Digestive Tract Disorders PDF

# Digestive Tract Disorders **Dr. Doaa Abdelgawad Said** **Assistant Professor of Pediatric Nursing** **Pediatric Nursing Department** ## Diarrheal Disorders - Diarrhea is a symptom that results from disorders involving digestive, absorptive, and secretory functions. - Diarrhea is caused by abnor...

# Digestive Tract Disorders **Dr. Doaa Abdelgawad Said** **Assistant Professor of Pediatric Nursing** **Pediatric Nursing Department** ## Diarrheal Disorders - Diarrhea is a symptom that results from disorders involving digestive, absorptive, and secretory functions. - Diarrhea is caused by abnormal intestinal water and electrolyte transport. - Worldwide, there are an estimated 1.7 billion episodes of diarrhea each year. ## Diarrhea is defined as - An increase in the fluidity, volume, and number of stools relative to the usual habits of each individual. Frequent passage of formed stools can’t be considered as diarrhea. - Exclusively breast-fed babies often pass several loose (pasty) or semi-liquid stools each day, this is also not diarrhea. However, it is the consistency rather than the number of stools that is the most important feature. ## Morbidity and Mortality in Egypt **Morbidity** - Seasonally adjusted diarrhea incidence was 3.6 episodes per child under five years of age per year. - This means a minimum estimate of 30 million cases annually in Egypt. **Mortality** - Diarrheal disease is a major cause of death in children in the developing world, including Egypt, a quarter of infant and childhood mortality is related to diarrhea. - It is estimated that 15000 Egyptian infants and preschool children die yearly from diarrhea (about 42 deaths every day), 80% of them being in the first two years of life. ## Seriousness of diarrheal disorders during infancy - With limited intake and/or extra loss of fluid during diarrhea, the child may have: - **Acute dehydration** - **Malnutrition:** mothers may not feed their children during the episode or even for some days after the diarrhea improves. ## Incidence of diarrhea - The peak incidence of diarrhea is between 6 months to 2 years. This is due to: 1. Declining level of maternal antibodies. 2. Exposure to enteric pathogens through contaminated weaning food. 3. The pleasure of picking-up contaminated objects and putting them in the mouth while crawling. ## N.B - Teething is not a cause of diarrhea. Diarrhea that occurs during teething is usually caused by an intestinal infection, so it should be treated properly. - The lifespan of intestinal mucosal cells is 3-5 days. New normal cells will replace the destroyed cells damaged by toxins, within this period. That is why diarrhea is usually a self-limited disease of 3-5 days duration self-limited. ## Factors that predispose to diarrhea 1. **Age:** As a rule, the younger the child, the greater the susceptibility, and the more severe the diarrhea. 2. **Impaired health:** Malnourished or immunocompromised children are more susceptible and tend to have more severe diarrhea. 3. **Environment:** Diarrhea occurs with greater frequency where there is crowding, substandard sanitation, poor facilities for preparation and refrigeration of food, and generally inadequate health care education. ## Types of Diarrhea Diarrheal disturbances involve the: - Stomach and intestines **(gastroenteritis)** - The small intestine **(enteritis)**. - The colon **(colitis)**. - The colon and intestines **(enterocolitis)**. ## Classification of diarrhea: - **Acute.** - **Dysentery.** - **Chronic.** ## Acute diarrhea - It's defined as a sudden increase in frequency and a change in consistency of stools and is usually self-limited (14 days’ duration) and subsides without specific treatment if dehydration does not occur ## Causes of acute diarrhea: **Infection and Parasitic Infestation as**: - ✓ **Bacteria**-Salmonella, Shigella, Staphylococcus aureus. - ✓ **Viruses**-Rotavirus, parvovirus. - ✓ **Parasites**-Giardia lamblia, Entamoeba histolytica. ## Associated Conditions **Infections:** - Upper respiratory tract infections. - Urinary tract infections. - Otitis media. ## Dietary Causes - Overfeeding. - Introduction of new foods. - Reinstituting milk too soon after diarrheal episode. - Osmotic diarrhea from excess sugar in formula or juice. ## Medications as: - Antibiotics - Laxatives ## Toxic as: - ingestion of heavy metals (lead, mercury) ## Functional as: - irritable bowel syndrome ## Other as: - hirschsprung enterocolitis ## Dysentery: - This is diarrhea with visible fresh blood in the stool. Its squeal includes anorexia and damage to the intestinal mucosa. ## Chronic diarrhea - Chronic diarrhea is an increase in stool frequency and increased water content with duration of more than 14 days. - Chronic nonspecific diarrhea (CNSD), also known as irritable colon in children 6 to 54 months of age (4.5 years). ## Causes of chronic diarrhea: - **Malabsorptive Causes** as Lactose intolerance, pancreatic insufficiency - **Allergic Causes** as allergic gastroenteropathy, Eosinophilic gastroenteritis - **Immunodeficiency:** as human immunodeficiency virus or acquired immunodeficiency syndrome - **Inflammatory Bowel Disease** as ulcerative colitis. - **Endocrine Causes** as hyperthyroidism, congenital adrenal hyperplasia - **Motility Disorders** as Hirschsprung disease. - **Parasitic Infestations** as ascaris organisms giardia organisms - **Other Causes** as radiation enteritis, abdominal tumors ## Complication of diarrhea: - **Dehydration** - **Malnutrition** ## Dehydration - It is one of the consequences of watery diarrhea. It is caused by the loss of water and electrolytes in liquid stools and vomiting. - Fever can make it worse as it causes additional loss of water. - Dehydration can lead to hypovolemia, cardiovascular collapse, and death if not treated promptly. ## Types of dehydration | | Description | | :-- | :------------------------------------------------------------------------------------------------- | | □ | **Isotonic** (isosmotic or isonatremic) dehydration: occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportions. | | ✓ | Water and sodium are lost in approximately equal amounts. | | □ | **Hypotonic** (hyposmotic or hyponatremic) dehydration: occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. | | □ | **Hypertonic** (hyperosmotic or hypernatremic) dehydration: results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. | ## Nursing management of diarrhea **Nursing Assessment** It includes taking the child's history, measuring weight, and temperature, and assessing the degree of dehydration. **1- History** - Personal characteristics (age and sex) and socioeconomic background (home environment, income, education, occupation, beliefs… etc.). - Duration of the episode. - Frequency and consistency of stool. - Presence or absence of mucus, pus or blood in stool. - Child's ability to drink and or presence of thirst. - Presence of vomiting, fever or other problems (cough, otitis media). - Last time urine passed. - Feeding practices before and during illness. - Treatment during this episode (ORS, drugs). - Vaccination taken especially measles vaccine. **2- Assessment of the degree of dehydration** Assessment of the degree of dehydration is based on four signs which are the most important to be detected: | Signs | A | B | C | | :-------------------- | :----------------------------------------------------------------------------------------------------------------------------- | :-------------------------------------------------------------------------------------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------------------- | | G-General condition | No signs of dehydration loss < 5% of body weight | Some dehydration loss 5-10% of body weight | Severe dehydration loss > 10% of body weight | | | Well and alert | Restlessness and irritable | Lethargic, floppy unconscious | | E- Eyes | Normal | Sunken | Very sunken and dry | | M- Thirst | Drinks normally | Thirsty, drinks eagerly | Drinks poorly or unable to drink. | | S-Skin pinch | Goes back quickly | Goes back slowly | Goes back very slowly (>2 seconds). | | Decide | Child has no sings of dehydration (Mild) | If 2 or more signs are present, there is moderate dehydration. | If 2 or more signs are present there is severe dehydration. | | Select treatment plan | Plan A | Plan B | Plan C | **Other signs that are used in the assessment of dehydration are:** 1. **Anterior fontanel:** normal depressed or severely depressed. 2. **Mucous membrane of the mouth and tongue:** moist, dry or very dry. 3. **Tears:** present in mild dehydration, absent in severe dehydration. 4. **Pulse (radial)** as dehydration increases, pulse becomes more rapid. In severe dehydration pulse becomes weak. 5. **Extremities:** in severe dehydration, skin becomes cool and moist and the nail bed may be cyanosed. 6. **Breathing:** rapid deep breathing is a sign of acidosis. **3-Weighing ** - Is essential as it helps to estimate the amount of fluid required, for an initial rehydration. Patient should be weighted to the nearest 50-100 grams in the beginning of the assessment and reading should be recorded. Towards the end of rehydration, the child should have gained weight. ## Diagnostic Evaluation To initiate a therapeutic plan, several factors must be determined: - The degree of dehydration based on physical assessment - The type of dehydration based on the pathophysiology of the specific illness responsible for the dehydrated state - Specific physical signs other than general signs - Initial plasma sodium concentrations - Serum bicarbonate concentration (CO2) - Any associated electrolyte (especially serum potassium) and acid-base imbalances (as indicated). ## Therapy of dehydration **Oral rehydration** The rehydration therapy in the form of ORS is considered an effective treatment of dehydration, it is a mixture of water, glucose, and electrolytes and is used to correct or prevent dehydration. **Glucose is added (2%) to promote sodium absorption.** Increasing the concentration of glucose by 2% increases the osmolality of the solution and may cause osmotic diarrhea. **Composition of ORS** | Components G/L | Amount G/L | | :---------------------- | :---------- | | Sodium chloride. | 3.5 G/L | | Tri-sodium citrate. | 2.9 G/L | | potassium chloride | 1.5 G/L | | Glucose | 20.0 G/L | **N.B.** The use of citrate increases the shelf life of ORS and therefore lowers its cost. Tape water is used to dissolve the mixture and needs no boiling. It is given by cup and spoon, but it can be given by nasogastric tube when the patient is unable to drink but not in shock. **N.B.** - The use of citrate increases the shelf life of ORS and therefore lowers its cost. - Tape water is used to dissolve the mixture and needs no boiling. It is given by cup and spoon, but it can be given by nasogastric tube in the following conditions: - When the child is unable to drink but not in shock. - When the child has severe repeated vomiting, or if dehydration is not improving when ORS is given slowly by cup and spoon. ## Intravenous rehydration takes place in the following conditions: - Severe dehydration. - Failure of oral rehydration due to extreme fatigue, coma, uncontrollable vomiting, unimproved, or worse signs of dehydration and glucose mal-absorption. ## Treatment plan | Treatment | Plan A | Plan B | Plan C | | :---------------- | :----------------------------------------------------------------------------------------------------------------------------- | :-------------------------------------------------------------------------------------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------------------- | | Where | At home | In outpatient rehydration center | In hospital | | 1- Fluid therapy | Give more fluid than usual | Gives ORS | Give IV fluids | | What type | Homemade fluids (rice, water, tea without sugar, soup, and yogurt). | | Pansol Ringer's lactate. Normal saline | | How much | Give after each loose stool for child <2 years: 50-­­100ml <br> -For child > 2 years:100­–200 ml. | 75 ml/kg body weight in 4 hours. | 100 ml/kg of body wt. given in 3 – 6 hrs. <br> 1st 30 ml/kg given in 1/2 to 1 hr. <br> Next 70 ml/kg given in 2.5 – 5hrs, longer time is used for infant < 1 year. (Ν.Β*) | | How given | Slowly (1spoon/1-­­2 min) <br> By cup, spoon, cup alone, dropper, or | Slowly (1spoon/1-­­2 min) by cup and spoon, cup alone, dropper/syringe. Nasogastic tube. | I.V. | ## Feeding: - Breastfeeding should never be stopped even during initial rehydration. Milk or milk formula given as usual (after rehydration). - Soft and semisolid weaning food usually taken by the child, should be given after rehydration (yogurt, mashed potatoes, rice pudding, cereals, vegetable soup and beans). **Avoid giving too sweaty food, or food with high fiber content.** ## Advice the mother to bring the child to a health facility: - Frequent large stools. - Repeated vomiting - Increased thirst - No improvement after days - Bloody stool . - Fever. **N.B.** Infant under 12 months: first give 30 ml/kg in 1 hour, then give 70 ml/kg in 5 hours. ## Further assessment: - Reassess the patient's condition when there is: - No signs of dehydration shift to plan A. - Some dehydration shift to plan B. - Severe dehydration shift to plan C. ## Guidance during interventions - Mothers should be taught how to give ORS (one teaspoonful every 1-2 minutes, and the child should be in a semi-sitting position). - Give ORS as much as he desires. - If vomiting occurs, wait 10 minutes, and then continue giving ORS but more slowly (one teaspoonful every 2-3 minutes). - Watch for puffy eyes as a sign of over hydration. If this occurs, stop ORS solution and give breast-feeding and plain water. When puffiness is gone, the child is considered fully hydrated. Further treatment should follow treatment plan A. ## Feeding during and after the episode 1. During diarrhea, give the child as much food as he wants. 2. Offer food every 3-4 hours. 3. Small frequent feeding is better tolerated than less frequent, and large feedings. 4. Children with anorexia have to be gently encouraged to eat. 5. After stoppage of diarrhea, give one extra meal per day for 2 weeks in normal child and for longer periods in malnourished one. ## Advantage of continued feeding during diarrhea - **Preserves body weight and sustains growth,** thus maintaining strength and health avoiding lowered resistance. - **The contact of foodstuffs with the gut mucosa protects** its absorptive capacity, and stimulates the production of digestive **enzymes**. - **Easily digestible foods may enhance intestinal salt and water absorption by** providing organic molecules, which facilities their absorption. - **Studies have shown that continued feeding actually hastens recovery from a diarrheal episode.** ## Assessment of the progress of rehydration - The patient's progress should be assessed at least every hour. - The signs of a satisfactory response are: 1. **Return of a strong radial pulse.** 2. **Improved consciousness level.** 3. **Ability to drink.** 4. **Much improved skin turgor.** 5. **Passage of urine** ## Drugs therapy in diarrhea - Those called anti-diarrheal drugs (e.g., Antibiotics, Anti-diarrheal, Anti-motility, & Anti-emetics) should never be given to the child. Nothing more than ORS solution, and continued feeding, is needed in the vast majority of cases. - Substances like bismuth, and chalk mixture may modify the characteristics of stool but not their frequency, amount or water content. The mother may believe that the condition has improved and focuses on the stool, and not the state of hydration. ## Prevention of diarrhea 1. **Promotion of breast-feeding** 2. **Improved weaning practices** 3. **Proper use of water for hygiene, and drinking** 4. **Personal hygiene** 5. **Use of latrines** 6. **Measles vaccination** ## Thank you.