peds GI

Formula Intolerance

• Signs of formula intolerance:
  • Diarrhea, vomiting
  • Blood or mucus in stool
  • Pulls legs up towards abdomen in pain
  • Difficulty gaining weight
  • Switching formulas should stop issues
• Milk protein allergy: can cause vomiting, blood in stools, hives, irritability, wheezing, cough, congestion, reflux
  • Must use hydrolyzed formulas
  • Can do stool sample to test
  • If breastfeeding, mother must avoid all milk products & soy

Gastrointestinal Reflux

• Occurs when gastric contents reflux back up into esophagus, making esophageal mucosa vulnerable to injury from gastric acid
• Smaller stomach, shorter esophagus, and immature esophageal sphincter muscle = contributes to increased symptoms in infants
• GERD = tissue damage from GER
• Risk factors: prematurity, neurological impairments, asthma, Cystic Fibrosis, cerebral palsy
• Peak incidence occurs at 4 months old
• About 40% of infants experience GER
• Must differentiate between GERD / GER
• Expected findings:
  • Infants: spitting up or forceful vomiting, irritability, excessive crying, blood in vomit, arching of back, stiffening – colicky baby
  • Failure to thrive
  • Apnea (ALTE/BRUE) or other Respiratory problems (choking with feedings, cough)
• Children: heartburn, abdominal pain, difficulty swallowing, chronic cough, noncardiac chest pain
• If inflammation left untreated, scarring and strictures may form
• Management of GER
  • None: if gaining weight & happy
  • Nursing Care:
  • Small, frequent meals
  • Avoidance of foods that worsen reflux
  • Elevate head after meals
• Avoid foods that worsen reflux: caffeine, citrus, peppermint, spicy or fried foods
• Medication
  • PPI: omeprazole (Prilosec), lansoprazole (prevacid)
  • Most effective when given 30 mins before breakfast
  • Need to take for several days before improvement
  • H2 receptor antagonists (cimetidine, ranitidine (zantact), famotidine (Pepcid)
  • Helps to reduce gastric secretions, may stimulate some increase in esophageal sphincter tone
• Thickened feedings (usually rice cereal or oat cereal)
• Feeding tubes: if unable to gain weight
• If aspiration risk: will need duodenal or jejunal feeding tube (G or J tube) or surgery (Nissen Fundoplication)
  • Nissen Fundoplication
  • Operation done to tighten the outlet of the esophagus as it empties into the stomach
  • Wraps fundus of stomach around the distal esophagus
  • Necessary for children who have complications related to aspiration or for those who have persistent symptoms that are not relieved by medication
  • Appropriate for patients with loss of tone over time
  • With or without G-tube
  • Diet after surgery should start slow with clears, then soft foods

Acute Gastroenteritis

• An inflammation of the stomach and intestines
• Most common causes: viruses, bacteria (food poisoning), and intestinal parasites
  • Viruses: usually cause of mild gastro; Norwalk-like virus (norovirus), adenoviruses, enterovirus and rotaviruses
  • Bacteria: usually produce high fevers, severe GI symptoms, and dehydration; campylobacter, salmonella, E. Coli (sicker, more severe), watch out for dehydration
  • Parasites: Giardia lamblia
• Presentation: vomiting, diarrhea, generalized abdominal pain, fever
• Education:
  • Decrease spread (make sure to wash hands, especially after diaper changes wash toys)
  • Maintain hydration, small amounts more frequently
  • Watch for signs of dehydration
  • Treatment depends on cause
  • Virus: self-limiting,, comfort care
  • Bacteria: antibiotic depending on cause
  • Parasite: Giardia treat with metronidazole (Flagyl)

Dehydration

• Levels:
  • Mild: behavior, mucous membranes, anterior fontanel, pulse, and blood pressure within expected findings
  • Possible slight thirst
• Moderate: pulse slightly increased, dry mucous membranes, decreased tears, normal to sunken anterior fontanel on infants
  • Cap refill 2-4 seconds
  • Possible thirst and irritability
• Severe: tachycardia present, orthostatic blood pressure can progress to shock, dry mucous membranes, no tearing, sunken eyeballs, sunken anterior fontanel
  • Cap refill > 4 seconds
  • Oliguria or anuria
• Nursing actions:
  • Oral rehydration FIRST for mild-moderate dehydration
  • If unable to drink enough to correct fluid losses, will need IV
  • Assess cap refill, monitor vital signs, monitor weight, maintain accurate I&O
  • start with pedialyte for young children and gatorade in older children
  • give 10-15 mLs every 15 minutes

Pyloric Stenosis

• Pyloric sphincter= ring of smooth muscle between the stomach and the duodenum
• Thickened pyloric sphincter creates narrowing & obstruction
• As stomach continues to try to push food through, peristalsis becomes so powerful that food is ejected into the esophagus and out of the mouth = projectile vomiting
• More common in first born males
• Most common at age 3 weeks
• What does it look like:
  • Failed formula changes
  • Projectile vomiting
  • Dehydrated
  • Constant hunger
  • Fluid electrolyte imbalance
  • Risk for metabolic alkalosis
  • On exam, olive shaped mass in RUQ
  • constant hunger because milk is not making its  way through
  • hyperkalemia
  • metabolic alkalosis because of all the vomiting
  • pyloric sphincter is so hard
• Management of Pyloric Stenosis
  • Need an ultrasound to confirm
  • Need to correct fluid and electrolyte imbalance
  • *at risk for hypokalemia & metabolic alkalosis*
  • Need surgery
  • Nursing Considerations:
  • Need fluid support prior to surgery
  • NPO prior to surgery
    • 4-6 hours postop can start clear liquids like pedialyte
    • 24 hours can go to formula or breastmilk
  • Pain management
  • Slow feeding protocol after surgery
  • Anticipatory guidance about setbacks

Hirschsprung’s Disease

• Aka Congenital aganglionic megacolon
• Stools have ribbon pattern
• Congenital condition in which the nerve cells of the myenteric plexus are absent in the distal bowel & rectum
  • Is a sustained sympathetic stimulation (cannot relax)
  • Decreased enteric nerve stimulation (loses motility)
  • Results in decreased motility & mechanical obstruction
  • Rectal internal sphincter cannot relax
  • Absence of parasympathetic ganglion cells in end of large intestine near rectum
• Diagnosis:
  • rectal biopsy to confirm absence of ganglion cells
  • X-ray: with contrast, will see dilated portions of colon
• Risk Factors: male gender, genetics, trisomy 21
• Hirschsprung’s Infant presentation
  • will not pass meconium
  • will see vomiting,
  • can either be bile stained or of fecal material
  • will see abdominal distension, constipation
  • anorexia and poor feeding
  • may see temporary relief with enema
• Hirschsprung’s Older Children presentation
  • History of constipation since birth
  • Distension of abdomen
  • Thin abdominal wall with observable peristaltic movement
  • Stool appears ribbon like, fluid like, or in pellet form
  • Failure to grow; will see loss of subcutaneous fat
  • Child may appear malnourished or have stunted growth
  • Anemia
• SARCASM
  • Sigmoid colon
  • Absence of movement
  • Ribbon shaped stool & Rectal biopsy for diagnosis
  • Congenital / will see constipation
  • Abdominal obstruction / abnormal feeding
  • Syndrome (common in those with Down Syndrome)
  • Meconium (infant will not pass in first 24 hours)
• Management
  • Surgery to remove aganglionic bowel
  • “pull through” normal section pulled through colon and attached to anus
  • If very ill, surgery will be done in two steps; will have temporary ostomy while gut heals
  • High protein, high calorie, low fiber diet
  • May need TPN in some cases
  • Monitor for signs of enterocolitis
• Complication
  • Hirschsprung’s associated enterocolitis = inflammation and obstruction of intestines
  • Occurs in about 20% of neonates with Hirschsprung
  • Perforation of obstructed bowel
  • Presenting symptoms:
  • Foul smelling diarrhea either with or without blood
  • Fevers
  • Abdominal distension
  • Lethargy
  • Poor feeding
  • LIFE THREATENING – can lead to toxic megacolon and perforation of bowel
  • Can lead to sepsis if not treated urgently
  • Need antibiotics, fluid resuscitation, and decompression of obstructed bowel

Intussusception

• Telescoping of bowel on itself
• Results in lymphatic and venous obstruction leading to edema
  • With progression/ no treatment, ischemia and increased mucus into \n intestine will occur
• Most common in those 3 months to 6 years
  • More concerning if patient older
• Findings:
  • Sudden, excruciating pain (drawing knees up to chest)
  • Currant jelly stools
  • Palpable abdominal mass (sausage shaped)
  • May see vomiting, fever, distended abdomen
• Treatment:
  • Air enema
  • surgery
• most common in infants under 1 but can happen in up to 6
• first symptoms: abdominal screaming, pulling knees up to chest
• slough of mucus and blood - jelly stool
• can be fever if infection, ischemia,
• air enema - pressure from air will untelescope intestines - has to be done in radiology - we watch for signs and bowel perforation
• can try air enema again but if that doesn't work will go to surgery
• because of ischemia possibility will do air enema pretty quickly after confirmed diagnosis

The extreme: Short Bowel Syndrome

• Aka “short gut”
• Loss of so much bowel, can’t be nourished enterally
  • NEC
  • Intussusception
  • Hirschsprung
  • Gastroschisis
• Will be TPN dependent
  • Will need central line
  • Liver burden
  • Failure to Thrive
• Often have severe diarrhea due to accelerated intestinal transit, gastric acid hypersecretion, intestinal bacterial overgrowth, malabsorption of fats
• can be due to condition or nonfunctional
• cannot be fed enterally because not enough length in bowel to absorb
• liver burden with TPN and lipids
• Watch for signs of dehydration & electrolyte imbalances
  • May see diarrhea, greasy, foul-smelling stools
  • Fatigue
  • Weight loss
  • Malnutrition (can’t absorb everything because it moves through GI tract so rapidly)
• Must monitor intake & output and weight
• Complications:
  • Central line infections & sepsis
  • Chronic renal failure

Biliary Atresia

• Complete or partial obstruction of the bile ducts inside or outside the liver
• Congenital condition, ducts do not develop normally
• Bile flow from liver to gallbladder is blocked 🡪 liver damage 🡪 cirrhosis of liver
  • Bile can’t flow so it backs up into the liver
• Early diagnosis = key to prevent or slow liver damage
  • Will see increased AST, ALT, bili
• scan (hepatobiliary iminodiacetic acid scan) to see if bile ducts / gallbladder are working properly; liver biopsy
• Kasai procedure = only effective treatment
  • Removes biliary tree and adds new to drain bile
• Hidascan to see flow of bili
• Need liver transplant
• Initially asymptomatic, then start with jaundice; as bili continues to rise will se distension and hepatomegaly
• Presentation:
  • jaundice at 3-4 weeks
  • Distended abdomen
  • Dark urine (due to increased bili)
  • Pale or clay colored stools (due to bile pigments)
  • Slow or no weight gain
  • Bruising, bleeding, intense itching as it progresses
  • Failure to thrive is common

Constipation

• A SYMPTOM NOT A DISEASE
• A decrease in bowel movement frequency or increase in stool hardness for at least 2 weeks
• Often associated with painful bowel movements, blood streaked or retained stool, abdominal pain, lack of appetite or stool incontinence
• Trouble for more than 2 weeks
• A triangle of frequency, consistency, ease
• Frequency alone is not criterion
• Caused by:
• Structural causes:
  • hirschsprung's or other strictures
• Systemic causes:
  • hypothyroidism, chronic lead poisoning,
  • can be side effect of medications: antiepileptic, opioids, iron
• can be in kids just starting school because they don’t want to go or are scared to go
• can lead to encopresis: leakage of stool around hard stool
• *need to evaluate condition further if patient develops vomiting, abdominal distension, pain or evidence of growth failure; need to make sure there is nothing else going on
• Treatment
• Need to both restore normal bowel function & stooling pattern
• First line: miralax
  • Osmotic laxative – draws water into stool
  • Usually takes 1-2 days for effect
  • Can cause incontinence, abdominal pain, nausea, bloating
• Can also use:
  • Docusate sodium (senna): stimulant – acts as a local irritant in the colon, stimulating peristalsis
  • Can cause diaper rash, do not use in those <1 year old
• Magnesium hydroxide: laxative – causes osmotic gradient leading to laxative effect (aggressive)
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Diarrhea

• Abnormal transport of fluid and electrolytes across intestinal mucosa

• A sudden increase in frequency and change in consistency of stool

• Major cause of illness under age 5

• Can be mild to severe, acute or chronic

• Chronic if more than 14 days

• Causes

  • Viral, bacterial, parasitic
  • Associated with other infections such as URI, UTI
  • Dietary
  • Medicine-related

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Viral diarrhea:

• Most common cause of diarrhea in children <5 y/o
• Fever
• Onset of watery stools
• Diarrhea for 5-7 days, vomiting for about 2 days
• Transmission = fecal oral
• Example: Rotavirus

Parasitic diarrhea:

• Enterobius Vermicularis
  • Perianal itching, sleeplessness, restless
  • Ingested or inhaled eggs hatch in upper intestines and mature then migrate out of intestine & lay eggs
• Giardia lamblia
  • Children < 5 = Diarrhea, vomiting, anorexia
  • Older children: abdominal cramps, malodorous, pale, greasy stools
  • Transmitted person to person, food or animals

Bacterial diarrhea:

• Length of symptoms depends on source

• Can be transmitted through undercooked meats, person to person, from pets, contaminated water

• Examples: Yersinia, e. coli, salmonella, clostridium difficile, clostridium botulinum, shigella, norovirus, staph

• More severe, higher fevers, worse symptoms

• Nursing care for diarrhea

  • Obtain child’s weight at same time each day
  • Avoid rectal temps
  • Initiate IV fluids as ordered if needed
  • Administer antibiotics as prescribed (for Shigella, C. Diff, G. lamblia)
  • Avoid antibiotics with Salmonella and E. Coli
  • Avoid antimotility agents with E. Coli, Salmonella, Shigella

• Education:

  • Child should stay home from school/ daycare during incubation period
  • Diet changes needed
  • Avoid fruit juices, stick to BRAT diet
  • Frequent skin care to avoid skin breakdown
  • Avoid antimotility agents because we want them to poop it out

• To prevent spread of infection:

  • Clean toys and child care areas thoroughly
  • Hand hygiene after toileting and after changing diapers

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Appendicitis

• Inflammation of the vermiform appendix caused from an obstruction of the lumen of the appendix
  • Causes of obstruction: fecalith, stenosis, parasitic infection, tumor
  • Mucus continues to be secreted and bacteria grows causing increased pressure
  • impaired perfusion
• Average age of presentation=10 years old
• If untreated, can become gangrenous & ruptures
  • Rupture can occur within first 48 hours of complaint
  • More likely to rupture in younger children when not suspected
  • Can lead to sepsis and shock
• Chief Complaint:
  • Vague midline pain that moves to RLQ and intensifies
  • Vomiting, diarrhea
  • Fevers
  • anorexia
• Exam findings:
  • Rebound tenderness
  • Rigid abdomen
  • Guarding
  • Rovsing: palpation on the left lower quadrant of the abdomen results in pain in the right lower quadrant (at McBurney’s point)
  • Obturator: pain during internal rotation of right hip
  • Psoas:  pain at extension of right hip
• Enemas, heat packs, and laxatives can’t be given
• Morphine, toradol, antibiotics: most common treatment/plan
• Diagnostics:
• Labs:
  • Electrolytes
  • Increased WBC
  • Urine
• Imaging:
  • US versus CT
  • ultrasound first to avoid CT
  • can look for swelling
  • cannot be officially diagnosed without CT
• Shift to left: increase in WBC
• Nursing care pre and post appendectomy
• Pre Appy
  • Monitor for signs of sepsis including increased heart rate and respiratory rate, fever, decreased bp
  • Watch for sudden relief of pain
  • Pain relief
  • Promote comfort
  • Administer antibiotics
  • NPO
• Post Appy
  • Pain management
  • Semi-fowlers
  • Wound care (can either be laparoscopic or open)
  • NG tube for decompression
  • IV antibiotics
  • Prevention of complications
  • Wound infection
  • Line infection
  • UTI
  • Abscess
  • Pneumonia
  • Get up first day to get everything moving

Appendectomy complication

• peritonitis (inflammation in the peritoneal cavity)
• Signs: fever, sudden relief of pain after perforation followed by diffuse increase in pain, irritability, rigid abdomen, pallor
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Failure to thrive

• Weight for age that is less than the 5th percentile on multiple occasions or weight deceleration
• Clinical Manifestations:
  • Poor weight gain
  • Vomiting, food refusal, food fixation
  • Irritability
  • Nonorganic causes: food restriction, food rituals, poor appetite
  • organic causes: vomiting, diarrhea
• Diagnostics:
  • Height, weight, BMI
  • Feeding assessment (quality of food, ability to chew / swallow, 24 hour diet recall)
  • BMP, vit d, lead, zinc, iron
  • Albumin (with severe FTT)
  • CBC, ESR, electrolytes
  • Stool studies
  • Sweat chloride test
  • TSH

Celiac Disease

• Gluten sensitive enteropathy

• An autoimmune reaction to gluten that leads to intestinal inflammation, atrophy, and malabsorption

• Gluten= protein found in wheat, rye, barley

• Chronic, irreversible disease

• In early onset, fat absorption is impaired, leading to excretion of large amounts of fat in the stool

• As it progresses, there is a malabsorption of proteins, carbs, and fat-soluble vitamins

• Diagnosis: transglutaminase IgA – if positive a biopsy of small intestine is done to evaluate intestinal mucosa damage

  • Should also get CBC, ferritin levels, iron levels – at risk for iron deficiency anemia

• official diagnosis: get piece of intestine via colonoscopy

• can do bloodwork to see if colonoscopy is necessary - but very expensive

• Assessment findings:

  • Weight loss
  • Diarrhea
  • Vomiting
  • Foul-smelling stools
  • Delayed growth and development
  • Can get dermatitis herpetiformis (blistering, pruritic skin rash on elbows, knees, buttocks

• Severe form:

  • Iron deficiency anemia
  • Vit b 12 deficiency
  • Osteopenia / osteoporosis r/t calcium malabsorption

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