Gastrointestinal

1
Gastrointestinal

• Elisa A. Mancuso, RNC-NIC,MS,FNS
• Professor of Nursing

2
Anatomy and Physiology of GI Tract

• Process and absorb nutrients
• Maintain metabolic process
• Support growth and development
• Detoxification
• Maintain fluid and electrolyte balance

3
Gastroesophageal RefluxGER/GERD

• Passive regurgitation into esophagus
• Relaxation of the cardiac sphincter or
• (LES) lower esophageal sphincter
• Gastroesophageal Reflux Disease (GERD)
• when GER causes symptoms
• clinical problems
• complications- Esophageal Strictures

4
Clinical Signs

• Infants
• Regurgitation / Spitting Up
• Apnea/Bradycardia
• ?? Risk of Aspiration PN
• Irritability ?? Crying
• Esophagitis RT HCL irritation
• Poor weight gain
• Heme stools Anemia

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Clinical Signs

• Young child
• Heartburn/Chest pain
• Abdominal pain
• Dysphagia
• Hoarseness/Wheezing/Stridor
• Chronic Cough Sinusitis
• Disturbed Sleep

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Diagnosis

• Upper GI Barium Swallow
• Check patency of sphincter via fluroscopy
• Evaluates anatomy but will not give of times
  reflux occurs
• Barium
• Contrast medium shows-up as bright white
• Not absorbed can harden cause constipation
• ? bowels sounds
• ? stools for passage of white barium
• May need laxative

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Diagnosis

• Esophageal PH monitor-probe
• Detects episodes of reflux over 24 H.
• Frequency of Reflux
• Time Duration of acid reflux episodes
• ? Feedings
• ? Positioning
• ? Sleeping
• ? Apnea Bradycardia
• Upper Endoscopy
• Identifies esophageal strictures
• Biopsy reveals extent of damage

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Therapy Goals

• Eliminate Symptoms
• Heal Esophagus
• Prevent complications
• Positioning
• ?? HOB _at_ 300 lt after feedings.
• Side or prone is best position.
• AAP recommends back to sleep to ?SIDS.
• Car seats can ?risk for GER

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Nutrition

• Infant Feedings
• Small, frequent feedings (30cc q 3H)
• Thicken formula
• 5cc rice cereal/30cc of formula
• Provide quiet times after meals
• Older child
• ? caffeine, soda chocolate.
• Avoid skipping meals.
• No NSAIDS, Steroids, cigarette or alcohol

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Medications

• H2 Blockers (Histamine receptor antagonists)
• ? HCL content.
• Ranitidine (Zantac) gt1 month
• Give 2 H pc
• Famotidine (Pepcid) gt1 year
• Nizatidine (Axid) gt12 years
• Cimetidine (Tagamet)gt16 years

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Medications

• Proton Pump Inhibitors (PPI)
• ? Gastric emptying time
• Block acid secretion
• Lansoprazole (Prevacid) gt 1 year
• Omeprazole (Prilosec) gt 2 years
• Nexium use 30 minutes pc

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Medications

• Prokinetic
• ? Resting sphincter pressure
• ? Contractility of esophagus
• ? Efficacy ? adverse side effects for children
• Bethanechol (Urecholine)
• May exacerbate respiratory symptoms
• Cisapride (Propulsid)
• NA due to cardiac arrhythmias and death
• Metoclopramide (Reglan)
• Restlessness, drowsiness and
• irreversible CNS (EPS)

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Gastroenteritis

• 500 deaths /year
• 600 million/year for hospitalization lost job
  time
• Inflammation of stomach and intestine
• Enterotoxins
• ? loss of H2O and electrolytes
• severe dehydration and hypovolemic shock
• Intestinal mucosa of infants is more H2O
  permeable
• ECF gt ICF
• Lose more fluid and electrolytes than older
• child

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Diarrhea

• ? of stools ? consistency
• Severe electrolyte imbalances
• ?? H20 loss
• ? NA, ? K, ? HCO3
• Metabolic acidosis

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Etiology

• Food irritants, lactose intolerant
• Contaminated food products
• Stress
• Malnutrition
• Antibiotics
• Ampicillin, EES Tetracycline can induce C-Diff
• Infections
• Bacterial E Coli, Salmonella Shigella
• Parasitic- Giardia
• Viral Rotovirus
• 200,000 hospitalizations annually with 20-40
  deaths/year

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Signs and Symptoms

• Depends on pathogen
• Diarrhea
• Bloody or non-bloody
• Acute or chronic
• Vomiting
• Fever
• Dehydration
• ? dry mucous membranes, sunken fontanels,
• ? HR,
• ? Output
• ? diapers, ?tears
• tenting

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Diagnosis

• Stool culture
• C S
• Guaiac
• Positive inflammation of lining of intestine
  or E-coli
• O P (Ova Parasites)
• store in a warm place
• Pale yellow, foul smelling stools Rota
• Greenish stools Giardia or C-Diff

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Therapy

• Enteric Precautions!
• Gown, gloves separate linen/garbage bag
• Fluid Replacement (IV NPO x 24H)
• Replace fluids lost with aggressive IV hydration
• Monitor electrolytes and correct imbalances
• NPO rest the bowel
• Rehydration - start with pedialyte
• ORT 11 basis 10ml/kg or ½ cup to 1 cup fluid for
  every stool
• No juice or high sugar drinks acts as laxative
• BRAT diet
• Bananas, Rice, Applesauce Toast
• Advance to regular as tolerated
• Vit/mineral supplements
• ? calories ? protein to promote
  healing
• ? fat and fiber

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Medications

• Anticholingerics Atropine (Donnatal)
• Relaxes GI tract ?peristalsis
• Antispasmotics Diazepam (Valium)
• ? Diarrhea cramping
• Antibiotics
• Broad Spectrum Penicillin or Cephalothin
  (Keflin)
• Localized Sulfasalazine (Azulfidine)
• Antiseptic Anti-inflammatory
• ? bacterial count in bowel
• 1/3 dose sm intestines 2/3 dose lg intestine
• Interferes with absorption of folic Acid
• Need Folic acid supplements
• Antidiarrheal Paragoric (Tincture of
  opium)
• ? Frequency of stools delays transit in
  intestines
• Not recommended in infectious diarrhea

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Constipation

• Altered consistency (Not ? frequency)
• Dry, hard stools, pebble like
• Blood streaked due to rectal fissures
• Abdominal distension
• Pain
• Bloating N/V
• Encopresis
• Leakage of stool around hard mass
• soiling of underwear

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Etiology

• Poor elimination pattern
• Retention of stool
• excessive H2O reabsorption in colon
• Dry, hard stool
• ? Activity Level
• Drug SE (Narcotics)
• ? Roughage in diet
• Change in formula or switch to whole milk
• R/O medical conditions (Obstruction)
• Hypothyroidism, CF, Hirschsprung
• ? Abdominal X-ray, Lower GI series

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Therapy

• ?? Fluid ?Fiber intake
• Fresh fruits and vegetables
• ? Carbohydrate Fructose foods
• ? Activity
• Bowel training
• Develop routine ? regular habits
• Glycerin suppository or enema.
• Medications
• MOM and miralax safest.
• Lactulose, Sorbitol, Colace
• Gylcerin suppositories

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Hirschprungs Disease

• Congenital Aganglionic Megacolon
• Absence of ganglion cells in distal area of colon
• No innervation ? no peristalsis ? ? distention
  megacolon
• Mechanical obstruction RT ? Motility
• No relaxation of internal rectal sphincter
• No evacuation of stool, liquids or flatus!
• 25 of all cases of neonatal intestinal
  obstruction
• Males 4x gt females

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Signs and Symptoms

• Infants
• Do not pass meconium in 1st 24 hours.
• Abdominal distension
• Bilious vomiting
• Not tolerating feedings
• Failure to Thrive
• Palpable fecal mass

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Signs and Symptoms

• Older children
• Chronic constipation
• Recurrent distension
• Diarrhea alternates with constipation
• ? of episodes ? mortality
• Visible peristalsis
• Ribbon-like foul smelling stools
• Malnourished anemic

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Diagnosis

• Anorectal Exam
• Tight internal sphincter no stool
• Sudden release of gas and stool
• Barium enema
• Distinct change in distal portion of colon
• Very distended to saw toothed appearance
• Wont pass barium
• Full Thickness Rectal Biopsy
• Definitive diagnosis shows absence of
• ganglionic cells

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Therapy

• NGT- decompression
• ? Abdominal girth and bowel sounds q 1H
• Cleansing NS enemas till clear a surgery
• IV therapy
• Hydration electrolyte replacement
• Meds
• Sulfasuxidine, Neomycin and Kanamycin SO4
• Local antibiotics ?? Flora of colon
• Prevent infection and sterilize bowel
• Watch for Necrotizing Enterocolitis (NEC)!
• ? Abd. distention, Ruddy undertone
• Guiac stools/emesis/ NG drainage

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Treatment

• Mild Rare
• Treat chronic constipation with stool softeners
  and cleansing enemas
• ModerateSurgery
• Remove aganglionic portions of bowel
• Temporary colostomy
• Proximal stoma functional stoma (Stool)
• Distal stoma mucous or H2O drainage
• NPO until positive bowel sounds
• Diet
• ? Protein ? Calories
• Gradually ? Volume consistency
• Reverse Colostomy _at_ 2-3 months or 8-10 kg
• Re-anastomose both ends

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Pyloric Stenosis

• Abnormal severe narrowing _at_ pylorus
• Hypertrophy Hyperplasia of pylorus muscle
• Not present _at_ birth Not Congenital
• Muscle becomes cartilaginous thickens
• Twice the size!
• Males 5x gt females
• Sonogram shows solid mass
• Barium swallow
• Delayed gastric emptying

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Clinical signs

• 2-4 weeks p birth
• Visible L ? R peristalsis waves
• Visible or palpable mass (olive shaped)
• Feeding residuals
• Entire contents never emptied
• ? residual q feeding
• Projectile vomiting
• As early as one week and as late as 5 months
• Moderate/severe up to 3 due to ? Pressure ?
  Volume
• Metabolic Alkalosis Failure to Thrive (?
  Weight)
• Irritable and hungry
• Eager for next feeding

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Therapy

• Surgery-Pyloromyotomy
• Pre-op
• NGT replace drainage with 1/2 NS added to IV
• NPO, strict I O, IV, daily weight, and ? abd
  girth
• Post-op
• Position on R side with HOB elevated
• Assess incision site
• ? Steri strips over mid upper abd.
• DSD change PRN
• Continue assessment of I O, girth and daily
  weights
• Feedings
• Slowly introduce when BS present
• 15cc D5W q 3H x 3 feedings then 15cc ½ strength
  formula
• ? in volume then ? to full strength formula
• Any vomiting hold feed
• and return to previous volume tolerated

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Intussusception

• Telescoping of bowel into itself
• ? Risk between 3-12 months old
• Males 3 x gt risk than females
• Pushes bowel inward obstruction
• Stops peristalsis completely
• No bowel sounds distal to obstruction
• ? Incidence _at_ ileocecal valve

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Signs and Symptoms

• Palpable sausage mass in RUQ
• Sudden acute abdominal pain
• Colicky, wavelike intermittent pain
• Draw-up knees in pain with guarding
• Hyperactive BS proximal to obstruction
• ? Peristalsis before obstruction
• Distended abdomen and ? tender with palpation
• Constipation no feces or flatus passed
• Jelly stools
• ? pressure on bowel walls, ischemia and blood
• Fecal vomiting and dehydration (?H2O ?Na ? Cl)
• Lethargy Shock
• Initially ? HR ? BP,
• then ? HR ? BP ? Temp clammy

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Therapy

• Barium Enema
• Diagnostic and curative 85
• Forces bowel out
• Do not do if you suspect ischemia or strangulated
  /infarction of bowel
• Surgery
• Resect all affected areas re-anastomose
• No colostomy needed
• Same care as for Hirschprungs

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Appendicitis

• Inflammation of vermiform appendix _at_ cecum
• Peak incidence at 10-12 years
• Pathophysiology
• Feces trapped in appendix (fecalith) or food
• Obstruction ? Ischemia ? Infection ? Inflammation
  ? Perforation
• Rupture of appendix and contents
• Medical emergency!
• Peritonitis Life threatening

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Signs and Symptoms

• Children describe pain as general or vague
• Abdominal pain starts _at_ peri-umbilical then
  localizes _at_ RLQ McBurneys point
• Anorexia N/V/D,
• Low grade temp 100-101
• ? WBC gt 12 - 15,000
• Hypoactive BS over affected area
• Constipation RT paralytic ileus
• Rebound tenderness after palpation
• Positive Hop test
• CT scan with oral and IV contrast

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Therapy

• Pre-op
• NPO, IV antibiotics no pain meds!
• No enema!
• ? Abdomen
• Distention via girth
• Bowel sounds
• Stool pattern
• Post-op
• ? s/s infection, obstruction/ileus
• Pain management ATC x 1st 24 H
• Splinting, cough and deep breathing
• Early ambulation
• NPO until positive bowel sounds
• passing flatus

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Perforation

• Medical Emergency!
• High temp 104
• Rigid (board like) abdomen
• ? Abd. distention
• Diffuse pain or sudden relief of RLQ pain
• Very sick appearing
• STAT OR!
• Need 7-10 days triple antibiotics post op

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Malabsorption Syndromes

• Impaired digestion/absorption
• Fluids Electrolytes
• Chronic diarrhea
• Etiology
• CF Lactase deficiency
• Decreased/ absent digestive enzymes
• Celiac Ulcerative Colitis
• Absorptive defects
• Short bowel syndrome
• Extensive resection of bowel RT NEC

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Celiac Disease

• Gluten Induced Enteropathy
• 2nd to CF possible genetic component
• ? incidence when solids are delayed until 6
  months
• Inability to digest gliadin or protein part of
• wheat, barley, rye and oats
• ? accumulation of toxic substance
• Glutamine damages mucosal cells ? villi atrophy
• ?? absorptive surface of small intestine
• Lifelong Dietary modification needed
• to prevent chronic symptoms

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Clinical signs

• Usually _at_ 9 months
• Need 3-6 months after introduction of grains
• Drop on growth chart lt25
• Steatorrhea
• Abdominal distention/pain
• Anorexia
• Irritability Uncooperative
• Muscle wasting in legs buttocks
• ?Vitamin A, D, E K Anemia

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Therapy

• Serum Antiglidian Antibody (AGA)
• Newer test - Tissue Transglutaminase (tTG)
• Jejunal biopsy
• Flat surface and ?? of villi
• ? ? Absorption
• Fecal collection 72 hours
• ? stetorrhea
• Gluten free Diet Lifelong Therapy
• No Wheat, Barley, Rye or Oats
• No prepared foods, pizza, pasta,
• hot dogs, cold cuts, bread
• Only Corn or Rice
• In 1 week Rapid improvement
• ? appetitite and ? weight
• Symptoms are gone, this is diagnostic

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Complications

• Anemia
• Growth retardation
• Osteoporosis ? bone mass and softening
• Failure to Thrive
• Celiac Crisis-
• Infection, hidden source of gluten food or
  binging
• Abdominal distension
• Profuse watery foul smelling stools
• Metabolic Acidosis
• Vomiting ? Dehydration? Electrolyte imbalances
• Therapy
• IV fluids albumin for shock
• Steroids for mucosal inflammation

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Short Bowel Syndrome

• ?? Mucosal surface area RT resection
• Gastroschisis, Bowel Atresia, NEC, Chrons
• ?? Ability to digest absorb nutrients
• Severity of symptoms RT amount and location of
  resected intestines
• gt60 ?? absorption
• Diarrhea
• Food intolerance
• Abdominal distention
• ?? weight

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Therapy

• Maintain nutritional status via IV TPN therapy
• ? Growth development
• ? Broviac S/S infection
• ? Renal hepatic function
• ? Labs
• Parental Anticipatory Guidance
• Bowel Liver Transplant

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Biliary Atresia

• Female gt Male
• Congenital obstruction or absence of a portion of
  bile ducts.
• Irreversible obliteration of extrahepatic bile
  ducts.
• Impaired flow of bile from liver
• to small intestine and gallbladder.
• Back-up of bile into liver.

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Clinical signs

• Jaundice gt 2 weeks
• Hepatosplenomegaly
• Abdominal distention
• Ascites RT portal ? BP
• Clay colored (Acholic) stools RT lack of bile
• Poor weight gain
• Failure to Thrive
• Irritability RT ?? toxins

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Therapy

• Surgery only for extrahepatic atresia
• Provides drainage for bile.
• 80-90 will still require liver transplant
• Phototherapy
• Diet - ?? Na
• Meds
• Cholestyramine - Bile acid binding
• Phenobarbital - ?Irritability ? Bilirubin
• Lasix - ?Ascites
• Plan care during awake periods
• ?? Toxic products accumulate
• ?? Irritability restlessness