Gastrointestinal disorders 2 Flashcards
▪ Return of gastric contents into the esophagus
▪ Backward movement of gastric content
▪ Neuromuscular disturbance in which the cardiac sphincter and lower portion of the esophagus are lax,
therefore allow easy regurgitation of gastric contents into esophagus
GastroEsophageal Reflux Disease (GERD)
s/s of peritonitis
relief of pain, increased PR and RR, fever, vomiting, absence of bowel sounds and
increased abdominal distention
INTUSSUSCEPTION is associated with
Cystic fibrosis & Celiac disease
NURSING CARE for gerd
- Identifying children with symptoms that suggest GER
- Preparing for surgery and post-op care
▪ Same as in any abdominal surgery
▪ Skin care on the gastrostomy site - Maintain adequate nutrition
▪ Weigh daily
▪ Use of pacifier for non-nutritive needs - Educating parents regarding home care
cause of hirschsprungs
- Absence of ganglion cells in a segment of the
colon
signs of Behavioral changes
irritability, fretfulness,
uncooperativeness, apathy
nutrition for hirschsprungs
low fiber, high calorie, high protein diet/TPN as ordered
INTUSSUSCEPTION
- Monitoring for s/s of complications = v/s and stools
▪ Passage of a normal brown stool indicates intussusception has reduced itself - Maintain or establishing fluid and electrolyte balance
- Preparing for hydrostatic reduction and/or surgery=routine pre and postop care for abdominal surgery
▪ Pre-op = Preparation of parents, IVF, NGT for decompression, antibiotics
▪ Post-op = managing pain
MANAGEMENT of hirschsprungs: to keep stool small and soft so that they can be easily evacuated
Low residue diet
Reduce amount of acid in the gastric contents and prevent esophagitis
H2 antagonists
DIAGNOSTIC TEST of celiac
* Often follows screening test
* Demonstrates changes in mucusa and positive
clinical response to a gluten-free diet
jejunal biopsy
INTUSSUSCEPTION management: Done at the time of diagnostic testing
* The force exerted by the flowing
barium is usually sufficient to push the
invaginated portion (80-90% of cases)
HYDROSTATIC REDUCTION (by barium enema)
INTUSSUSCEPTION types: cecum invaginates into colon
Cecocolic
new approach of pyloromyotomy: use small incision for
the laparoscope = shorter surgical time,
more rapid post-op feeding and quicker
discharge
laparoscopy
Risk Factors of gerd
- Prematurity (hypotonia)
- Infants with bronchopulmonary dysplasia
- Asthma
- TEF/EA repair
- Gastrostomy placement
- Neurologic disorders (cerebral palsy)
- Cystic fybrosis
- Scoliosis – in relation to pressure in the stomach
- Hernia
clinical manifestation of GERD that means erosion of esophageal
tissue
hematemesis and melena
diagnosis for HPS
- History and physical exam
- Ultrasonography
- Upper GI series (barium swallow) – delay in gastric
emptying - Blood tests
Pharmacology Management of GERD
a. H2 antagonists
b. Proton pump inhibitor
c. Prokinetic agents
Majority
have mild GER that generally improves by ***** of age and requires only conservative lifestyle
changes and/or medical therapy.
12-18 months
colostomy care color
pink to reddish pink
HYPERTROPHIC PYLORIC STENOSIS manifestations
- Projectile vomiting
- No evidence of pain or discomfort except that of
chronic hunger - s/s of dehydration-decreased number of stools
- weight loss
- distended upper abdomen
- readily palpable olive shaped mass in the upper
abdomen (epigastrium just to the right of the
umbilicus) - visible peristaltic waves that move L→R across
epigastrium - hyperactive bowel sounds
Prokinetic agents
Metoclopramide HCl
Diagnosis for GERD: radionuclide scanning for evaluation of gastric emptying (after feeding a radioactive compound)
Scintigraphy
s/s of bleediing
hypovolemic shock
severe complications for GERD that requires surgery
recurrent aspiration pneumonia, apnea, severe esophagitis, failure to
thrive, failure to respond to medical therapy
MANAGEMENT of hirschsprungs
➢ Most require surgery rather than medical therapy
for mild cases (1-3)
- Low residue diet
- Stool softeners
- Isotonic irrigations
o Not tap water-water intoxication
o Not soap suds - Surgery
feeding in colic
- Feed slowly
- Burp frequently
- Keep in upright position during feeding
- Do not overfeed
- If breastfeeding, avoid feeding foods that may contribute to gas formation such as onions, cabbage,
collards, dry beans
other names for CELIAC DISEASE
- Gluten – induced enteropathy
- Gluten – sensitive enteropathy
- Celiac sprue
surgical management of hirschsprungs
a) PERINEAL ONE STAGE OPERATION PULL THROUGH PROCEDURE (POOP procedure )
b) Staged repair
1. Palliative
2. Corrective
s/s of enterocolitis
fever, explosive watery diarrhea, dehydration, severe prostration- septic shock
MANAGEMENT of hirschsprungs:to prevent impaction until child is toilet trained; use volume appropriate to
weight of the child
Isotonic irrigations
- An invagination or telescoping of one portion of
intestines into another - Invagination of the cecum in colon producing obstruction
of the intestines - Telescoping of bowel into itself
INTUSSUSCEPTION
Dance sign
empty RLQ
Diagnosis for GERD: pH determined at distal esophagus (insertion of small catheter into esophagus through
nose)→ to determine the number of reflux episodes
24 hour pH probe study
If frequent reflux disease, there is something wrong with ***
cardiac sphincter
complications of celiac
- growth retardation
- malignant lymphoma of small intestines
- esophageal and GI cancers
nutritional supplements for celiac
vitamins, Fe and calories
= leading cause of death in children with Hirschprung’s disease = inflammation of small bowel
and colon;
enterocolitis
clinical manifestations of hirschsprungs in childhood
▪ Constipation (because of
absence of peristalsis)
o Chronic constipation –
▪ Ribbon like foul smelling stools
▪ Visible peristalsis
▪ Fecal masses easily palpable
▪ Poorly nourished and anemic
Cause of GERD
❖ Relaxed cardiac sphincter
1. related to dysfunction of lower esophageal
sphincter(LES)→transient relaxation of the LES
(TRLES)
2. delayed gastric emptying→ gastric distention
(overfeeding, gas)
3. increased abdominal pressure
cause of celiac disease
- unknown; genetic predisposition + environmental
factors
a. Genetics
b. Gluten exposure
c. GUT Microbiome
d. Medical Conditions
e. Environmental Factors
management for HPS
- SURGERY
* PYLOROMYOTOMY (FREDET-RAMSTEDT
PROCEDURE)
triad symptoms oof intussusception
- Pain
- Vomiting –
- Passage of red currant jelly like stools
Increase resting LES pressure mildly and increase the rate of gastric emptying)
→ BUTS/e-restlessness, drowsiness, extrapyramidal reactions and in some,
increase number of reflux episodes
Prokinetic agents
clinical manifestations of GERD in respiratory problems
recurrent pneumonia,
chronic cough, wheezes, stridor, gagging, choking at end of feedings
Educating parents regarding home care in gerd
a. Feeding
▪ Thickened (1 tsp-1 tbsp of rice cereal/oz of formula)
▪ Small frequent feeding
▪ Frequent burping
❖ Above measures are to minimize reflux
b. Positioning
c. Medications and their side effects
d. How to suction mouth and nose if vomiting occurs
e. Gastrostomy feeding and gastrostomy site care
clinical manifestations of GERD
- Passive regurgitation, spitting up/vomiting
(effortless and non-projectile) - Poor weight gain
- Hematemesis and melena
- Irritability or excessive crying
- Heartburn in older children
- Anemia secondary to blood loss due to irritation of the lining of the esophagus (HCl)
- Respiratory problems
- Dysphagia
Management of GERD:
→ Valve mechanism by 360o wrap of the fundus (greater curvature of the stomach) around the esophagus
→ A gastrostomy tube is usually inserted during the procedure
NISSEN FUNDOPLICATION
Celiac disease is secondary to what
CF
can be found in BROW food that can destroy walls of intestines
Gliadin
DIAGNOSTIC TEST of celiac
* screening test for presence of antigliadin; and
antireticulin and antiendomysial Ig A and Ig G
antibodies (antibodies to connective tissue)
* absence in gluten-free diet
blood test
a substance in wheat and other grains, may be found in a variety of foods
including breads, cakes, cereals, pasta, commercial dairy products and alcoholic
beverages.
gluten
results of ultasonography in HPS
elongated sausage-shaped mass
with an elongated pyloric channel
DIAGNOSTIC TEST of celiac
- Blood test
- Jejunal biopsy
- HAL genetic test
INTUSSUSCEPTION DIAGNOSIS
- History and physical exam
- Abdominal radiograph to detect intraperitoneal air
from a bowel perforation
▪ If (+) barium enema is contraindicated - Barium enema – obstruction of the flow of barium
- Ultrasound
- Rectal exam – mucus and blood
ethnicity at risk of celiac disease
caucasians
COMPLICATIONS OF SURGERY in gerd
small bowel obstruction, retching, gas-bloat syndrome,
Dumping syndrome
INTUSSUSCEPTION incidence
- onset: abrupt
- one of the most frequent causes of intestinal obstruction between 3 months to 5 years of age; 50%
below 1 year (3-12 months )of age - Males 2x>females
results of blood tests in HPS
metabolic alterations from extensive
vomiting
▪ Hypochloremia , hyponatremia,hypokalemia
▪ Increased pH and HCO3
▪ increase BUN-dehydration
dumping syndrome is a combination of
profuse sweating, nausea and dizziness)
MANAGEMENT of celiac
- lifelong dietary modification
- specific nutritional supplements
ER Becomes GERD when complications
such as
failure to thrive, bleeding or dysphagia
INTUSSUSCEPTION types: most common; ileum invaginates into
cecum and ascending colon
Ileocolic
Mechanical obstruction due to inadequate motility of the intestines
HIRSCHPRUNG’S DISEASE
clinical manifestations of hirschsprungs in infancy
▪ Failure to thrive (failure to gain
weight and delayed growth)
▪ abdominal distention
▪ episodes of vomiting
▪ Constipation alternating with
diarrhea
▪ Ominous sign (enterocolitis)
o Explosive, watery
diarrhea, fever, severe
prostration
GER and GERD may occur as separate disease entity
- recurrent episodes of unexplained crying inability to be consoled
- occurs around 1-2 weeks of age; subsides spontaneously by 16 weeks
COLIC
common cause of GERD
/ most common mechanism
Relaxed cardiac sphincter
cause of HYPERTROPHIC PYLORIC STENOSIS
unknown, genetic predisposition children of parents
who had PS as infants
Represents symptoms/tissue damage that result from GER
GERD
INTUSSUSCEPTION types
- Ileocolic
- Cecocolic
- Ileoileal
positioning in feeding for GERD
✓ PRONE (head elevated/flat) after feeding and at night
o NOT SUPINE/INFANT SEAT – worsens GER→↑intraabdominal pressure (could lead to aspiration)
diagnosis of hirschsprungs: biopsy samples of the inside of the large intestine, near the anus
* If no ganglion cells are seen on the biopsy samples, Hirschsprung’s Disease is diagnosed →(failure of the
ganglion cells to migrate at the GI tract during gestation (rectum & proximal large intestine) → internal
anal sphincter fails to relax → absence of peristalsis → accumulation of intestinal contents → distention
of bowels → megacolon
rectal biopsy
NURSING CARE in hirschsprungs
- Monitoring v/s including abdominal circumference and ominous signs (enterocolitis)
- Maintain fluid and electrolyte balance-IVF, I&O
- Maintain adequate nutrition-low fiber, high calorie, high protein diet/TPN as ordered
- Help parents adjust to the congenital defect in the child
- Prepare client for surgery
▪ Psychologic and physical preparation similar to those scheduled for abdominal surgery
▪ Repeated saline enemas to empty the bowel and or colonic irrigation using antibiotic solution to
decrease bacterial flora (or by systemic antibiotics) - Postoperative care
▪ Colostomy care – normal pink to reddish pink - Discharge = assist parents in colostomy care
diagnosis of hirschsprungs
- HISTORY (passage & characteristic of stool) AND CLINICAL manifestations
- Barium enema
- Rectal biopsy
- Abdominal X-ray
- Rectal Examination
dilated action of colon (due to fecal materials left because of no motility)
megacolon
how is Projectile vomiting in HPS
-3 ft from infant which usually
occurs 30-60 minutes after feeding
NURSING DIAGNOSES
➢ Fluid volume deficit r/t frequent vomiting
➢ Altered nutrition: less than body requirements r/t vomiting and lack of absorption of nutrients
➢ High risk for infection r/t surgical incision
incidence of hirschsprungs
- Accounts for 1⁄4 of all cases of neonatal obstruction although diagnosed in later infancy/childhood
- Males 4x>females
- Familiar pattern in small cases
- More common in children with Down’s syndrome
- Can present as an acute (life threatening) / chronic disorder
diagnosis of hirschsprungs: The pictures of the intestine will show a wide or dilated area next to a narrow area of intestine. The
narrow area is the part of the bowel without ganglion cells. The wide area of the intestine is healthy
bowel filled with stool that can’t be passed.
Barium enema
nursing care for celiac
- Health education in maintaining a gluten-free diet
for the child
* Thorough explanation of the disease process
* Gluten free diet should not be discontinued
when the child is symptom free
INTUSSUSCEPTION CLINICAL MANIFESTATIONS
- Pain – acute, severe, colicky abdominal pain
▪ Child screams and draws knees onto the chest
▪ Appears normal and comfortable during intervals
between episodes of pain - Vomiting – bile-stained (obstruction is below Ampulla
of Vater) - Passage of red currant jelly like stools (because fecal
material is unable to move beyond the obstruction,
the stool contains blood and mucus) - Palpable sausage shaped mass in RUQ
- Empty RLQ (Dance sign)
- Tender, distended abdomen
- Lethargy
signs of impaired absorption of nutrients
- Malnutrition
- Muscle wasting (prominent in legs and
buttocks) - Anemia
- Anorexia
- Abdominal distention
H2 antagonists
Cimetidine (tagamet), famotidine (Pepcid), Ranitidine (Zantac)
diet for celiac
high protein, high calorie, no gluten
CAREGIVER TEACHING INFORMATION in Colic
A. Feeding
B. Swaddle to decrease self stimulation by jerky or sudden movements
C. Take the infant for a car ride
D. Use a swing for at least 20 minutes
E. Walk or rock the infant while applying gentle pressure to his abdomen
F. gently massage the infant’s back while he is lying down
G. Supply background or “white” noise ( hair dryer, Vacuum cleaner, fan) or play a womb sound
tape(known as “souffle” toy) or some sound music
H. Place the infant in a quiet darkened room to reduce environment stimulus
INTUSSUSCEPTION complications
- Perforation
- Peritonitis
- Sepsis
DIAGNOSTIC TEST of celiac
test for the presence of HAL DO2
HAL DQ8
HAL genetic test
management of gerd: Alternative for children with neurologic impairment who are continuously tube fed
PERCUTANEOUS GASTROJEJUNOSTOMY and placement of jejunostomy tube
(attempt to vomit but nothing goes out/up),
retching
signs of celiac crisis
- acute sever episodes of profuse, watery
diarrhea and vomiting - Precipitated by : infections (respiratory,
GIT), prolonged fluid and electrolyte
depletion, emotional disturbance
Associated with respiratory symptom of GERD
apnea, bronchospasm,
pneumonia
Block acid production
Proton pump inhibitor
complications of hirschsprungs
*Obstruction→↑abdominal circumference, absence of stool, vomiting, pain and decreased or absent bowel
sounds
* Bowel perforation
a) peritonitis
b) bleeding
* Enterocolitis
* Dehydration
signs of Projectile vomiting in HPS
▪ Child is “good eater” /”avid nurser” who vomits
occasionally or shortly after feeding and eagerly
accepts a second feeding after vomiting (Chronic
hunger)
▪ Nonbilous-stale milk (undigested)
▪ Blood tinged – repeated irritation to the
esophagus
❖ Electrolyte depletion – METABOLIC
ALKALOSIS
Management of GERD
- Diet-thickened feedings
- Pharmacology
- Surgery
- NON-SURGICAL PERCUTANEOUS GASTROJEJUNOSTOMY and placement of jejunostomy tube
CLINICAL MANIFESTATIONS celiac disease
- Chronic, insidious, noted after introduction of glutencontaining grains in the diet, typically between 1-5 y/o
1. Impaired fat absorption
2. Impaired absorption of nutrients
3. Behavioral changes
4. Celiac crisis
most common mechanism of GERD
Relaxed cardiac sphincter
transient relaxation of the LES
(TRLES
post op NURSING CARE for HPS
a. Maintain fluid and electrolyte balance
b. Minimize weight loss
* Small frequent feedings
* Clear liquid-formula
c. Promote rest and comfort
* Swaddle infant to maintain warmth and comfort
* Encourage parents to hold and cuddle the infant
* Provide pacifier to meet the infant’s need to suck
* Avoid pressure on incision-diaper-slide gently under the butt rather than
* Administer acetaminophen as ordered
d. Prevent infection
* Keep surgical wound clean and dry
* Check for s/s of infection
e. Discharge planning and patient’s family home care teaching
* s/s of infection and notify physician
* fold diaper so that it doesn’t touch incision
INTUSSUSCEPTION types: ileum invaginates into another portion of
the ileum
Ileoileal
Identifying children with symptoms that suggest GER
▪ History of feeding problems
▪ Observe for episodes of vomiting, note color, consistency and amount
▪ Observe for respiratory distress at end of feeding
- sharp, visceral pain resulting from torsion, obstruction, or smooth muscle spasm of a hallow or tubular organ,
such as a ureter or the intestines
COLIC
- Disease of the proximal intestine characterized by abnormal mucosa and permanent intolerance to gluten
- Inherited Autoimmune disease
celiac disease
signs of . Impaired fat absorption (assos. with cystic fibrosis)
- Steatorrhea (excessively large, pale, oily,
frothy stools) - Exceedingly foul smelling stools
hallmark of megacolon
Chronic constipation
INTUSSUSCEPTION management
- Non-surgical
a. HYDROSTATIC REDUCTION (by barium enema)
b.PNEUMATIC INSUFFLATION (AIR ENEMA) - Surgical (Open) – manual reduction of invagination
and resection of nonviable intestine when necessary
clinical manifestations of hirschsprungs in NB
▪ failure to pass meconium within
24-48 hours after birth
▪ abdominal distention (can be
associated with gas)
▪ bile stained emesis
▪ refusal to suck = weight loss and
dehydration
▪ irritability
- A hypertrophic obstruction of the circular muscle of the pyloric canal
- Gastric outlet obstruction – Hypertrophy of the pyloric sphincter causing stenosis and obstruction
HYPERTROPHIC PYLORIC STENOSIS
management for HPS:
▪ standard treatment
▪ Longitudinal incision through the circular
muscle fibers of the pylorus down to, but
not including the submucosa
▪ Approaches:
→ Before: RUQ incision that left a scar in the
abdomen
→ Now: Laparoscopy
PYLOROMYOTOMY (FREDET-RAMSTEDT
PROCEDURE)
surgical management of hirschsprungs:Removal of aganglionic segment and temporary colostomy made with the
part of the bowel with normal nerve transmission to allow this part to rest and let child
gain weight
palliative staged repair
1st signs of celiac
failure to thrive, diarrhea
other name for HYPERTROPHIC PYLORIC STENOSIS
INFANTILE HYPERTROPHIC PYLORIC STENOSIS
NTUSSUSCEPTION management:
* No risk of peritonitis
* More rapid
PNEUMATIC INSUFFLATION (AIR ENEMA)
allow the intestine to
relax so stool can pass through the intestine and
out of the body. Without these special nerve
cells, the intestine can’t relax and it becomes
very narrow
ganglion cells
Complication of GER:
persistent esophagitis with scarring, recurrent
aspiration pneumonia
barrett’s esophagus
when they eat with food gluten, it damages/destructs the villi found in small intestine
will result to malnourishment and decrease bone density)
. CELIAC DISEASE
meaning of electrolyte depletion
metabolic alkalosis
HYPERTROPHIC PYLORIC STENOSIS incidence
- one of the most common conditions requiring surgery in infants
- First few weeks of life (1-10 weeks)
- First born male infants (5x)>females
- Full term>premature infants
- Caucasians, less frequently in Asians and blacks
celiac disease:
substitute BROW with corn and rice
Foods to avoid: bread, cake, doughnuts, cookies,
crackers, preserved foods with gluten as filler,
commercially prepared ice cream, malted milk,
prepared puddings, grains, BROW, crackers, cereals,
spaghetti, macaroni noodles
NURSING CARE for HPS
- Maintain fluid and electrolyte balance and Minimize weight loss
* Monitor I & O, weight, urine sp. gr., character of stools,
* IVF - Provide supportive care to parents
* Encourage participation in care, verbalization of fears and concerns, provide simple and clear explanation
regarding condition and care
* Inform that occasional vomiting after surgery may occur - Prepare infant for surgery
surgical management of hirschsprungs: done without making an incision on the abdomen. Instead,
small laparoscopic (telescopic) instruments are used and the operation is done through
the anus.
PERINEAL ONE STAGE OPERATION PULL THROUGH PROCEDURE (POOP procedure )
Proton pump inhibitor
Omeprazole (Prilosec), lansoprazole (prevacid)
INTUSSUSCEPTION cause
Unknown
* May be the result of hypertrophy of Peyer’s patches,
bowel rumors, or polyps
* Idiopathic (90% of cases) likely a result of
hypertrophy of intestinal lymphoid tissue (Peyer’s
patches) secondary to viral infection (recurrent bout
of gastroenteritis)
complication of HPS
persistent pyloric obstruction,
wound dehiscence and GER
Other name of hirschsprung’s disease
congenital aganglionic megacolon
complication of surgery in hirschsprungs
anal stricture → further therapy=dilation or bowel retraining therapy
Diagnosis for GERD
- History and child’s feeding pattern and clinical manifestations
- Barium swallow (esophagography)
- 24 hour pH probe study
- Scintigraphy
Diagnosis for GERD: to establish presence of reflux
Barium swallow (esophagography)
closure of the colostomy and reanastomosis of working part of colon to
point near anus
o Several months later when child weighs approximately 20 lbs (9kg)
o After closure of the colostomy = fecal incontinence and constipation may persist
corrective staged repair
without nerve tissue in the colon/rectum
aganglionic
