Gastrointestinal Disorders

1. Gastrointestinal Disorders Jan Bazner-Chandler CPNP, RN, MSN

2. Embryonic Development • Failure to fuse = cleft lip and palate • Failure to differentiate = duodenal stenosis • Atresia or abnormal closing of structure: • Esophogeal atresia • Anal-rectal malformation • Biliary atresia

3. Fetal Development • Fistula is an abnormal connection • Tracheal esophageal fistula • Anal-rectal malformations with fistula • Incomplete or abnormal placement • Mal-rotation • Diaphragmatic hernia

4. Prenatal History • Birth weight • Prematurity • History of maternal infection • Polyhydramnios • Down’s Syndrome

5. Health History • Congenital anomalies • Growth or feeding problems • Travel • Economic status • Food preparation • General hygiene • Family history of allergies

6. Present Illness • Onset and duration of symptoms • Weight loss or gain • Recent changes in diet

7. Vomiting • Reflexive = infection or allergy • Central = central nervous system • head trauma • meningitis • CNS tumor

8. Vomiting • Gastritis = bloody or coffee ground appearance • Gastroenteritis = undigested food • Obstructive • Bile stained = below pylorus • Brown or fecal = intestinal obstruction

9. Nursing Assessment • Abdominal distention • Abdominal circumference • Abdominal pain • Acute / diffuse / localized • Abdominal assessment • Inspect / auscultation / palpation / measure

10. Measuring Abdominal Girth Bowden Text

11. Diagnostic Tests • Flat plate of abdomen • Fluid • Gas • Structural changes • Barium swallow or UGI • Strictures • Foreign body • Motility disorder

12. Abdominal X-ray

13. Diagnostic Tests • Utrasound • Visualize organs • Cysts • Abscess • appendicitis • CT scan = tumors, abscess, obstruction • 24 hour probe = Gastro esophogeal reflux • Biopsy of liver, esophagus, stomach, intestine

14. Stool and Blood • White blood cells • Ova and Parasite • Bacterial cultures • Blood

15. Failure to Thrive Inadequate growth resulting from inability to obtain or use calories required for growth.

16. FTT • Organic • Physical cause identified: heart defect, GER, renal insufficiency, malabsorption, endocrine disease, cystic fibrosis, AIDS. • Non-organic • Inadequate intake of calories • Disturbed mother-infant bonding • Idiopathic: unexplained

17. Cleft Lip and Palate • Most common craniofacial anomaly • 1 in 700 births • Males 3 to 1 • Higher in Asians • Familial history • Can be diagnosed in utero by ultrasound

18. Cleft Lip Incomplete fusion of the primitive oral cavity • Obvious at birth • Infant may have problems with sucking • Surgery in 2 to 3 months • Goals of surgery • Close the defect • Symmetrical appearance

19. Feeding

20. Cleft Lip Plasticsurgery.org

21. Cleft Lip Plasticsurgery.org

22. Post Surgery Care • Airway management • Pain control • Position in infant seat – upright position • Elbow restraints • Wound care as ordered by MD • Minimizing crying • Feeding techniques

23. Cleft Lip Repair

24. Cleft Palate Cleft palate occurs when the palatine plates fail to migrate and fuse between the 7th and 12th week of gestation. Diagnosed by looking into infants mouth.

25. Cleft Palate Pedisurg.com

26. Cleft Palate Pedisurg.com

27. Cleft Palate May cause problems with feeding due to inability to generate negative suction pressure in the oropharynx and regurgitation of milk into nasal cavity. Pedisurg.com

28. Cleft Palate Repair • Done between 9 and 12 months • Babies should be weaned from bottle or breast prior to the surgical procedure. • Done around 1 year of age after teeth have erupted and before the child is talking to promote better speech outcomes

29. Palate Repair • Pre-surgery feeding • Alternate nipple design • Breast feeding consultant • ESSR • Enlarge / stimulate / swallow / rest

30. Post Surgery Repair • Position of side • NPO for 48 hours • Suction with bulb syringe only • Avoid injury to palate with syringes, straws, cups etc.

31. Long Term Referrals • Hearing • Speech • Dental • Psychological • Team approach to care

32. Esophagus ends in a blind pouch. Infant has a lot of mucous at birth. The rational for giving sterile water for the first feed. Esophageal Atresia Bowden Text

33. E.A. Tracheo- esophageal Fistula 85 to 90% of defects Failure of the esophagus to recanalize between 4th and 6th week of development. Bowden Text

34. Clinical Manifestations • Excessive drooling / frothy mucus • Inability to pass NG tube • Choking and cyanosis with feeding • High risk for aspiration of HCL from stomach causing a chemical pneumonia.

35. X-ray Findings

36. Pre-surgery Care • NPO • Up in infant seat or HOB elevated • Continuous suction • G-tube to decompress stomach

37. Post Surgery Care Ball & Bindler

38. Post Operative Care • Respiratory support • Gastric decompression • Chest Tube • Gentle suctioning • TPN until taking PO’s • Antibiotics

39. Long Term Complications • 5 to 15% experience leaking at operative site. • Aspiration • Dysphagia / difficulty swallowing • Stricture of esophagus • Coughing • Regurgitation

40. Pyloric Stenosis Most common cause of gastric outlet obstruction in infants. • 1 in 500 • More common in males • 3 weeks to 2 months of age • History of regurgitation and non-bilious vomiting shortly after feeding. • Vomiting becomes projectile

41. Pyloric Stenosis Ball & Bindler

42. Clinical Manifestations • Projectile vomiting • Visible peristaltic waves • Olive shape mass in the upper abdomen to right of the midline • Electrolyte imbalance

43. Management Pre-surgery • NPO / document any emesis • IV therapy / Correct electrolyte imbalance • Comfort infant and caretakers

44. Feeding Post-operatively • Give 10 ml oral electrolyte solution after recovered from anesthesia • Start pyloric re-feeding protocol. • Increase feeding volumes from clear fluids to dilute to full-strength formula. • Keep feeding record • Assess for vomiting • Discharged when taking full-strength formula

45. Hernias • A hernia is a protrusion of an organ or part of an organ through the wall of the cavity in which it is contained.

46. Inguinal Hernia Bowden & Greenberg

47. Inguinal Hernia • Inguinal hernia is the most common congenital anomaly requiring surgical repair in infants: 80% • It is a protrusion of peritoneal sac into the processus vaginalis • Most common in males and pre-term infants.

48. Inguinal Hernia

49. Hydrocele Bowden & Greenberg

50. Hydrocele • Caused by peritoneal fluid communication with the scrotal area through a patent processus vaginalis. • Often will resolve on its own unless associated with an inguinal hernia.