Lessons 16-17: Fecal Diversion In Children Flashcards
Gastroschisis
Herniation of bowel through the abdominal wall
- No amniotic covering
- Exposed bowel is shortened
- Bowel is thickened and edematous
- More common among premature infants (15-30%)
Treatment
- Exposed organs kept moist and elevated in sterile bag
- Can repair and return bowel to abdominal and close defect
- Diversion is rarely required
Omphalocele
Abdominal organs herniate through umbilical ring and abdominal wall defect
- Organs still covered with amniotic membrane
- Structures are protected
- Bowel structure is normal
- 60% have other major defects
Treatment
- Operative repair is done at birth
- Diversion usually not required
Congenital - Intestinal Atresia
Loss of GI continuity
- Occurs d/t vascular accident in utero
- Variable: stenosis → total separation
Management
- Resection of severely dilated portions of proximal bowel
- End-to-end anastomosis
- Need to protect terminal ileum
- Ostomy rarely required
Exception
- Esophageal atresia
- Will need esophagostomy if reanastomosis delayed
Congenital - Anorectal Malformation (Low Defect)
Low defect
- Bowel terminates distal to puborectalis
— Sphincter is intact
- Malformation
— Anal opening covered by skin or
— Anal opening displaced/misaligned with anal canal
Management
- Anoplasty to establish opening aligned with anal canal
- Good long term prognosis
Congenital - Anorectal Malformation (High Defect)
Bowel terminates above puborectalis and sphincter may be missing
Malformation
- Anorectal atresia
- Rectum ends in blind pouch
- Rectum ends in fistula to vagina, bladder, or urethra
Management
- Diverting colostomy
- Posterior sagittal anorectoplasty
— Pull through procedure to re-establish continuity of bowel and perineum
— Colostomy closure
— Anorectal dilation to prevent stenosis
— Continence issue d/t lack of sphincter
Congenital - Volvulus
Twisting of abnormally mobile bowel around mesentery
- Partial and intermittent
— Treatment involves resection of abnormally mobile bowel
- Acute and complete
— Rapid development of ischemia
— Risk for perforation
— Presents with bilious vomiting and acute abdomen
Treatment
- End-to-end anastomosis
- Resection with proximal stoma and distal mucous fistula
- Temporary diversion
Congenital - Meconium Ileus
Intestinal blockage caused by dried meconium in distal ileum and ascending colon
- Typically infants with cystic fibrosis
— Drying of the meconium
— Altered transport of sodium, chloride and water
S/S
- Vomiting
- Abdo distension
- Feeding intolerance
Management
- NG decompression
- IV fluids
- Antibiotics
- Hyperosmolar enema
- Mucomyst irrigation
Surgical
- Enterotomy and irrigation → no ostomy
- Resection with temporary ostomy and mucous fistula
Congenital - Hirschsprung Disease (Short-Segment)
- Innervation develops proximal to distal bowel
— Rectum and sigmoid involved - Denervated bowel collapses and obstructs proximal bowel
Diagnosis can be delayed
- X-ray → transitional zone of narrowing
- Rectal biopsy → confirm absence of ganglion cells
Management
- Temp diverting colostomy to decompress
- Resection of a ganglion if bowel
- Closure of colostomy once anastomosis healed
— Will need to learn to dilate anastomotic line to prevent strictures
Congenital - Hirschsprung Disease (Long-Segment)
- Effects varying lengths of colon
- Causes functional obstruction with collapse of colon and dilation of small bowel
- Identified through feeding intolerance
Treatment
- Colonic resection with ileal rectal anastomosis
- Temp ileostomy
Necrotizing Enterocolitis - Presentation
Early
- Temperature instability
- Apnea
- Bradycardia
- Thrombocytopenia
Late
- Abdo distension
- Absent bowel sounds
- Bloody stool
- Palpable loops of bowel
- Oliguria
- Hypotension
Necrotizing Enterocolitis - Management
Management
- NPO
- IV fluids
- NG tube
- Serial X-rays
Surgical
- Resection of fully necrotic bowel segment
- Preservation of viable and mildly ischemic bowel
- Usually resection, end ileostomy, and colonic mucous fistula
- Can also be end ileostomy with multiple mucous fistulas
— Close one end of segment and bring other to surface as stoma
Refeeding Ostomy Output
- For loop ileostomy or ileostomy with mucous fistula
- Children with high volume output and dehydration
Goal
- stimulate/maintain function of villi in distal bowel
- Enhance fluids + nutrient absorption
- Reduce dependence on TPN
Stool is collected and fed via catheter into distal os
Paediatric Ostomy - Stool Containment
- Based on need for skin prep and age
- Colostomy: can manage with diapering + moisture barrier ointment
- Ileostomy: should pouch to prevent enzymatic skin damage
