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 Intestinal obstruction (pediatric) - series | Lima Memorial Health System
  • 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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