GI Peds

When does the GI tract fully mature?

Age 2

What is the most common entry for infectious pathogens?

The mouth, because it is highly vascular

What is the Lower Esophageal Sphinter?

Prevents regurgitation of stomach contents up into esophagus or oral cavity.

When does esophagus develop?

1 month

What happens with narrowing of the esophagus?

Dysphagia

Stomach Capacity of a Newborn?

10-20 mL

Stomach Capacity of a 2 month?

200mL but can’t tolerate 200mL

Stomach Capacity of a 16 year old?

1,500 mL

Stomach Capacity of an adult?

2k-3k mL

When does Hydrochloric acid form?

6 months (at adult level)

How long is a full-term infant’s small intestine?

250 cm / 8 ft

How long is an adult’s small intestine?

600 cm / 20 ft

What is easily palpable at birth?

The liver, it is large compared to the rest of the body

Why do Infants/Children require larger fluid intake?

They excrete a greater amount of fluid leaving thema t risk of fluid loss with illness.

What does having a larger body surface for infants a bad thing?

Increased risk of insensible (unmeasurable) fluid loss.

What does having a higher Basal Metabolic rate mean?

Increase risk of insensible fluid loss and need for water (for excretory functions)

What do inspect for GI System?

Color, Hydration Status, Abdominal Size/Shape, Mental Status

Describe Inspection for Color?

• Check for Pallor → anemia/dehydration

• Icteric Sclerae (yellow eyes) or Jaundiced skin → inc bilirubin lvls

  • related to liver dysfunction

Describe Inspection of Hydration Status

• Decreased turgor or tenting → dehydration

• Absence of tears while crying → dehydration

Describe Inspection of Abdominal Size/Shape

• Protuberant (bulging outward) abdomen → ascites, fluid retention, gaseous distention, tumor

• Depressed/concave abdomen → high abdominal obstruction, dehydration

Describe Inspection of Mental Status

• Changes can occur w/ severe dehydration, anaphylactic rxn, and inc ammonia levels

  • Lethargy occurs more rapidly in children

Describe Auscultation of GI in Children

• Hyperactive BS → diarrhea, gastroenteritis

• Hypoactive or absent → obstructive process → REPORT

Describe Palpation for GI in Children

• Palpable kidneys (except neonates) → tumors, hydronephrosis

• Areas of firmness/masses → tumor, stool in abdomen

  • Tender = Abnormal

  • Right Upper tenderness → liver enlargement

  • Right Lower pain → rebound tenderness (pain upon release of pressure) → warning sign of appendicitis

Stool Collection Techniques

• Diapers, Runny Stool, Older Ambulator Child, Bedridden Child

Describe Diapers (Stool Collection Method)

• Tongue blade to scrape a specimen into the collection container

  • Not sterile procedure, stool isn’t sterile

Describe Runny Stool (Stool Collection Method)

• piece of plastic wrap in the diaper

  • very liquid stool - requires urine bag to the anal area

Describe Older Ambulatory Stool Collection Method

• 1st → urinate in toilet

• Retrieve specimen from a clean collection container fitting under the seat at the back of the toilet

Describe Bedridden Child (Stool Collection Method)

• Collect specimen from a clean bedpan

• Don’t allow urine to contaminate the stool specimen

What are Stool Diversions?

• surgical procedures of bringing portion of small or large

  intestine to surface of abdomen creating an ostomy

Describe Ostomy Care

• Materials: warm washcloths, skin barrier powder/paste, and/or sealant (protects skin), pencil/pen, scissors, pattern to measure stoma size

• Take off Pouch → Observe stoma and skin

  • Stoma should be moist and pink or red → proper circulation to intestine

  • Notify MD if volume of stool increases or if stoma is prolapses or retracted

• Measure stoma, mark new pouch, and cut the backing → apply new pouch → need to be changed q 1-4 days

Describe Ostomy education

• Avoid tight clothing around site

• Store supplies in cool/dry place

• Inform Schools

Upper GI Series (Barium Swallow)

• Visualizes form, position, mucosal folds, peristaltic activity & motility of esophagus, stomach, upper GI tract

• X-rays after drinking barium contrast

When do you use a Barium Swallow?

Foreign body ingestion,abdominal pain, dysphagia, malrotation

Barium Enema

• A barium enema is a special type of X-ray that takes images of the large intestine (colon, rectum and anus).

• It uses a contrast substance to coat the large intestine

Gastric emptying study

• A medical test that measures how long it takes for food or drink to move through the stomach and empty from it.

• It is used to assess gastric motility

Abdominal Ultrasound

An abdominal ultrasound is a medical imaging test that uses sound waves to see inside the belly area, also called the abdomen

CT Scan

• With or Without Contrast

MRI

Generates a strong magnetic field, radio waves, and a computer algorithm to create detailed images without any radiation

When do you use an Abdominal Ultrasound?

Abdominal pain, V, pregnancy, abnormal

liver tests, masses, enlarged organs

• Do not use barium, decreases visualization of organs

Flat Plate of Abdomen

Radiograph of patient lying flat, examines the abdomen

Gastroscopy (EGD)

• visualization & biopsies of upper GI tract w/ fiberoptic instrument

When do you need a EGD?

• dysphagia, foreign body removal, epigastric/abdominal pain, celiac disease

Colonoscopy

• Lower endoscopy

• visualization & biopsies of lower GI tract w/ fiberoptic instrument

Common Medical Treatments

• Hydration (oral, enteral, and IV)

• Providing adequate nutrition (oral, enteral, and IV)

• Enemas and bowel preparations

• Ostomies—surgical opening into a digestive organ

• Probiotics—support/replace intestinal microbial flora

• Medications

Describe Cleansing Enema

• Insert of Fluid into rectum to soften stool and stimulate bowel movement

  • Used for fecal impaction or severe constipation

Describe Bowel Prep

• Highly osmotic fluids to induce severe diarrhea to clean the entire bowel

• Prep for colonoscopy or Bowel Surgery

Different Types of Feeding Tubes

• Orogastric (OG)

• Nasogastric (NG)

• Gastrostomy

• Jejunostomy

Oral Rehydration Therapy

• Fluids containing electrolytes and glucose to prevent dehydration/promote rehydration

  • 75 mmol/L Sodium Chloride

  • 13.5g/L Glucose

    • Pedialyte, Infalyte, Ricelyte

  • Mild/Mod Rehydr: requires 50 to 100 mL/kg of ORS over 4 hours

  • NOT for rehydration: tap water, milk, undiluted fruit juice, soup, broth

Probiotics

• Food supplement containing dormant bacteria, when activated = alter intestinal microflora

Total Parental Nutrition

TPN - Intravenous Complete Nutrition, provides glucose, protein, lipids, vitamins, and minerals

List of Medications

• Histamine-2 blockers (proton pump inhibitors)

• Prokinetics

• Antibacterial/antibiotics

• Corticosteroids, immunosuppressants

• Stimulants, laxatives

• Antidiarrheals and antiemetics

• Anticholinergics

• Anti-inflammatories

Describe Histamine-2 blockers

Proton pump inhibitors

• decrease in histamine production → reducing gastric acid secretion, used for heartburn, esophagitis, GERD, benign duodenal/gastric ulcers

  • NI: causes drowsiness/dizziness

Describe Prokinetics

• They stimulate muscle contractions in the stomach and intestines to:

  • Speed up gastric emptying

  • Reduce reflux by tightening the lower esophageal sphincter (LES)

• For erosive esophagitis, symptomatic GERD, H. Pylori eradication

  • headache, nausea, abdominal pain, diarrhea

Describe Corticosteroids

• Act systemically to reduce inflammation and suppress normal immune response

• Used for inflammatory bowel disease, autoimmune disorders

  • Systemic Adverse Effects: hirsutism, osteoporosis, GI Upset, cushingoid appearance, intraocular pressure, personality changes

Describe Immunosuppressants

• Suppress immune system to keep autoimmune disorders in remission (Crohns, Ulcerative Colitis, Autoimmune Hepatits)

• Check levels to determine metabolite levels

  • Potential hepatotoxicity

Describe Stimulants

• Stimulates peristalsis in large intestine produces BM

• Relieves constipation

  • Can cause cramping/diarrhea, assess stool patterns

Describe Laxatives

• softens stool to allow easier passage through colon.

• Relieves Constipation

  • Monitor stool patterns and doses (adjust for child)

Describe Antidiarrheals

• Decreases peristalsis prolonging passing of stool through intestine.

• Treats diarrhea related to short bowel syndrome, chronic nonspecific diarrhea, IBS (irritable bowel syndrome)

  • May cause drowsiness or constipation

Describe Antiemetics

• Acts on CNS transmitters to prevent nausea and vomitting

  • CNS effects; drowsiness or irritability

Describe Anticholinergics

• Controls abdominal spasms and cramping associated with IBS, functional bowel disorders

  • May cause excessive thirst, dizziness

  • Encourage plenty of fluid intake

Describe Anti-Inflammatory

• Reduces inflammation in the colon associative w/ ulcerative colitis, proctitis.

  • monitor stool output for presence of oral medication as it indicated poor absorption

Risk Factors for GI Disorders

• Prematurity

• Family Hx

• Genetic Sx

• Chronic Illness

• Prenatal factors

• Exposure to infectious agents

• Foreign Travel

• Immune Deficiency, Chronic Steroid use

Risk Factors for Dehydration

• Diarrhea

• Vomiting

• Decreased Oral Intake

• Sustained High Fever

• Diabetic Ketoacidosis

• Extensive burns

Acute GI disorders

• Dehydration, vomiting, diarrhea

• Oral candidiasis and oral lesions

• Appendicitis

• Intussusception, malrotation, and volvulus

• Hypertrophic pyloric stenosis

What is Malrotation?

Birth defect that occurs when the intestines do not correctly or completely rotate into their normal final position during development.

What is Volvulus?

condition where part of the intestine twists around and folds over itself, leading to bowel obstruction

Structural Anomalies of GI Tract

• Cleft Lip & Palate

• Meckel Diverticulum

• Hernias (inguinal & umbilical)

Chronic GI Disorders

• GER, GERD

• Peptic Ulcer disease

• constipation/encopresis (functional fecal incontinence or soiling)

• Hirschsprung Disease

• Short Bowel Syndrome

• Celiac disease

• Inflammatory bowel disease (Chron’s, Colitis)

• Failure to Thrive

Hepatobiliary Disorders

• Pancreatitis

• Gallbladder disease

• Biliary Atresia

• Hepatitis (multiple types)

• Cirrhosis and portal hypertension

• Liver transplantation

When does the Suck and Swallow reflex develop?

34 weeks

When do coordinated oral pharyngeal movements (to swallow solids) develop?

2 months

When is Stool frequency highest?

Infancy

When do we gain control of stool?

Achieved by 18 months to 4 years

Describe Preschooler GI Development Changes

• Continues having appetite fluctuations, with periods of overeating or refusal to eat

  • Weight gain 4-5 lbs/year

Describe Toddler GI Development Changes

• Weight gain 5-6lbs/year

• Growth of digestive system slows during toddler, leading to reduction in caloric needs

  • Avg toddler needs 102/kcal/kg (46kcal/lb)

Functional Gastrointestinal Disorders

• GERD

• Vomiting

• Diarrhea

• Constipation

• Irritable Bowel Syndrome (IBS)

Obstructive Disorders

• Hypertrophic pyloric stenosis

• Intussusception

• Volvulus

• Hirschsprung's disease

Describe Diarrhea

• Acute or Chronic excessive loss of fluid and electrolytes in the stool

  • Acute = caused by viruses

  • Chronic = longer than 2 wks

Risk Factors for Chronic Diarrhea

• Ingestion of undercooked meats, foreign travel, day care attendance, well water use

Diarrhea Assessment

• Moderate - Severe: decrease tear production, sunken orbits, dry mucous membranes, lethargy, tenting

• Anal area = redness and rash

Diarrhea Management

• Restore F/E balance

• Oral Rehydration therapy

• Acute diarrhea (infect) → hand hygiene, preventative measures

• Chronic → Fluid Intake

• Can be result from excessive intake of formula, water, fruit juice

  • avoid fluids high glucose → worsens

Describe GER

Gastroesophageal Reflux

• Return of gastric contents from the stomach through the lower esophageal sphincter into the esophagus

• Benign, occurs during 1st year of life, resolves 12-18months

• Common in premmies

  • Assessment: nonbilious vomiting and regurg

Describe GERD

Gastroesophageal Reflux Disease

• Gastric contents back into the esophagus or oropharynx (Pathologic)

• In Infants older than 6months, children with congenital or neurological problems (Physiologic)

• Not relieved by simple measures

• Complications: laryngitis, recurrent pneumonia, asthma, acute life-threatening events, apnea

Describe GERD Assessment

• Regurg feedings with slow growth/poor weight gain

• esophagitis - excessive crying

• Apnea/Resp Problems

• Anemia

  • Not all children vomit → irritability, posturing, grimacing w/ feedings

• Diagnosis:

  • Upper GI

  • Barium Swallow

  • 24hr Intra-esophageal pH monitoring study

Describe GERD Management

• Promoting safe feeding techniques/positioning

  • Elevated HOB, upright 30 min after feeding

  • Avoid prone

  • Small frequent feeding

  • Burp

• Medication:

  • Decr acid production, stabilize pH

  • Prokinetic agents - empties stomach quickly and minimizes gastric contents

• Post OP Care

  • Nissen fundoplication

  • Gastrostomy tube

Describe Nissen Fundoplication

• Creates one way valve by wrapping gastric fundus 360 degrees around lower end of esophagus

• Severe cases may need G-Tube for 6-8 weeks after surgery

Describe Appendicitis

• Inflammation or Infection of Appendix

• Rare in children < 2 yrs

• Begins as pain in periumbilical area

  • Progresses over 4-6 hrs in right lower area

• S/S: low grade fever, nausea, anorexia

• Sudden pain relief - rupture of appendix → peritonitis

Describe Perforation

• hole that forms in a structure

  • Typically GI

• Perforation of appendix → pain relieved → returns as peritonitis

• Abdominal distention

• High fever

• Dehydrated

Interventions of Perforation

• Extra Fluids

• NG to decompress stomach

• IV antibiotics prior to surgery

• Fever and Pain Control

• AMBULATE

• Cough and Deep Breathe

• Pain Management

Assessment Appendiciits

• Symptoms develop over 12 hr period

• Pain, anorexia, nausea/vomiting, fever simultaneously

• Vomiting precedes pain, suspect Gastroenteritis

• Pain precedes vomiting, appendicitis

• Child may lie down in knee-chest position

• Greatest pain in right lower

Describe Intussusception

• proximal segment of bowel ‘telescopes’ (sucks into itself) into a more distal segment

  • Common cause of intest obstruct 3-25 months

• Causes: edema, vascular compromise, and ultimately partial/total bowel obstruction

• 1-2 yr old

• Risk Factors: cystic fibrosis, celiac disease, 24hrs to treat bowel becomes necrotic → septic → death

• Diagnosed: Contrast Enema

Intussusception Assessment

• Sx flare and regress

• hallmark sign: sausage shaped mass in upper mid abdomen

• Bleeding results in passage of blood and mucous in stool

  • Currrant Jelly Stool (late sign)

• pain mimics colic

• pulls legs up toward abdomen

• bilious vomiting (late sign) → REPORT MD

Intussusception Management

• 1st choice - air enema

• barium enema - reduces large percentages of intussusception cases

• portion of bowel must be resected if interventions are unsuccessful

Describe Hirschsprung Disease

• Obstruction from motility of intestinal tract

  • Due to lack of ganglion cells in intestine

    • Congential Megacolon

• Risk Factors - Chromosomal abnormalities, family hx of hirsch, down syndrome

Hirschsprung Disease Diagnosis and Symptoms

• Newborn

• Failure to pass meconium with first 48hrs of life

• Failure to thrive

• Poor feeding

• Chronic constipation, vomiting, abdominal obstruction

• Diagnosis:

  • Xray, dilated loop of bowel

  • Barium enema

  • Biopsy

Hirschsprung Disease Management/Treatment

• Promote proper bowel function

• Surgical resection of aganglionic

  bowel and reanastomosis of remaining intestine

• Rectal Biopsy

• Ostomy to divert stool through stoma → allows resected area to heal → closed later

Describe Cleft Lip

Most Common Congential Craniofacial anomaly

• 1 in every 700 births

• 30% have genetic syndromes

  • Heart defect, ear malform, skeletal deform, GU abnorm

• Occurs early in Pregnancy

  • 5-6 weeks gestation = lip tissue fuses

  • 7-9 palate closes

• Lip or Palate does not fuse → CLEFT

• 50% of infants with cleft lips have cleft palate

• Buildup of fluid in middle ear → Otitis media

Cleft Lip Characteristics

• Primary/Permanent teeth - missing, malformed, unusually positioned

• Nasal quality to speech, delays in speech development

• Unilateral (left side more common) or bilateral

Cleft Lip Management

• Surgical repair

  • Lip: 2-3 months

  • Palate: 6-9 months

• Prevent injury to suture line

• Promote adequate nutrition

• Encourage infant-parent bonding

Describe Failure to Thrive

• Inadequate growth resulting from inability to obtain or use calories required for growth

• Uses standards of infants and toddlers younger than 3 yrs

• Organic (physical cause): heart defect, GER, renal insufficiency, malabsorption, endocrine disease, cystic fibrosis, AIDS

• Non-Organic (no associ medical condition): Neglect, inadequate intake of calories, disturbed bonding