Upper and Lower GI System

Upper GI System (Nutrient Intake & Ingestion)

• The upper GI system includes the mouth and esophagus
• The tongue senses the taste and texture of food and initiates salivation in the mouth
• Saliva contains amylase and ptyalin which starts the breakdown of complex starches into disaccharides
• The esophagus transports food to the stomach through peristalsis (wave-like contractions)

Stomach Function

• Food mixes with gastric fluids and then moves to the small intestine
• Hydrochloric acid (HCl) and digestive enzymes break down food further in the stomach

Lower GI System (Digestion, Absorption, Metabolism)

• The small intestine is the primary site of absorption
• The villi and folds within the small intestine increase the absorptive surface area
• Disaccharides are converted into monosaccharides within the small intestine
• The small intestine absorbs carbohydrates, fats, proteins, minerals, and vitamins, facilitating their entry into systemic circulation

Small Intestine Segments

• The duodenum (first segment) receives bile from the liver and pancreatic enzymes
• The jejunum absorbs water, protein, carbohydrates, and vitamins
• The breakdown of fats occurs via lipases secreted by the pancreas in the jejunum
• Fats are absorbed by the lymphatic system in the jejunum
• Trypsin breaks down proteins into amino acids, which enter systemic circulation, in the jejunum
• The ileum (final segment) absorbs bile salts, vitamin C, vitamin B12, and chloride

Large Intestine

• The large intestine begins at the cecum and ends at the rectum
• Segments includes the ascending colon (right side), transverse colon (horizontal across the abdomen), descending colon (left side), and the sigmoid colon (pelvic cavity) then moves to the rectum, to the anal canal to the anus (defecation)
• The major function of the large intestine is to absorb water and eliminate solid waste

Liver

• It is the largest organ located under the right diaphragm
• Functions include metabolizing carbohydrates, fats, and proteins
• Breaks down toxins like drugs and alcohol
• Produces bile, prothrombin, and fibrinogen for clotting
• It stores Vitamins A, D, E, K, and iron

Gallbladder

• Stores bile and releases it into the duodenum to aid fat digestion

Pancreas

• Functions is to produce pancreatic enzymes for digestion
• It secretes insulin and glucagon, which regulate blood sugar

Newborn Adaptations

• The tongue positioned to aid sucking & breathing simultaneously
• The posterior soft palate is longer which aids with milk swallowing
• The smaller oral passage controls liquid intake
• A newborn's stomach empties every 2-3 hours, requiring frequent feeding
• The newborn liver and pancreas are immature until 6 months
• Oral drugs are absorbed in the small intestine in newborns

Enzymatic Immaturity in Infants

• Amylase (carbs), lipase (fats), and trypsin (proteins) are not fully functional until about 4 months of age
• Gastric pH remains lower than adult levels until 20-30 months in infants
• The immature liver & pancreas until ~ 6 months increases hypoglycemia risk

Feeding Considerations for Infants

• No solid foods are recommended before 4 months because pancreatic lipase is not fully secreted until age 1
• Breastfeeding is preferred for easier digestion and immune benefits
• Do not give cow's milk until 1 year old

Toddlers

• Growth slows, leading to a decreased appetite
• The caloric needs drop from 108 kcal/kg (infancy) to 102 kcal/kg in toddlers
• Food jags (fixation on specific foods) are common
• Avoid force feeding or calling food bad
• It is important to conduct a physical assessment with the techniques of look, listen, percuss and palpate

Preschoolers

• Appetite fluctuations continue
• Reassure parents that picky eating is normal
• Encourage variety in the diet
• The GI system is mature enough to eat a full range of food by age 4-5
• They gain around 4 to 5 lb

School-age & Adolescents

• The GI system matures, resulting in more stable digestion
• Stools become more like adults, occurring approximately 1x/day
• The liver and spleen enlarge during growth spurts

Cleft Lip and Cleft Palate Definition

• A cleft lip (CL) is an opening in the upper lip
• A cleft palate (CP) is any opening found in the roof of the mouth

Cleft Lip and Cleft Palate Prevalence

• Cleft Lip and Palate occurs in about 5.6 per 10,000 live births
• Cleft lip is observed more commonly in males (2:1), but females more commonly have cleft palate (1:2)

Cleft Lip and Cleft Palate Risk Factors

• Maternal age >35 increases the probability
• Taking drugs like Methotrexate and seizure drugs
• Consumption of smoking and alcohol Exposure to folic acid deficiency
• Being of American Indian or Alaska Native decent

Cleft Lip and Cleft Palate Nursing Care

• Assess airway & sucking ability
• Special feeding tools are required
• There should be use of a modified short nipple for (CP) babies and a longer nipple or regular sucking for (CL) babies
• You should consult a lactation specialist

Cleft Lip and Cleft Palate Prevention

• Take folic acid Supplements (400 mcg/day)
• Do not take teratogenic medications like Methotrexate
• Do not encourage exposure to smoking or alcohol

Surgical Consideration for Cleft Lip and Cleft Palate

• CL repair at ~3 months helps promote bonding
• CP repair at ~6 months (before speech develops)

Anorectal Malformations

• Rectal Atresia: Complete obstruction that requires immediate surgery
• Anorectal Stenosis: Narrowing causes ribbon-like stool with abdominal distension and difficulty passing stool

Imperforate Anus

• Imperforate Anus is the absence of an anal opening, potentially involving fistulas to other organs Potential connections include the rectum to other organs, passage of meconium through the vagina or scrotum May not be immediately apparent at birth, identified as peristalsis forces meconium through the abdominal passage

Management of Anorectal Malformations

• Prevention is not possible
• Diagnosed through Magnetic Renaissance Imaging to rule out spinal cord issues as well as X-ray, MRI, and Ultrasound imaging to locate the defect
• Anal dilation is used for mild cases, colostomy placement with severe instances, and surgical repair is utilized is a two-stage process for high defects

Nursing Care:

• Includes NPO status, administering IV fluids, pain management, and monitoring potential infection
• Medical care involves repeated manual dilation to treat anal stenosis and potential colostomy care
• Post-operative includes monitoring vitals, intake and output, maintaining fluids, and administering NAS to resume oral feelings with fiber

Definition of Hypertrophic Pyloric Stenosis (HPS)

• It involves the thickening of the pyloric sphincter, leading to a narrowing of the gastric outlet
• This prevents stomach contents from emptying into the small intestine
• Idiopathic Hypertrophic Pyloric Stenosis (IHPS) typically manifests between 3–6 weeks of age

Hypertrophic Pyloric Stenosis (HPS): Incidence & Risk Factors

• It occurs in 3 in 1,000 live births
• More common in males with a (4:1 – 6:1 male-to-female ratio)
• 30% of cases occur in firstborn children

Hypertrophic Pyloric Stenosis (HPS): Signs & Symptoms

• A classic symptom presents with projectile vomiting
• Postprandial is a defining feature, occurring after a meal
• The vomit is notably non-bilious, forceful, and may reach several feet
• The infant experiences insatiable hunger
• The patient may be labs that can demonstrate metabolic alkalosis
• You will be able to see visible reverse peristalsis (left to right wave-like motion is LUQ).
• The infant will experience weight loss, dehydration and constipation

Hypertrophic Pyloric Stenosis (HPS): Diagnosis Physical Exam

Palpation reveals an olive-shaped, moveable, firm mass above and to the right of the umbilicus

Hypertrophic Pyloric Stenosis (HPS): Imaging

• Ultrasound (Gold standard) shows elongation & thickening of the pylorus
• A Barium upper GI series may be needed for diagnosis

Hypertrophic Pyloric Stenosis (HPS): Prevention

• There is no known protocol for prevention, however good prenatal care promotes optimal fetal development

Hypertrophic Pyloric Stenosis (HPS): Nursing Care

• It is important to monitor for dehydration via skin turgor, fontanelle, mucous membranes, urine output, and weight
• Management includes NPO status, NG tube placement, and IV fluid
• You should educate parents that vomiting is to common after the first 24-36 hours after surgery

Hypertrophic Pyloric Stenosis (HPS): Surgical Care

Pyloromyotomy is used with a laparoscopic incision of the pyloric muscle to relieve obstruction

Hypertrophic Pyloric Stenosis (HPS): Postoperative Feeding Schedule

• You should first feed Pedialyte 15 mL every 2 hours for the first 2 feeds
• You can increase to half-strength formula and increase volume if tolerated
• Slowly increase to full strength formula if all goes well

Hypertrophic Pyloric Stenosis (HPS): Education & Discharge Instructions

• You must monitor for signs of infection and keep the surgical site clean and dry
• You should also continue to monitor feeding tolerance as vomiting should be reported if excessive within 48 hours

Definition of Intussusception

• Telescoping (invagination) is when one portion of the intestine goes into another
• Most commonly found at the ileocecal valve
• It leads to obstruction, ischemia, and potential bowel perforation

Intussusception: Incidence & Risk Factors

• Most commonly, intestinal obstruction occurs in infants (6–36 months old) and may follow a recent upper respiratory infection
• Predisposing factors include polyps, Meckel’s diverticulum, constipation, lymphomas, and parasites

Intussusception: Signs & Symptoms

• Presentation includes vomiting (may become bilious, non-bilious, with obstruction), as well as a sausage-shaped mass in the RUQ (Dance’s sign) and fever

Intussusception: Classic Symptomatic Triad:

(1) involves intermittent severe abdominal pain with (2) drawing up of legs between lethargy that is relieved by (3) currant-jelly stool

Intussusception: Diagnosis

• It is best seen with an abdominal palpation (sausage-shaped mass in RUQ)
• You can assess a barium enema (Gold standard) and abdominal ultrasound before diagnosis

Intussusception: Prevention

Cannot be prevented, but prenatal care promotes fetal health.

Intussusception: Nursing Care

• Monitor for signs of perforation, peritonitis, and shock via rigid abdomen and decreased urine activity
• Monitor and record stool for passage of normal stool (indicate resolution).
• You may provide supportive care with pain control hydration

Intussusception: Medical Care

• Can include a barium or air enema is diagnostic & therapeutic (successful in 65–90% of cases)
• The child must be observed for 24 hours post procedure (risk of recurrence).

Intussusception: Surgical Care

• Surgery is required if the enema is unsuccessful
• It is carried out with a manual reduction and potential resection should necrosis be present

Intussusception: Education & Discharge Instructions

• You must monitor for signs of recurrence (abdominal pain, vomiting, and blood stools)
• It is important to maintain proper hydration and wound care

Appendicitis: Definition

• You will encounter inflammation of the appendix, most common to abdominal surgery and can obstruct ischemia with necrosis and potential rupture
• Most common found between 6–10 years of age

Appendicitis: Symptoms

• The early sign is a periumbilical pain which peaks every 4 hours then moves to the right lower quadrant
• Other signs include vomiting anorexia, mucus-like stools, constipation and a low grade fever
• Perforation is suspected if pain suddenly disappears at an emergency situation

Appendicitis: Risk Factors

• More common in boys than girls, Caucasians, with risk of perforation doubling under 5 years of age.

Appendicitis: Diagnosis

• Diagnosed with RLQ tenderness on the physical exam
• Rebound tenderness is an indication that pain increases with pressure is released
• You may also use rovings’s sign so diagnose which indicated pain with tapping LLQ
• Imaging can be done through an ultrasound or CT scan to detect inflammation

Appendicitis: Nursing Considerations

• It's important to monitor for signs of perforation
• Put your patient in NPO
• There is need for maintenance fluids

Appendicitis: Treatment

• The treatment for it involves removal of the appendix which is termed appendectomy There is potential for open-surgical repair if perforated with abscess or peritonitis

Diarrhea: Definition

• A patient is classified with diarrhea for increased stool movements with the amount of water
• It usually lasts less than 14 days an is commonly caused by infections
• Acidosis is common

Diarrhea: Symptoms

• Watery stools with nausea, vomiting, cramping, and abdominal pain will be encountered
• They can also present with mucus membranes is feverish and in lethargy
• There should be a medical history taken

Diarrhea: Diagnostics

You can use a culture to assess the bacteria and parasites

Diarrhea: Treatment

Supportive treatment that includes hydration and encourage Pedialyte Avoid sugar as it provides support

Diarrhea: Education

Proper hygiene for utensils and food handling needs to practiced Resume normal diet

Chronic Diarrhea Definition

Requires two weeks lasting with infections and allergic

Vomiting Signs/Symptoms

• Look for non-bilious for infections and metabolic problems
• Observe for bilious vomiting, which indicates obstruction
• Hematemesis should prompt you for an esophageal and esophageal assessment.

Constipation Definition

• Is infrequent passage of loose stools
• Can lead to hard stool
• Must be occurring for 2 weeks

GI: Interventions

• You should monitor for pain and fluid overload
• Do not give laxatives
• The use of antibiotics can increase the infection rate