GER and Celiac Disease Flashcards
GER: what is it?
-Transfer of gastric content into the esophagus
-1 in 700 children have significant problem with GER
-Etiology: unknown
>transient relaxation of LES: may go up or down
>delayed gastric emptying: sits too long, doesn’t empty, relfux
>Prematurity: more premature baby gets GER
>Gastric distention (when not burping)
>Anything that increase abd pressure (ex: coughing)
>Certain Meds
>Gastric tube in place increases changes for GER
Differences between GER and GERD?
- *GERD- adulthood
- “D” stands for disease: start to see permanent damage (symptomatic)
- Some kids with GER can develop GERD - *GER- common in kids, especially in babies
If the stomach content reflux back up, what happens?
Reflux up to the esophagus and erodes the esophagus (Big Concern!): can cause irritations
What are the clinical manifestation of GER?
- *Passive REgurgitation and emesis (most common symptom!)
- poor weight gain (not keeping food down)
- Heme-positive emesis or stool (blood in stool, come from esophagus)
- irritability
- Heart burn (bc of esophageal irritation)
- Anemia (not taking enough iron)
- Gagging/choking after feeds
- Recurrent pneumonia (constant regurg, increase agitation)
- Premies: apnea, bradycardia
- Otitis Media (middle ear infection): has to do with fluid regurging back
- Burning sensation: anywhere along esophagus to stomach
- Bronchospasm: aspiration pneumonia (CONCERN!)
Diagnostics for GER
-History: Hx of respiratory problems, may be aspirating and parents don’t realize
-Exam: looking for frequent vomiting
-Can Briac the stool (test it)
-Diagnostic studies
>Barium Swallow: look for reflux of barium in esophagus
>Upper GI series: distinguishes GER and pyloric stenosis
>Esophageal pH monitoring/probe: probe in place above LES for 24 hours, take continuous reading w pH in esophagus, can also be used for biopsy
-Need help from parents to calm crying baby
-EGD
Normal pH levels
In esophagus: 4-6
In Gastric: 1.9 (more acidic)
decrease pH = increase gastric content = immediate are is more acidic
Treatment and Nursing Care of GER
-Small, frequent feeds, burp (don’t over distend stomach)
-Continuous NG-esp if severe GER and FTT (still small feeding)
-Thickened feedings: can thicken breast milk, thicken with rice cereal (1TBS to ! oz.)
>when doing calorie count, consider the TBS of rice cereal
-Frequent burping
-Positioning: turn to side, don’t want prone
-weight/Harness
Which side to you position the patient for GER and why?
help increase chance of gastric emptying, put them on their right side bc of gravity
Why do you thicken the fluids for GER pts?
because gravity pulls the thicken content down and tends to stay down
-sometimes it can increase coughing (be careful bc it’s going to open LES. Make sure they are not aspirating
Treatment: Medication for GER
- H2 inhibitors: cimetadine (Tagamet (help to treat mild esophagitis, inhibits hydrogen ion, make it less acidic), Ranitidine (zantac), Famitodine (Pepcid)
- Omeprazole (Prilosec or Prevacid): proton pump inhibitors (more potent gastric acid inhibitor or H2, keeps acid down, give 30 min before meal)
- Metoclopramide (Reglan): often used in kids, promotes esophageal parastalsis, increase gastric emptying = decrease reflux = increase tone of LES
- Gisapride (Propulsid): increase LES tone, help w/ gastric emptying, not used often bc cause cardiac arrhythmia’s (SE)
Treatment and Prognosis for GER
- Surgical Intervention: Nissen Fundoplication- wrap gastric fundus around lower esophagus, distal esophagus gets smaller and takes more pressure to open LES
- Not REVERSIBLE!
- Used when everything else fails!
- Prognosis: most cases-mild and resolve- 1y/o (can take up to 12-18 months, some kids take up full 18 mo, tell parent not to worry)
- Most can manage with medical tx
Parent Teaching with GER
Avoid foods that:
- Decrease LES tone: chocolate, tomato, carbonated fluids
* *if breastfeeding-mom needs to aboid those food too! - Increase gastric acid secretions: avoid spicy food, citrus, fruit juice
Complications of GER
- esophageal strictures: for persistent esophagitis
- recurrent respiratory distress: for aspiration problem
- FTT
- Aspiration Pneumonia
- Don’t forget esophageal erosion
Celiac Disease: What is it?
-Gluten induced enteropathy aka celiac sprue
-Malabsorptive syndrome with a defect in metabolism of gluten which cause impaired absorption of fat and nutrients
-MOST COMMON 1-5Y/O (could be diagnose as young as 9 mo.)
>why? has to do with what foods were introduced and when
>Rice is ok
>Beans, pastas, oats, white bread- takes a few months to see s/s (will see damage done to the villi)
-More adults are diagnosed with this
Etiology of Celiac Disease
-Exact etiology is unknown
-Believe it is:
>inborn error of metabolism
>autoimmune process- gluten acts like an antigen and destroy intestinal mucous
*PERMANENT intolerance to wheat, rye, barley oats (ex: gravy, cake, beer other grains)
>Think it is an allergic rx to Gliadin component of gluten
Pathophysiology of celiac disease: Gluten
-Gluten has 2 portions
>Glutenin (good)
>Gliadin (Bad): pt with this disease has an intolerance for Gliadin portion
-With Celiac Disease
>intolerance for Gliadin portion
>found in wheat rye, barley oats
-Gliadin- not fully digested so you end up with accumulation of glutamine (which is the one that is going to do the damage)
Pathophysiology of celiac disease: Result
-glutamine is toxic to intestinal mucosal cells
-villi become damaged:
>decreases in #’s
>atrophy
-can decrease intestinal absorption by 95% (weight loss, FTT)
Clinical Manifestation of Celiac Disease
- STEATORRHEA (fatty poop): also found in cystic fibrosis, foul smell, greasy, distinctive
- general malnutrition: tends to progressive
- abdominal distention
- Vit deficiencies
- FTT (organic)
- Chronic diarrhea
- Muscle wasting (esp. buttocks and extremities)
- Anemia
- LE edema
- Anorexia
Vit Deficiencies causes what?
- Decrease in protein can lead to peripheral edema bc protein draw in water and with low protein, water escape into interstitial space causing edema
- decrease vit D and calcium: causes osteoporosis
- decrease iron and folic acid: anemia
- problem absorbing Vit K: can cause bleeding, bruising, and decrease clotting
- decrease carb absorption: no energy
- decrease B12: part cause of anemia
Abdominal distention and muscle wasting with celiac disease
- problems with metabolism = end up with bloating and gas distention
- tend to develop lactose intolerance, which also contributes to gas distention to the colon
- typical with malnutrition
Celiac Disease: Diagnostics
- sweat chloride test to rule out Cystic fibrosis bc of steatorrhea
- Jejunal biopsy: villous atrophy (Bx small bowel to confirm the mucosa and decrease # of flatten villi
- Initiate gluten free diet: remission of symptoms (give gluten free, then put gluten back into diet to see if gluten is the problem
Celiac Crisis
- profuse, watery diarrhea = severe dehydration, shock, metabolic acidosis, electrolyte imbalance
- Precipitating factors: gluten in diet, psychological stress, **anticholinergic drugs (OTC drugs): mimic SNS, so when it does it relaxes smooth muscle and GI muscle and decrease blood supply to gut and damage villi
Celiac Treatment
-Restore F&E/AB balance
-Eliminate or minimize gluten from diet
-Dietary Management:
>eliminate wheat, rye, barley, oats
>Supplements of folic acid, iron, and fat-soluble vitamins
-REMEMBER: We can’t fix this, we can only control this!!!
