Gastrointestinal System Disorders Among Children PDF

Gastrointestinal System Disorder Among Children by Dr. fatma Ahmed  Objectives: At the end of this lecture, the participants will be able to:  1- Identify the anatomy and physiology of gastrointestinal system in children.  2- Identify the common gastrointestinal pro...

Gastrointestinal System Disorder Among Children by Dr. fatma Ahmed  Objectives: At the end of this lecture, the participants will be able to:  1- Identify the anatomy and physiology of gastrointestinal system in children.  2- Identify the common gastrointestinal problems in children (diarrhea, sever gastroenteritis , Hepatitis A and dehydration).  3- List the etiology, clinical manifestation of these disorders.  4- Apply nursing intervention for these disorders among children.  Introduction  Digestive disorders affecting infants and children range from simple problems that most children experience from time to time, such as ordinary vomiting or diarrhea, to more serious illnesses. Digestive disorders can have significant effects on the health of a child. A healthy digestive system processes the foods and liquids that we eat, vitamins, minerals, proteins, carbohydrates, and fats that are vital for the body to function properly. The Digestive System - An Overview What is digestion?  Food and drink must be changed into smaller molecules of nutrients to be absorbed into the blood and carried to cells throughout the body. Digestion is the process by which food and drink are broken down into smaller parts so that the body can use them to build and nourish cells, and to provide energy. How does the digestive process work? Digestion involves: The mixing of food. The movement of food through the digestive tract. A chemical breakdown of large molecules of food into smaller molecules. Digestion begins in the mouth, where food and drink are taken in, and is completed in the small intestine. What is included in the digestive system? The digestive system is made up of the digestive tract and other organs that aid in digestion. The digestive tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus, consisting of the following: mouth esophagus stomach small intestine large intestine (includes the colon and rectum) anus Cont, Organs that help with digestion, but are not part of the digestive tract, include the following: tongue glands in the mouth that make saliva pancreas liver gallbladder Parts of other organ systems, like nerves and blood, also play a major role in the digestive process. How does food move through the digestive system? In a wave-like movement called peristalsis, muscles propel food and liquid along the digestive tract. In general, there are six steps in the process of moving food and liquid through the digestive system: 1- The first major muscle movement is swallowing food or liquid. The start of swallowing is voluntary, but once it begins, the process becomes involuntary and continues under the control of the nerves. 2- The esophagus, which connects the throat above with the stomach below, is the first organ into which the swallowed food goes. 3- Where the esophagus and stomach join, there is a ring like valve that closes the passage between the two organs. When food nears the closed ring, the surrounding muscles relax and allow the food to pass into the stomach, and then it closes again. 4- The food then enters the stomach, which completes three mechanical tasks: stores, mixes, and empties. First, the stomach stores the swallowed food and liquid, which requires the muscle of the upper part of the stomach to relax and accept large volumes of swallowed material. Second, the lower part of the stomach mixes up the food, liquid, and digestive juices produced by the stomach by muscle action. Third, the stomach empties the contents into the small intestine. 5- The food is digested in the small intestine and dissolved by the juices from the pancreas, liver, and intestine and the contents of the intestine are mixed and pushed forward to allow further digestion. 6- Last, the digested nutrients are absorbed through the intestinal walls. The waste products, including undigested parts of the food, known as fiber, and older cells that have been shed from the mucosa, move into the colon. Waste products usually in the colon remain for a day or two until the feces are expelled by a bowel movement. Common Children's Digestive Problems There are many problems that may affect a child's digestive system that require clinical care by health care professional. Diarrhea: Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Diarrhea is a hallmark sign o gastroenteritis. Incidence of diarrhea:- Approximately 24% of all deaths in children living in developing countries are related to diarrhea and dehydration.   The causes of diarrhea:  can develop after eating contaminated food or putting a contaminated object (or hand) into the mouth. The viruses that commonly cause gastroenteritis are spread easily. Careful hygiene (especially hand washing) can prevent these infections from spreading.  Lack of clean water, poor hygiene, nutritional deficiency, and poor sanitation are major risk factors, especially for bacterial or parasitic pathogens.  Diet over feeding, unbalanced diet, e.g. fat and carbohydrates in formula, unclean or unsterile technique in preparing diet.  `Specific infection as Salmonella, or Shigella organism or viral infection.  Sometimes as a result of administration of antibiotics.  Intestinal parasites. If there is blood or mucous in the stools, bacteria may be a source for the diarrhea. Parasites may also cause diarrhea. Stool cultures will often be obtained if the diarrhea is present more than one week, if there is a history of exposure to some bacteria There is sudden onset, within 1 to 6 hours, of a lot of diarrhea, abdominal cramps and nausea or vomiting. The symptoms improve within 8 to 24 hours.  or parasite, or if there is blood or mucous in the stools.  Metabolic disorders hyperthyroidism.  Emotional disorders.  Clinical manifestation of Diarrhea:  Most intestinal infection is Acute: Assessment: Patient may manifest  1. Onset of diarrhea may be sudden usually accompanied by vomiting and low grade fever.  2. Hyperactive bowel sounds and sometime abdominal distention Passage of loose liquid watery stools for more than 3 times  Poor skin turgor  Dehydration associated electrolyte disturbances depend on the severity and types of dehydration.  Dry lips and oral mucosa  cries as if in Pain and irritable  Stomach cramping  Therapeutic Management :  The major goals in the management of acute diarrhea include  1. Assessment of fluid and electrolyte imbalance.  2. Rehydration.  3. Maintenance fluid therapy, and  4. Reintroduction of an adequate diet.  Nursing Management of Diarrhea:  Nursing Assessment:  It includes taking the patients history, measuring weight and temperature and assessing the degree of dehydration. History:  1. Personal characteristics (age and sex) and socioeconomic background (home environment, income, education, occupation, beliefs etc.). 2. Frequency and consistency of stool.  3. Presence or absence of mucus, pus or blood in stool.  4. Patient’s ability to drink and or presence of thirst.  5. Presence of vomiting, fever or other problems (cough, otitis media). 6. Feeding practices before and during illness.  7. Treatment during diarrhea (ORS, drugs antiemetic during vomiting). Prevention of diarrhea: The prevention of diarrhea is important, as it has proved to be effective in lowering diarrhea morbidity at the national and personal level. It includes the following: 1) Promotion of breast-feeding: breast-feeding should be exclusive for the first 6months and continued for at least 2 years. Breast-feeding should be continued during illness, including diarrhea. If formula feeding is necessary, mothers should be properly instructed regarding, the choice, preparation and sterilization of feeding bottles and milk formula. 2) Improved weaning practices: Start giving weaning foods at 4-6 months of age (6 moths for breast feeding and 4 months in bottle feeding). Proper choice of weaning foods: nutritive value, digestibility, suitability to age and acceptability. Proper hygiene measures in preparing giving and storing weaning foods minimize the risk of bacterial contamination. Prevent weaning in hot weather (it is flies cont, Prevention of diarrhea: 3)Proper use of water for hygiene and drinking: helps to-encourage hygiene practices such as hand washing, cleaning of eating, and water. Store drinking water in clean covered containers protected from animals and children. Water for drinking, if suspected of being contaminated, should be boiled for a few seconds. 4) Personal hygiene: Washing hands after defection, after cleaning a child who has defecated, and before preparing food or feeding a child. Also hands of children should be washed. 5) Measles vaccination: Because of the strong relationship between measles and serious diarrhea, measles immunization is a very cost effective measure and can prevent 25% of diarrhea associated deaths in children under 5 years of age.  Dehydration  Definition of dehydration:-  It is one of the consequences of watery diarrhea.  It is caused by the loss of water and electrolytes in liquid or loss stools and vomitus. Fever can make it worse as it causes additional loss of water. Dehydration is the key to treating vomiting at home is to avoid dehydration.. It depends on the size of the child, how much they are vomiting and if they are keeping some fluids down.  Types of Dehydration:  1. Isotonic (Isonatermic) dehydration: this is the most common result of acute watery diarrhea (more than 75% of cases). Deficits of water and sodium are balanced (water loss = sodium loss).   2. Hypertonic (Hypernatremic) dehydration: Loss of water is greater than that of sodium. The condition is more common in young infants who can’t verbally ask for water. It results from the intake of large a mounts of hypertonic fluids (high content of sodium or sugar) during diarrhea.  3. Hypotonic (Hyponatermic) dehydration: It is less common and the loss of sodium is greater than that of water. This result from the intake of large a mount water or Hypotonic fluids during diarrhea. Clinical Assessment of Severity of Dehydration : Signs and Symptoms Mild Dehydration Moderate Dehydration Severe Dehydration General Appearance Signs of mild dehydration include: A slightly dry mouth Thirst Children who are mildly dehydrated do not need immediate medical attention but should be monitored for signs of worsening dehydration. Signs of moderate or severe dehydration include: Decreased urination (not going to the bathroom or no wet diaper in six hours) A lack of tears when crying A dry mouth Sunken eyes Cool hands and feet Listlessness may be comatose  Management of Dehydration: Oral rehydration therapy — Oral rehydration therapy (ORT) was developed as a safer, less expensive, and easier alternative to intravenous (IV) fluids. Oral rehydration solution (ORS) is a liquid solution that contains glucose (a sugar) and electrolytes (sodium, potassium, chloride), which are lost during vomiting and diarrhea. ORS does not cure vomiting and diarrhea, but it does help to prevent and treat the dehydration that can develop because of a vomiting illness. Give the fluid by teaspoonful (5 milliliters each) every one to two minutes or as tolerated. The recommended amount is 50 milliliters of ORS per kilogram For a (9 kg) child, (450 milliliters) of ORS. This amount should be given gradually, spread out over about four hours. Measure the solution with a standardized medicine syringe or measuring cup or spoon, rather than a regular cup or spoon. After given the whole amount, the child can eat a normal diet. Children who refuse to drink or who vomit immediately after drinking ORS should be monitored closely for dehydration. Children who are not dehydrated can continue to drink ORS between episodes of vomiting to prevent dehydration. Hygiene measures — Hand washing is very effective and the preferred way to prevent the spread of infection.  assessment of dehydration: 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 increase, pulse becomes more rapid. In severe dehydrate pulse becomes weak. 5. Extremities: in severe dehydration, skin becomes cool and the nail bed may be cyanosed. 6. Breathing: rapid deep breathing is a sign of acidosis. 7. Weight is essential, as it helps to estimate the amount of fluid required for an initial re-hydration. assessment and recorded. Towards the end of re-hydration, the child should have gained weight.  Guidance during intervention: Mothers should be taught how to give ORS (one teaspoonful every 1-2 minutes and the child should be in a semi-sitting position). If vomiting occurs, wait 10 minutes, and then continue giving ORS solution 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. feeding during and after the episode: 1) During diarrhea give the child as much food he wants but Small frequent feedings 2) Children with anorexia have to be gently encouraged to eat. 3) Apple, pear, and cherry juice, and other beverages with high sugar content, should be avoided. High fat foods are more difficult to digest, and should be also avoided. Sports drinks should also be avoided since they have too much sugar and have inappropriate electrolyte levels. Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, and bread), lean meats, yogurt, fruits, and vegetables. The patient’s progress should be assessed at least every hour. The signs of a satisfactory response are:  Return of a strong radial pulse.  Improved consciousness level.  Ability to drink.  Much improved skin turgor.  Passage of urine.  Severe gastroenteritis Introduction: Gastroenteritis is a common worldwide problem. Five millions of children under the age of 5 years die every year with the complications of severe gastroenteritis. Most of these deaths occur in underdeveloped countries where nutritional deficiencies and environmental pollutions are common.  Diagnosis: Diagnosis of gastroenteritis is clinical and depends on the presence of acute diarrhea with or without fever and vomiting. Accurate diagnosis should include assessment of severity (mild, moderate, severe), possible causative organism (bacterial, viral, parasitic), and the associated complications. 1- Bacterial gastroenteritis: The possibility of bacterial enteritis is considerable when the fever is above38.5°C and the diarrhea is severe or bloody. The main causative, organisms are shigella, salmonella, E.coli. 2- Viral gastroenteritis: Fever is usually below 38°C and the diarrhea is usually watery and not severe. Rotavirus is by far the most common causative agent. 3- Parasitic enteritis: Clinical manifestations depend on the causative agent. the diarrhea is usually watery, foul-smelling, not severe and not associated with fever. diarrhea is commonly bloody but fever is absent.   Diagnosis of complications:  Several complications are common with severe gastroenteritis and are responsible for the high morbidity and mortality. These complications are most common in infants with severe bacterial gastroenteritis. 1- Dehydration, electrolyte disorders and acute renal failure. 2- Shock (circulatory failure), Convulsions , Coma: due to severe dehydration and electrolyte disturbance.  3- Bleeding  4- Persistent diarrhea: Persistent infection, malabsorption, malnutrition  Management: Mild and moderate cases of gastroenteritis can be safely managed at home. Prevention of dehydration, dietetic management and symptomatic treatment (fever, vomiting) are the main lines of therapy. Follow-up and re-evaluation within few days is important to identify deteriorating cases requiring hospital management. Severe cases should be hospitalized, closely monitored and urgent managed. 1. I.V. fluid therapy: It is indicated for treatment of shock, correction of dehydration, and treatment of electrolyte disorders. 2. Antibiotic therapy: is indicated in patients with high persistent fever especially when associated with early septic shock or laboratory manifestations suggesting severe bacterial infection. Ampicillin (100 mg/kg/day), or cefotaxime (100 mg/kg/day), I.V. in 2-3 divided doses. Therapy is continued for at least 5 days. 3. Treatment of complications: renal failure, convolutions and bleeding are common complications in severe cases.  Hepatitis: The word "hepatitis" means inflammation of the liver and also refers to a group of viral. infections that affect the liver. Viral hepatitis is a major health problem in developing and developed countries. The most common types are Hepatitis A, Hepatitis B, and Hepatitis C. Hepatitis A (HAV) The most common type found in children is hepatitis A which is transmitted by the fecal- oral route. The incidence in children increases in those living in crowded housing. It frequently occurs in small outbreaks caused by fecal contamination of food or drinking water by an infected food handler. It found in feces 2 or more weeks before the onset of symptoms and up to 1 week after the onset of jaundice. The virus is present in feces during the incubation period, so it can be carried and transmitted by persons who have undetectable, subclinical infections. Signs and symptoms of hepatitis:  It precedes jaundice and lasts from 1 to 21 days. This is the period of maximal infectivity for hepatitis (HAV). nausea; anorexia; fever; malaise; headache; right upper , discomfort; enlargement of the spleen, liver and lymph nodes; weight loss.  It lasts 2 to 4 weeks and is characterized by jaundice. Jaundice results when bilirubin diffuses into the tissues. The urine may darken because of excess bilirubin being excreted by the kidneys. The stool will be light colored, if conjugated bilirubin cannot flow out of the liver because of obstruction or inflammation of the bile ducts.  The convalescent stage of the begins as jaundice is disappearing and lasts weeks to months, with an average of 2 to 4 months. During this period the patient’s major complaint is malaise and easy fatigability. Hepatomegaly remains for several weeks, but splenomegaly subsides during this period. the disappearance of jaundice does not mean the patient has totally recovered  Diagnosis: Diagnosis is based on: o 1- the history (especially regarding possible exposure to a hepatitis virus) o 2- physical examination o 3- serologic markers (antibodies or antigens) indicating the presence of active infection with hepatitis A, previous infection. o 4- liver function tests o 5- bilirubin elevated, prothrombin time, and S. Albumin (not effect except in severe cases) Prognosis: The prognosis for children with hepatitis is variable and depends on the type of virus, the child’s age, and immunocompetence.  Management: The goals of management include early detection, support and monitoring of the disease, and prevention of spread of the disease. The pediatric nurse has an important role for promoting knowledge about viral hepatitis through instruct parents and children for Personal hygiene helps prevention of transmission, particularly fecal-oral transmission, as occurs with HAV performing proper hand washing before meals and after using bathroom the toys may become contaminated and it should not be shared  Cont, Management: use disposable gloves when handling blood, excrete any other body fluids. use disposable dishes, wash linens in hot soapy water and rinse well and dry separate child’s personal hygiene articles from other members of household. Teach parents and child of signs and symptoms of disease, how disease is transmitted, dietary inclusions of protein and carbohydrate, activity program and signs, symptoms of disease recurrence (pain, anorexic fever, nausea and vomiting, jaundice) to report.