Quiz 2: Gastrointestinal Flashcards
Cleft Lip and Cleft Palate
- You can have one or both together.
- All of them look different.
- More common in males
- May be unilateral or bilateral
- Multifactorial
What can cause cleft lip and cleft palate?
- Congenital anomalies (failure of soft tissue or bony structure to fuse during embryonic development)
- Hereditary
- Environmental factors: exposure to radiation or rubella virus, chromosomal abnormalities or teratogenic factors.
- Maternal deficiency: Folic acid deficiency
Birdie Uvula
- Smallest form of velar cleft.
- Not associated with speech or feeding problems.
What are clinical manifestations of cleft lip?**
- Slight notch or complete separation from the floor of the nose.
- Notched vermillion border.
- Variably sized clefts involving alveolar ridge
- Dental anomalies
What are clinical manifestations of cleft palates?**
- Nasal distortion
- Exposed nasal cavities
- Midline/Bilateral cleft with variable extension from uvula and soft/hard palates
How is a cleft lip/palate evaluated?
- Palpation of hard and soft palate.
- Cleft lip evaluated by looking
- Fetal ultrasound (reliable after 14 weeks gestation)
Cleft Lip/Palate Management include**
- Collaborative team management: surgeon; ears, nose and throat doctor; speech pathologist; dentist/orthodontist; neurologist
- Severity impacts who is involved.
Cleft Lip Closure
Done first at 2-3 months of age
Cleft palate closure
- Done at about 12 months of age
- Need to wait for normal palate changes with growth
- Closure is done before beginning speech
What are potential cleft lip/palate problems? **
- Recurrent middle ear infection
- Extensive orthodontic problems (d/t the palate and how the teeth will grow)
- Inadequate nasal airway (small nasal passages from surgery)
- Speech problems
Other problems include: - Emotional issues
- Cosmetic concerns
Potential problems of cleft lip/palate: Recurrent middle ear infection
- Caused by improper drainage
- Recurrent otitis media
- Can lead to hearing impairment (Conductive hearing loss)
Children with cleft lip/cleft palate: Differences in feedings**
Severity of condition effects feeding
- Higher-calorie formula (takes a lot of energy for these babies to eat, need more calories)
- Unable to acquire suction to feed so they need special nipples or other feeding devices.
- Burp frequently: they swallow more air
Children with cleft lip/palate: Feeding Instructions
- Hold infant in upright position and direct formula to the side and back of the mouth to prevent aspiration.
- Gradually feed small amounts and burp frequently.
- Provide short periods of rest for swallowing (children usually develop a feeding pattern of sucking/swallowing/resting)
- Do not remove nipple during feeds due to noises
- Limit feeding to 30 minutes and have baby sit upright for 30 minutes after feeding.
Hirschsprung Disease
Aka Congenital Aganglionic Megacolon
Congenital anomaly
What causes hirschsprung disease?
- Absence of ganglion cells in the affected area
- Once the stool gets to this part of the colon, peristalsis will stop and the stool will stop in that area causing the colon to enlarge.
Hirschsprung Disease results in
- Resulting in a loss of the rectoshincteric reflex
- Lack of peristalsis
- Results in a mechanical obstruction
What are clinical manifestations of Hirschsprung disease in newborns?
- Failure to pass meconium stool
- Refusal to suck
- Abdominal distention
- Bile stained vomitus
What are clinical manifestations of Hirschsprung disease in children?
- Failure to gain weight/thrive
- Delayed growth
- Abdominal distention
- Vomiting
- Constipation
- Visible peristalsis
- Ribbon/pellet-like, foul smelling stools***
How is Hirschsprung disease diagnosed?
- Barium Enema
- Rectal biopsy (confirms diagnosis)
Hirschsprung Disease Management
-Surgical removal of aganglionic portion of bowel
Complications of Hirschsprung Disease
- Anal strictures
- Incontinence
- Diaper Rash
- Constipation
Gastroesophogeal Reflux
Transfer of gastric contents into the esophagus.
Gastroesophageal Reflux most frequently occurs when?
- After meals
- At night
Children with Gastroesophageal Reflux are prone to develop what problems?
- Premature infants
- BPD
- Neurological disorders
- Tracheoesophageal repairs
- Scoliosis
- Asthma
-Cystic Fibrosis - Cerebral Palsy
What are clinical manifestations of gastroesophageal reflux? **
- Emesis
- Chronic cough**
- Hematemesis
- Anemia from blood loss
- Poor weight gain
- Irritability
- Heartburn in older children
Gastroesophageal reflux is the cause of apparent life threatening events including
- Chronic cough
- Recurrent stridor
- Reactive airway disease
- Recurrent pneumonia
How is gastroesophageal reflux evaluated?
- History and assessment
- Gold Standard: 24 hour pH monitoring
Management of Gastroesophageal Reflux: If no respiratory complications
- No treatment needed
- Small, frequent feedings
- Upright position after feeds
Management of Gastroesophageal Reflux
- Avoidance of acid exacerbating foods
- Lifestyle modifications
- Family teaching
- Surgical management
Gastroesophageal reflux management in infants
- Thickening of feedings
- Breast feeding may continue: more frequent feeding times or express milk for thickening with rice cereal.
- Burp frequently when feeding and handle them minimally after feedings.
Surgical Treatment for Gastroesophageal Reflux
Nissan fundoplication
What should you teach parents about managing gastroesophageal reflux in children? **
- Avoid fatty foods (i.e chocolate, tomato products, fruit juice, citric products, spicy foods)
- Avoid vigorous play after feeding
- Avoid feeding before bedtime
What medications are used to treat gastroesophageal reflux?
- PPI’s
- H2 Receptor Antagonists: i.e Ranitidine (can take regardless of meals)
- Antacids for symptom relief
- *MUST BE TAKEN CORRECTLY FOR THEM TO WORK (should be taken on empty stomach)
What are complications of gastroesophageal reflux?**
- Esophagitis
- Esophageal strictures
- Aspiration of gastric contents
- Aspiration pneumonia
- Bleeding
Appendicitis
- Inflammation of vermiform appendix caused by obstruction usually by hardened fecal material.
- Is the most common cause of emergency abdominal surgery in children
What are clinical manifestations of appendicitis?
- Pain that is exacerbated with movement; pain at McBurney Point
- Fever
- Increased WBC and C-reactive protein
- Vomiting
- Change in behavior
- Tachycardia
- Perforation may occur
How is appendicitis evaluated?
- Lab studies: WBC, CRP
- US
- CT scan (most reliable and most commonly used; quick and easy)
Management of Appendicitis**
Surgical removal of appendix: Laparoscopic appendectomy
Management of Appendicitis if ruptured
- NG Tube - with replacements (low intermittent suction; prevents vomiting; turn off to listen to bowel sounds)
- NPO
- Foley
- Ambulation: most important b/c it gets the bowels moving, decreases pain and helps to pass flatus. (Lot of gas is left over air from surgery)
- IV ABT
The difference of what will be done to manage appendicitis depends on whether the child is vomiting prior to the procedure or not: If the child is not vomiting
- Child will be NPO prior to surgery and then for 6-8 hours post surgery
- At this time range is when you want to start advancing their diet slowly (only if their bowel sounds are present do you let the child eat)
The difference of what will be done to manage appendicitis depends on whether the child is vomiting prior to the procedure or not: If ruptured and/or vomiting
- Sent to surgery and an NG tube is placed to suck out all of the contents and fluids in the stomach and essentially decompressing the stomach.
- After surgery -> just wait. Make walk around to manage pain and wait for the bowels to wake up.
- Once the bowel sounds are present, NG tube removed.
Appendectomy: Pre-op Administration
- IV F&E: prevents dehydration and corrects electrolyte imbalances
- ABT
- Comfort measures: Ice pack to abdomen for 20-30 min qh if prescribed; position in right side lying or low semi-Fowler’s; promotes comfort
Appendectomy: Pre-op Monitoring
- Bowel sounds
- Changes in level of pain
- Ruptured appendix and peritonitis
Appendectomy Pre-op: Need to avoid
- Use of pain meds (in an uncomplicated appendicitis): Don’t want to mask changes associated with perforation.
- Application of heat to abdomen: Increases chance of perforation d/t vasodilation
- Laxatives or enemas
Appendectomy Post-op: Monitor
- VS, especially temperature
- Drainage in peprose drain; may be inserted if perforation
Appendectomy Post-op: Maintain
- NPO till bowel function and sounds return
- NG tube suction and latency of tube if present
Pyloric Stenosis
- Occurs when the pyloric sphincter is thickened.
- This results in elongation and narrowing of the pyloric canal.
Pyloric Stenosis: Increased incidence
- Full-term infants
- First born children
- Boys
What happens in a baby with pyloric stenosis?
the baby eats, the contents go into the stomach and will just hang out in the stomach bc the stomach is essentially a big bowl but it kind of gets stuck there since the sphincter is thickened and won’t let the contents pass through → so as stomach tries to push down the baby ends up → projectile vomiting
What are clinical manifestations of pyloric stenosis? **
- Projectile vomiting
- Hunger after vomiting
- Failure to thrive (b/c they aren’t able to absorb anything if the contents aren’t going to the intestines)
- Dehydration
- Metabolic alkalosis
- Palpable olive-like mass in right upper abdomen
- Visible peristaltic waves
- Distended upper abdomen
How is pyloric stenosis diagnosed?
- History and assessment
- Ultrasound of upper GI
Management of Pyloric Stenosis
-Pyloromyotomy: gold standard; opening up the sphincter
Pyloromyotomy Post Op Feeding
- Begins 4-6 hours after surgery
- Start with pedialyte
- Gradually increase amount
- Advance to regular formula/breast milk
- Give slowly, burp frequently and handle minimally after feedings.
Pyloromyotomy Post Op Feeding: If they vomit, what should you do?
Stop, wait 2-3 hours and go back one (i.e if they vomited after breastfeeding, go back to pedialyte)
When can a child with pyloric stenosis go home?
When they can eat without projectile vomiting.
Intussusception
Proximal segment of bowel telescopes into a more distal segment -> basically the intestines go into and onto each other.
What are clinical manifestations of intussusception? **
- Sudden onset of cramps abdominal pain
- Red, currant, jelly-like stools: bloody
- Palpable sausage-shaped mass in upper right quadrant
- Inconsolable crying
- Drawing up of knees to chest
- Vomiting -> bilious
- Lethargic
How is intussusception treated?**
- Enema (will cause bowels to go to their normal positions)
- Surgery if indicated: Manually reduces the invagination and resecting any nonviable intestine.
- If nothing is done, the bowels will end up becoming necrotic.
*Recurrence after treatment is rare.
Celiac Disease
- Villous atrophy of the small intestine d/t gluten protein (which is toxic to intestinal mucosal cells).
- This leads to inadequate absorption.
Gluten substances include
- Wheat
- Barley
- Rye
- Oat grains
What are clinical manifestations of celiac disease? **
- Steatorrhea: excessively large, pale, oily, frothy stools
- Foul smelling stools
- Abdominal distention (all the time!)
- Irritability
- Profuse watery diarrhea and vomiting
- Anorexia (usually really thin because they aren’t absorbing what they need)
- Anemia
- Muscle wasting
Managment of Celiac Disease
- Dietary management: avoidance of gluten
- Administration of mineral and vitamin supplements: Fe, Folic acid, Fat soluble vitamins (ADEK)
- Read all labels b/c most of children’s favorite foods contain gluten (i.e bread, cake/cookies, spaghetti, hot dogs, pizza and ice cream)
Celiac Disease Prognosis
- Chronic disease
- If strict compliance, no complication or symptoms if diet is maintained.
- If non-compliant, increased risk of colon cancer.
Celiac Crisis is precipitated by:
- Fasting
- Infection
- Ingestion of gluten
Celiac Crisis causes
Profuse watery diarrhea and vomiting
Celiac Crisis leads to
- Rapid dehydration
- Electrolyte imbalance
- Severe acidosis
Biliary Atresia
- Progressive inflammatory process resulting in bile duct obstruction.
- Cause is unknown
- Not seen in fetus; manifestations shown a few weeks after birth.
If biliary atresia is left untreated:
- Leads to cirrhosis
- Liver failure
- Death by 2 y/o
What are clinical manifestations of biliary atresia?**
- Jaundice after 2 weeks
- Dark urine, grey stools (absence of bile pigment)
- Hepatomegaly
- As disease progresses: child appears thin, FTT, marked jaundice, evidence of rickets and major pruritus.
How is biliary atresia evaluated?
- Lab tests
- Abdominal US
- Liver biopsy
- Outcome is better if surgically treated before 2 mo old
Biliary Atresia Prognosis
- If untreated, death by 2 y/o
- Even if treated, many still develop liver failure and require transplant
Management of Biliary Atresia
- Kauai Portoenterostomy: allows bile to drain into the intestine
- Fat soluble vitamin supplementation
- Phenobarbital: stimulates bile flow
- Prophylactic ABT
- Management of portal HTN: control bleeding, restricting salt intake, using diuretics.
Foreign Bodies: Signs and Symptoms
- Acute coughing episode
- Abdominal pain
- Constipation
- Unilateral findings: lungs, nose
Foreign Body Complications
- Obstruction
- Ulceration
Foreign Body Evaluations
- History and assessment
- XRay
Foreign Body Treatment
- Urgent removal for sharp objects, magnetic or disc batteries, compromised GI tract
- Flexible endoscopy: allows for direct visualization
- Feed usual diet when gag reflex returns.
Constipation
A delay or difficulty in defecation that has lasted for 2 weeks or more
Encopresis
Repeated and involuntary defecation in a child older than 4 years who has normal colon and rectal anatomy.
What are causes of constipation?
- Changes in diet
- Dehydration
- Lack of exercise
- Emotional stress
- Pain from anal fissures
- Excessive milk intake
Encopresis results from
-Recurrent fecal impaction and enlarged rectum caused by chronic constipation
What are clinical manifestations of constipation?
- Absence of stool
- Abdominal pain
- Cramping without distention
What are clinical manifestations of encopresis?
- Soiled clothing
- Fecal odor without awareness
- Anal irritation
- Social withdrawal
How is constipation and encopresis evaluated?
- History
- Abdominal radiographs
- Rectal examination: not usually performed on children.
How is constipation and encopresis managed?
- Disimpaction
- Education: diet, fluids, activity
- Maintenance
- Changing habits
