GI Dysfunction

Pediatric Gastrointestinal System Overview

Review of the Gastrointestinal System

• Types of Gastrointestinal System:

  • Upper GI System:

  • Components: Mouth, esophagus, and stomach

  • Primary Function:

    • To take in food and fluids

    • Begin the digestive process

    • Propel food into the intestine

  • Lower GI System:

  • Components: Duodenum, liver, gallbladder, pancreas, jejunum, ileum, cecum, appendix, colon, rectum, anus

  • Primary Function:

    • Digest and absorb nutrients

    • Detoxify and excrete unwanted waste

    • Aid in fluid and electrolyte balance

Dehydration

• Causes:

  • Usually due to vomiting and/or diarrhea

  • Fever increases fluid loss

• Types of Dehydration:

  • Isotonic:

  • Primary form in children; electrolyte and water loss balanced

  • Hypotonic:

  • Electrolyte loss exceeds water loss

  • Hypertonic:

  • Water loss exceeds electrolyte loss; this is the most dangerous type

Degree of Dehydration (Clinical Signs)

• Mild (3-5% weight loss in infants, 3-4% in children):

  • Weight Loss: 3-4% in infants, 6-8% in children

  • Pulse: Normal

  • Respiratory Rate: Normal

  • Blood Pressure: Normal

  • Behavior: Normal

  • Thirst: Slight

  • Mucous Membranes: Normal (moist)

  • Tears: Present

  • Anterior Fontanel: Not visible even with supraclavicular pressure

  • External Jugular Vein: Visible jugular vein when supine

  • Skin: Capillary refill >2 seconds

  • Urine Output: Decreased

• Moderate (6-9% weight loss in infants, 6-8% in children):

  • Pulse: Slightly increased

  • Respiratory Rate: Slight tachypnea (rapid)

  • Blood Pressure: Normal to orthostatic (>10 mm Hg change)

  • Behavior: Irritable, more thirsty

  • Thirst: Moderate

  • Mucous Membranes: Dry

  • Tears: Decreased

  • Anterior Fontanel: Normal to sunken

  • External Jugular Vein: Not visible except with supraclavicular pressure

  • Skin: Slowed capillary refill (2-4 seconds), decreased turgor

  • Urine Output: Oliguria

• Severe (≥10% weight loss):

  • Pulse: Very increased

  • Respiratory Rate: Hyperpnea (deep and rapid)

  • Blood Pressure: Orthostatic to shock

  • Behavior: Hyperirritable to lethargic

  • Thirst: Intense

  • Mucous Membranes: Parched

  • Tears: Absent; sunken eyes

  • Anterior Fontanel: Visible when supine

  • External Jugular Vein: Not visible even with supraclavicular pressure

  • Skin: Very delayed capillary refill (>4 seconds), tenting; skin cool, acrocyanotic or mottled

  • Urine Output: Oliguria or anuria

Rehydration Strategies

• Mild to Moderate Dehydration:

  • Administer 50 mEq of sodium per liter in an Oral Rehydration Solution (ORS)

  • Continue breastfeeding

  • For mild dehydration: Give 50 mL/kg ORS to children

  • For moderate dehydration: Give 100 mL/kg ORS to children

• Severe Dehydration:

  • Requires oral rehydration: 30 mL/h for infants, 60 mL/h for toddlers, 90 mL/h for older children

  • Likely to require IV fluids if oral rehydration is intolerable

  • Add 10 mL/kg of fluid for each loose stool/vomiting episode

  • Unsweetened powdered Kool-Aid can enhance ORS flavor

  • Popsicles can provide 40-50 mL of fluids

Daily Maintenance Fluid Calculations (Holliday-Segar method):

• Body Weight 1-10 kg: 100 mL/kg

• Body Weight 11-20 kg: 1000 mL + 50 mL/kg for each kg >10 kg

• Body Weight >20 kg: 1500 mL + 20 mL/kg for each kg >20 kg

Water Intoxication

• Causes:

  • IV water overloading

  • Too rapid dialysis

  • Tap water enemas

  • Incorrectly mixed infant formula

  • Excess water ingestion

  • Rapid glucose decrease in DKA treatment

• Infant Vulnerability Factors:

  • Poor thirst mechanism

  • When formula is too diluted to save money

  • Using water for pacification

  • Vigorous hydration during fever

  • Infants at risk during swim lessons, water births, enemas, gastric lavage

Disorders of Prenatal Development (Structural Defects)

• Overview: Congenital anomalies impacting the GI tract (p. 1212)

• Specific Defects:

  • Cleft lip, cleft palate, or both

  • Esophageal atresia and tracheoesophageal fistula (TEF)

  • Upper gastrointestinal hernias (Omphalocele, Gastroschisis, Umbilical hernia)

  • Imperforate anus

Cleft Lip and Cleft Palate (p. 1215)

• Cause: Failure of maxillary and premaxillary processes to fuse during the 4th to 10th weeks of embryonic development

• Diagnosis: Apparent at birth

• Management:

  • Surgical repair is required (multiple stages)

  • Cleft Lip (CL) repair is typically at 2-3 months of age

  • Cleft Palate (CP) repair is recommended before 12 months of age to facilitate normal growth and development

• Nursing and Postoperative Care:

  • Protect the operative site using petroleum jelly

  • Utilize elbow immobilizers immediately post-operation until 7-10 days

  • Implement syringe feeding for 7-10 days

  • Avoid oral suction, tongue depressors, oral temperatures, pacifiers, straws, and spoons

  • Older infants/children should be placed on a soft diet, avoiding hard items

  • Long-term support is essential

  • Special feeder may be needed for cleft lip

Esophageal Atresia and Tracheoesophageal Fistula (TEF)

• Clinical Manifestations:

  • Excessive salivation and drooling

  • The three C’s of TEF: Coughing, Choking, Cyanosis

  • May also see apnea, respiratory distress during feeding, abdominal distension, and cardiac anomalies

• Nursing and Postoperative Care:

  • Maintain patent airway for infants exhibiting classic signs after birth

  • Remove secretions via suctioning the oropharynx

  • Administer antibiotic therapy due to aspiration

  • Use gastrostomy feedings until anastomosis has healed

  • Tracheomalacia: Potential complication including symptoms such as barking cough, stridor, wheeze, recurrent respiratory tract infections, cyanosis, and apnea

  • Provide home care instructions for children with a gastrostomy tube

Upper Gastrointestinal Hernias

• Definition: Protrusion of a part of an organ through the abdominal wall that may constrict organ perfusion.

• Types:

  • Omphalocele: Protrusion of intraabdominal viscera into the base of the umbilical cord, covered with a membrane.

  • Gastroschisis: Protrusion of intraabdominal viscera into the base of the umbilical cord, NOT covered with a membrane.

  • Umbilical Hernia: Common protrusion of umbilicus through an abdominal opening, usually self-resolving unless incarcerated or strangulated.

Omphalocele

• Nursing and Postoperative Care:

  • Preoperative Care: Keep viscera moist, and NG suction for decompression

  • Postoperative Care: NG suction for bowel evacuation, parenteral nutrition

Gastroschisis

• Nursing and Postoperative Care:

  • Preoperative Care: Cover with bowel bag, NG suction for bowel decompression

  • Postoperative Care: Monitor lower extremities for pulses and circulation (risk of vena cava compression by large bowel in small abdominal cavity), monitor for bowel function repair

Umbilical Hernia

• Description: Protrusion of the umbilicus through an abdominal opening, usually isolated and common.

• Resolution: Typically self-resolving but can become problematic if incarcerated (cannot be reduced manually) or strangulated (blood supply impaired).

• Treatment (Incarcerated/Strangulated): Surgical intervention

Motility Disorders

• Conditions Include:

  • Diarrhea

  • Constipation

  • Vomiting

  • Hirschsprung disease

  • Gastroesophageal reflux disease (GERD)

  • Irritable bowel syndrome

Diarrhea (p. 1178)

• Definition: A symptom of GI digestion, absorption, and secretory disorders

• Types:

  • Acute vs. chronic (Refer to Table 41.5 on p. 1179)

• Common Cause: Rotavirus - the most common cause of serious, potentially fatal gastroenteritis in children

• Transmission: Most pathogens spread via fecal-oral route (food/water or person-to-person)

• Nursing Care and Management:

  • Administer Oral Rehydration Therapy (ORS)

  • Home Treatment: 5-10 mL increments

  • Hospital Treatment: IV fluids and NPO for 12-48 hours; maintain accurate I & O and daily weights

Constipation (p. 1183)

• Definition: Alteration in frequency, consistency, or ease of bowel movements

• Symptoms in Children Over 4 Years Old: Less than 3 stools per week

• Indicators of Concern: Painful movements, blood-streaked stools, retained stools, abdominal pain, lack of appetite, stool incontinence

• Causes:

  • Structural/systemic causes

  • Medication causes (e.g., antihistamines)

  • Obstipation: Long intervals between movements

  • Encopresis: Constipation with fecal soiling

• Therapeutic Management:

  • Depends on cause; complete history and physical is necessary

  • Education for infants' families and establishing a routine

  • Dietary changes and maintenance therapy (softeners & laxatives) for children; educational support as needed

Vomiting (p. 1185)

• Distinction: Different from regurgitation

• Commonality: Frequent in children, typically self-limiting

• Assessment Considerations: Age, pattern, duration, color, and consistency of vomitus help to determine cause

• Management Goals:

  • Treat the underlying cause

  • Prevent complications

• Gathering Information on Infant Vomiting:

  • Questions to ask include:

  • Could you wipe the vomitus off the child with a rag?

  • Did the vomiting require clothes changes?

  • How big was the vomit circle?

  • Did it occur after every feeding?

  • Did it look like what was eaten or curdled?

  • What color was it?

  • Did it appear to project away from the child?

Hirschsprung Disease (p. 1187)

• Management:

  • Monitor abdominal circumferences

  • Surgical removal of the aganglionic section

  • Rectal dilations as necessary

Gastroesophageal Reflux and GERD (p. 1188)

• Therapeutic Management:

  • Dietary modifications: Thickened feeds may help infants

  • Lifestyle modifications: Positioning (upright)

  • Medications: H2 receptor antagonists, PPIs

  • Treatment for acute bleeding, surgical intervention for severe cases

  • Nursing care includes education

Obstructive Disorders

Hypertrophic Pyloric Stenosis

• Clinical Manifestations:

  • Projectile vomiting

  • Fussy and hungry after vomiting

  • Weight loss and dehydration

  • Can result in metabolic alkalosis

  • Distended upper abdomen; a palpable olive-shaped mass in the epigastrium to the right of the umbilicus

  • Visible peristalsis from left to right

• Treatment: Surgical intervention to divide the muscle (pyloromyotomy)

Intussusception (p. 1202)

• Clinical Manifestations:

  • Sudden acute abdominal pain

  • Screaming and drawing knees to chest

  • Bilious vomiting, lethargy, fever

  • Red, currant jelly-like stools

  • Tender, distended abdomen with a palpable sausage-shaped mass in the Upper Right Quadrant (URQ)

  • Empty Lower Right Quadrant (LRQ)

• Treatment: Guided enemas, IV fluids, NG decompression, and surgery

• Key Sign of Resolution: Normal brown stool indicates spontaneous resolution

Inflammatory and Infectious Disorders

Peptic Ulcer Disease

• Cause: Most primary ulcers arise from the bacterium Helicobacter pylori

• Goals of Management:

  • Relieve discomfort

  • Promote healing

  • Prevent complications and recurrence

• Medication Regimens: May include antibiotics, antacids, and PPIs; triple therapy for H. pylori is standard

Appendicitis

• Symptom Progression: Develops slowly, typically over a 12-hour period

  • First symptom: Periumbilical pain

  • Followed by: Nausea, RLQ pain, vomiting, and fever

• Plan of Action: If vomiting precedes pain, suspect gastroenteritis; if pain precedes vomiting, appendicitis is likely

• Positioning of Child: May assume side-lying knee-chest position in pain

• Key Symptoms: Greatest pain is usually in the right lower quadrant

• Important Signs: Sudden resolution of pain is a critical indicator of possible perforation, requiring urgent interventions

• Interventions Needed: Surgical intervention, IV antibiotics, and pain management

Meckel Diverticulum

• Description: Remnant of the fetal omphalomesenteric duct

• Clinical Manifestations:

  • Abdominal pain similar to appendicitis (may be vague and recurrent)

  • Bloody stools: presenting sign; usually painless (except for some infants)

  • Severe anemia, possible shock

• Management: Symptomatic cases require surgical intervention; post-operative care includes IV fluids and NG tube

Inflammatory Bowel Disease (IBD) (p. 1196)

• Therapeutic Management:

  • Nutritional support is critical due to growth failure and malnutrition

  • High protein and high-calorie dietary plans

  • Vitamin supplementation may be necessary

  • Using enteral formulas (elemental formulas) as needed via NG or TPN feeds

  • Surgical treatment when indicated

  • Nursing care focuses on patient education

Malabsorption Disorders

Conditions Include

• Lactose intolerance

• Celiac disease

• Short bowel syndrome

Celiac Disease

• Clinical Manifestations:

  • Impaired fat absorption

  • Impaired nutrient absorption

  • Behavioral changes

  • Celiac Crisis: Acute episodes of profuse, watery diarrhea and vomiting

• Management: Primarily dietary adjustments (gluten-free diet); annual evaluations are recommended even if stable

Hepatic Disorders

Types

• Hepatitis:** A, B, C, D, E

• Common Transmission for Hepatitis:

  • Hepatitis A: Fecal-Oral

  • Hepatitis B: Vaccination administered at birth

• Biliary Atresia:

  • Fatal if untreated; liver transplant can cure

• Cirrhosis: Definition as end-stage liver disease resulting primarily from hepatitis and biliary atresia.