for weeks.
  Therefore, strictly compliance with this diet
  program is required.

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• Most people suffering from chronic intestinal
  problems have been found to be addicted to the
  very foods that made them sick and continue to
  prevent their recovery. These people typically
  refuse to change their nutritional philosophy.

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Pyloric stenosis

• The stomach connects the esophagus to the small
  intestines The pylorus of the stomach is a small,
  narrow muscular sphincter through which food
  passes into the duodenum after it has been
  partially digested in the stomach.

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• Pyloric stenosis is a congenital defect in which
  the opening of the pylorus is too narrow. Food is
  thus unable to pass into the duodenum. Children
  with pyloric stenosis usually manifest forceful,
  "projectile" vomiting within the first 1-2 weeks
  of life.

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• After general anesthesia is administered and the
  patient is in deep sleep and pain free, the
  abdomen is cleaned and draped. A small incision
  is made in the abdomen.

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• The surgeon makes a cut into the pyloric muscle
  (stomach outlet) down to the mucosa, the inner
  layer of the stomach, thus releasing the
  restriction. No tissue is removed and the stomach
  lining is not opened. The pyloric muscle returns
  to normal size with time.

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• Children usually recover quickly. There are no
  long-term disadvantages to surgery. One to two
  days of hospitalization may be all that is
  required. Feedings by mouth are usually delayed
  for 12 hours after the operation. The stomach
  requires this short time to regain its ability to
  contract and to empty.

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• Most infants can advance from clear liquids to
  normal amounts of formula or breast feedings
  within 36 hours after the operation. Vomiting of
  one or two feedings in the first 24 to 48 hours
  after the operation is not uncommon.

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• Paper tapes will cover a small incision located
  on the childs right upper abdomen. A firm ridge
  may appear at the incision site, which is no
  cause for concern. Avoid bathing for at least 5
  days after the operation. Sponge bathing is
  permitted the day of discharge. Carefully pat dry
  the incision tapes after the sponge bath.

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Celiac disease

• is a life-long autoimmune disorder of the
  intestinal tract, which may have its onset in
  childhood or adulthood. (Celiac disease occurs
  with greater incidence in persons with other
  autoimmune disorders.)
• The disorder is characterized by sensitivity to
  the predominant wheat protein, gluten (or more
  specifically, the gliadin portion of the
  molecule).

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• The disease varies in severity with classic
  symptoms of malabsorption noted in some persons
  while others remain completely asymptomatic.

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• The disease has also been known as celiac sprue,
  nontropical sprue and gluten sensitive
  enteropathy. It is a genetic condition in which
  the immune system damages the small intestine
  when gluten enters the digestive system.

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• The body produces immune cells, which damage the
  villi. The villi in a healthy intestine have the
  appearance of a deep pile carpet. All these villi
  give the small intestine enormous absorptive
  surface.

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Gluten

• Gliadin, a protein portion of gluten, is the
  specific offender. Gluten is found in wheat,
  oats, rye.
• A gluten-free diet is not simply avoidance of
  bread and pasta. Starch, flour or additives from
  the toxic grains are added to many prepared foods
  and some medications.

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• Corn and rice and their byproducts contain no
  toxic gluten and are considered safe.

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Celiac disease

• Celiac disease is an absorption problem found in
  the small intestinal tract.  Celiac is caused by
  an excessive amount of mucous secreted by the
  cellular walls of the tract.  This mucous is
  produced in abundance to protect the already
  deformed and damaged cellular surface due to
  bacterial attacks and or parasite attacks

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• This typically occurs in the lower portion of the
  small intestinal tract because this area is the
  farthest away from the hydrochloric acid of the
  stomach.
• The organism either travel from the large colon
  into the small intestinal tract which is only
  achievable if the large intestinal tract is
  extremely dirty and constipated,

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• or through ingesting food that contained the
  germ.  Low levels of stomach acid may allow these
  microbes to survived the secretion of
  hydrochloric acid.
• An absorption problem develops when the mucous of
  the tract becomes too deep to allow nutrients to
  be absorbed.

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• This causes malnutrition in the body and weakens
  the immune system leaving the individual
  susceptible to many viruses.  The whole body
  becomes weakened as essential vitamins and
  mineral are not being absorbed.   

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• Nutrients  The best nutrient for protecting the
  lower intestines is vitamin B12 in the
  methylcobalmin form.  This type of B12 does not
  require any breakdown by the liver and is ready
  for absorption into the blood system via the
  mouth, stomach and duodenum.  From here the B12
  will make its way to the tissues that require the
  vitamin and the individual get healing from the
  inside out.

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• Suggestion  Diet free of sugar, starches, milk
  and gluten products such as wheat and rye. 
• Exclude refined products e.g. sugars, flour,
  table salt as it contains up to 70 sugar!  Sea
  salt from a health food store is a better choice
  as it contains many minerals.

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Complications of CD

• The disease usually is worse in the first
  portions of the small intestines. When only the
  top of the small intestine is smooth (flattened
  villi), gastrointestinal symptoms may not be
  present.
• There may or may not be discomfort, bloating or
  gas, possibly no diarrhea and/or constipation.

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• The presentation of CD is very serious (in spite
  of no intestinal symptoms) because many nutrients
  are absorbed in this area of the digestive
  system.

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• Vitamin B1 and B12 (numbness in extremities),
  Iron (anemia), Folic Acid (birth defects),
  Calcium and Vitamin D (bones and muscles),
  Vitamin E (nerves), Vitamin A (eyes) and Vitamin
  K (blood clotting) may be malabsorbed. That is,
  the nutrients from food and supplements are not
  absorbed properly.

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• When a larger portion of the small intestine is
  damaged, gas, bloating and discomfort can be
  present in addition to the malabsorption of
  nutrients.
• Until recently diagnosis was made when much of
  the intestine had been damaged, diarrhea and
  wasting appear in addition to malabsorption of
  nutrients.

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• Additional explanation of the complications of
  malabsorption include (besides weight loss,
  vitamin and mineral deficiencies) coagulopathy,
  osteopenia, bone fractures, lymphocytic gastritis
  and lymphocytic colitis/intestinal strictures and
  ulcerations may occur.
• Other complications include refractory and
  collagenous sprue as well as malignancy.

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• There is a three to four-fold increased incidence
  of all malignancies among undiagnosed celiac,
  half of which occur in the intestinal tract.
• Of those, there is a particularly high incidence
  of enterocyte associated T cell lymphoma of the
  small intestine (EATL).

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• This is very difficult to diagnose and warning
  symptoms may include unexplained or worsening
  diarrhea, weight loss and abdominal pain. There
  is also a much greater incidence of
  adenocarcinoma of the small intestine. The risk
  of malignancy returns to that of the general
  population after five years of maintaining a
  gluten-free lifestyle.

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• Untreated celiac disease will also negatively
  affect pregnancy outcome with relative incidences
  of spontaneous abortion and low birth weight
  being nearly nine and six times higher
  respectively. These improve markedly in treated
  celiac patients with unexplained neurological
  dysfunction.

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Side Effects

• Bone disease                                   
• Short stature in children
• Joint and bone aches                       
• Muscle weakness and cramps
• Anemia                                           
• Lactose intolerance
• Chronic fatigue                              
•   Edema (swelling)

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• Hyperactivity                                 
• Personality change
• Attention deficit                            
• Neurological disorders
• Ataxia (stumbling gait)                   
• Spinal cord lesions
• Eye problems                                 
• Dental defects

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Diagnosis

• Diagnosis of celiac disease should be considered
  when symptoms or laboratory findings indicate
  celiac disease could be an explanation of the
  person's health condition. A reliable assessment
  of gluten sensitivity is a celiac disease
  evaluation panel (of blood tests) which includes
• IgG and IgA Gliadin Antibodies (AGA)

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• IgA Endomysial Antibodies (EmA)
• IgA Reticulin Antibodies (ARA)
• These studies, whether positive or negative, are
  only suggestions and reasonably predictive of the
  possibility of celiac disease. Confirmation or
  exclusion of the disease requires a biopsy of the
  small intestine.

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• The biopsy is usually performed through an
  endoscope - commonly done under sedation - in
  which a flexible tube is passes through the mouth
  into the small intestine where several biopsies
  are obtained.

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• It is still advisable to obtain annual CBC,
  biochemical panel, iron levels, B12, folic acid
  and vitamin D-250H. A one-year post-treatment
  biopsy is important in establishing a new
  baseline, as all patients do not heal completely
  in spite of strict adherence to the diet. Bone
  densitometry at the time of diagnosis and
  periodically thereafter is important -
  particularly in female patients.

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• Celiac antibodies may be helpful in monitoring
  some patients, particularly those in whom
  noncompliance is suspected.
• It should be stated also that first-degree
  relatives of celiac should also be screened since
  celiac disease is a genetic disease.

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Treatment

• A life-long adherence to a gluten-free diet.
• This is a very under diagnosed disease because
  the symptoms are so varied. Until recently, only
  persons were diagnosed with celiac disease who
  presented with the most severe gastrointestinal
  symptoms such as diarrhea and weight loss.
  Currently, celiac disease experts advise that all
  the listed SIDE EFFECTS, ASSOCIATED AUTOIMMUNE
  DISORDERS and the FAMILY HISTORY should be
  considered diagnosis.

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