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

GastrointestinalGastrointestinalGastrointestinalGastrointestinal

Elisa A. Mancuso, RNC-Elisa A. Mancuso, RNC-NIC,MS,FNSNIC,MS,FNS

Professor of NursingProfessor of Nursing

Anatomy and Physiology of GI Tract

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

balance

Gastroesophageal Reflux

GER/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

Clinical Signs

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

Clinical Signs

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

DiagnosisUpper 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

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

Therapy Goals• Eliminate Symptoms• Heal Esophagus• Prevent complications

• Positioning– ↑↑ HOB @ 300 < after feedings.– Side or prone is best position. – AAP recommends back to sleep to

↓SIDS.– Car seats can ↑risk for GER

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

Medications

H2 Blockers (Histamine receptor antagonists) ↓ HCL content.

• Ranitidine (Zantac) >1 month – Give 2 H pc

• Famotidine (Pepcid) >1 year• Nizatidine (Axid) >12 years• Cimetidine (Tagamet)>16 years

Medications

Proton Pump Inhibitors (PPI) ↑ Gastric emptying time Block acid secretion

• Lansoprazole (Prevacid) > 1 year

• Omeprazole (Prilosec) > 2 years

• Nexium use 30 minutes pc

MedicationsProkinetic 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)

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 > ICF • Lose more fluid and electrolytes than

older child

Diarrhea

↟ # of stools & ↓ consistency

Severe electrolyte imbalances ↟↟ H20 loss ↓ NA, ↓ K+, ↓ HCO3 Metabolic acidosis

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

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

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

TherapyEnteric 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 1:1 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

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

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

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

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

Hirschprung’s 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 > females

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

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

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– Won’t pass barium

• Full Thickness Rectal Biopsy– Definitive diagnosis shows absence of – ganglionic cells

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

Treatment• Mild: Rare

– Treat chronic constipation with stool softeners and cleansing enemas

• Moderate:Surgery– 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 @ 2-3 months or 8-10 kg

– Re-anastomose both ends

Pyloric Stenosis

• Abnormal severe narrowing @ pylorus• Hypertrophy & Hyperplasia of pylorus

muscle • Not present @ birth = Not Congenital• Muscle becomes cartilaginous &

thickens • Twice the size!• Males 5x > females• Sonogram shows solid mass• Barium swallow

– Delayed gastric emptying

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

TherapySurgery-Pyloromyotomy

Pre-op• NGT & replace drainage with 1/2 NS added to IV• NPO, strict I & O, IV, daily weight, and ✔ abd girthPost-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

Intussusception

• Telescoping of bowel into itself• ↑ Risk between 3-12 months old• Males 3 x > risk than females• Pushes bowel inward = obstruction

– Stops peristalsis completely – No bowel sounds distal to

obstruction• ↑ Incidence @ ileocecal valve

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

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

Appendicitis

• Inflammation of vermiform appendix @ cecum

• Peak incidence at 10-12 yearsPathophysiology

• Feces trapped in appendix (fecalith) or food

• Obstruction → Ischemia → Infection → Inflammation → Perforation– Rupture of appendix and contents– Medical emergency!– Peritonitis – Life threatening

Signs and Symptoms• Children describe pain as general or

vague• Abdominal pain starts @ peri-umbilical

then localizes @ RLQ McBurney’s point• Anorexia N/V/D, • Low grade temp 100-101 • WBC > 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

TherapyPre-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

PerforationMedical 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

Malabsorption Syndromes

• Impaired digestion/absorption– Fluids & Electrolytes

• Chronic diarrheaEtiology

• CF Lactase deficiency– Decreased/ absent digestive enzymes

• Celiac Ulcerative Colitis– Absorptive defects

• Short bowel syndrome – Extensive resection of bowel RT NEC

Celiac DiseaseGluten 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

Clinical signs• Usually @ 9 months

– Need 3-6 months after introduction of grains

• Drop on growth chart <25 %• Steatorrhea• Abdominal distention/pain• Anorexia• Irritability & Uncooperative• Muscle wasting in legs &

buttocks• ↓Vitamin A, D, E & K = Anemia

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

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

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– >60 % = ↓↓ absorption

• Diarrhea• Food intolerance• Abdominal distention• ↓↓ weight

Therapy

• Maintain nutritional status via IV & TPN therapy – ✔ Growth & development – ✔ Broviac – S/S infection– ✔ Renal & hepatic function– ✔ Labs

• Parental Anticipatory Guidance• Bowel & Liver Transplant

Biliary Atresia

• Female > 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.

Clinical signs

• Jaundice > 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

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