Gastrointestinal Disorders in Children PDF

Gastrointestional Disorders in Children  Hirshprung’s Disease (congenital aganglionic megacolon) Hirshprungs Disease Mechanical obstruction caused by inadequate motility of part of the intestine No nerve...

Gastrointestional Disorders in Children  Hirshprung’s Disease (congenital aganglionic megacolon) Hirshprungs Disease Mechanical obstruction caused by inadequate motility of part of the intestine No nerve fibers= decreased peristalsis (accumulation of stool in this portion) it includes the rectum and proximal portiion  Incidence ¼ of all neonatal obstruction but may not be diagnosed until later in infancy or childhood More common in children with Downs Syndrome 4x more common in males 1 in 5,000 births  Pathophysiology Absence of ganglionic cells in one or more segments of the colon Etiology unknown Results in absence of propulsive movements (peristalsis) leading to accumulation of intestinal contents & distention of bowel proximal to defect (megacolon)  Internal anal sphincter fails to relax Intestinal distention and ischemia of bowel wall leads to enterocolitis (inflammation of small bowel and colon) which is leading cause of death in children with Hirshprungs  Signs and Symptoms Newborn period *Failure to pass meconium within 24 to 48 hrs. after birth - *Reluctance to ingest fluids *Bile-stained vomitus *Abdominal distention monitor abdominal girth in this infant.  Infancy failure to thrive constipation abdominal distention episodes of diarrhea and vomiting fever severe exhaustion  Childhood Constipation Ribbon-like, foul-smelling stool Abdominal distention Visible peristalsis Fecal masses easily palpable Poorly nourished child and anemic  Diagnosis Rectal exam - tight internal sphincter and absence of stool Barium enema-contrast enemas should be avoided if patient has enterocolitis can cause peritonitis Anorectal manometry looking for relaxation of anal sphincter Definitive diagnosis is rectal biopsy looking for absence of ganglionic cells  Treatment temporary ostomy is the surgery Pull through surgery Pull-through Surgery done through rectum; pull out bowels  Enterocolitis Inflammation of intestine & colon Asses for signs of perforated bowel *vital signs – shock *absent bowel sounds, distention & tenderness *vomiting *irritable, dyspnea & cyanosis *fever – NO RECTAL TEMPS  Irrigations for Enterocolitis in Children with Hirschsprung Disease If your child has Hirschsprung disease they can get an infection in the large intestine called enterocolitis that may make them very sick. The symptoms of enterocolitis are: Fever Swollen belly (distention) Constipation (not stooling) Vomiting Explosive diarrhea Foul smelling stool or gas A colonic irrigation is used to clear the bowels when there is a concern for enterocolitis. This is done by using small amounts of salt water (saline) injected into the rectum through a large tube (catheter) to irrigate the colon. It is different from an enema, which uses a large amount of saline with a stimulant, such as soap, to cause your child to have a large bowel movement. You should give your child a colonic irrigation first, following the steps on page 2, and then call your doctor. While your child has symptoms of enterocolitis, you will need to irrigate 3 times a day or more often, if needed. If your child recently had surgery for Hirschsprung disease, do not give your child a colonic irrigation for at least 2 to 4 weeks after surgery. If it has been less than 4 weeks since your child’s surgery and they have symptoms of enterocolitis, take your child to your local Emergency room to be seen right away.  Post–op Care Colostomy care Prevent contamination of wound with urine Impaired skin integrity due to incontinence NPO until bowel sounds return or flatus passed – IV fluids Pain control Strict I&O really good skincare; https://www.youtube.com/watch?v=nxeEkO1xf7c  Gastroesaphegeal Reflux * Dysfunction of LES * Delayed gastric emptying * Poor clearance of esophageal acid * Susceptibility of esophageal mucosa to acid injury  Etiology trachea is connected to stomach can look like respiratory distress Prematurity,tracheal-esphogeal atresia, neurological disorders, can cause a decrease in messages from brain to sphincter. (its not telling the spchinter to close) scoliosis, asthma, CF Partial or incomplete swallowing dysfunctions Theophylline & caffeine Increased abdominal pressure tumor Infants with short LES most common cause  Incidence 3% of all newborns Peaks between 1-4 months of age Usually resolves by 6-12 months of age they start to sit up at 6-12 months and introduction of solid foods which is why it gets Boys affected 3x better more than girls  Signs and Symptoms Vomiting Weight loss, FTT Irritable because of aspiration; near threating life event; increase in mucous production = apnea which Respiratory illness causes bradycardia. Coughing, choking, apnea, bradycardia Hiccups Recurrent weight loss Heme (+) stools ulcerations can cause blood in the stools Sandifer’s syndrome behavioral resolves in 24 months. modication or attention to feeding is important Sandifer’s Syndrome Torticollus and acid reflux this is how is perscribed hyperextension and torticolus sx: mimic seizures this looks like they are having a seizure and might be confused occurs in less 1% and can result in an increase in anticonvulsant medication (its sx after feedings is a tell tell sale. important to do a reflux workup) average duration is 1-3 minutes  Diagnostic Tests Radionuclide tests monitoring of brain waves 24 hour esophageal ph monitoring This is the gold standard. looking at percentage of time the PH is under 4 # of episodes the PH is lower than 4 longer than 5 mins duration of episode the PH is under 4 Endoscopy & esophageal biopsy looking to detect esophogitis and duodneum inflammation  Management Depends on severity *Thriving infant w/o respiratory complication >Small frequent feedings >Thickened feedings with rice cereal >Positioning with HOB elevated Position and feedings! Failure to Thrive infants with severe reflux, who failed to respond to medical therapy or have an anatomic abnormality contributing to symptoms * NG feedings and/or surgery (Nissen Fundoplication) Nissen Fundoplication gas bloat syndrome is a complication gas gets built up and they have to loosen fundiplicaiton  Medications all of these meds are given 30 minutes before meals H2 blockers – cemetidine(Tagamet), famotidine (Pepcid) approved for under 1yr of age Proton pump inhibitors - omeprazole (Prilosec), lansoprazole (Prevacid) after 1yr of age they don't develop tolerance Prokinetic – metoclopramide (Reglan) this is given if they have delayed gastric emptying zantac has carcinogens =taken off market  Nursing Risk for aspiration elevate HOB Impaired swallowing Acute painkeep them elevated to reduce relux Imbalanced nutrition Knowledge deficit most parents are taught how to do CPR due to side effects of bradycardia and aspiration Parental anxiety offer parent an at home apnea monitor at night to relieve some anxiety Sandifer’s Syndrome https://www.youtube.com/watch?v=Pc1im_tZKEE Crohn’s Disease  Pathophysiology Chronic inflammatory Disease Occur in any part of GI tract from mouth to anus, with ileum, colon & rectum most common Transmural involving all 3 layers of mucosa  Etiology Unknown Triggers – viral & infectious agents, food allergies and immunological dysfunction Stress Genetic influence: IBD susceptibility genes More common in whites, 3-6x more common in Jewish descent Men = women, runs in families  Signs and Symptoms Abdominal pain with cramps, diarrhea, weight loss & poor growth Fever, anorexia, rectal bleeding, perianal discomfort and fissures or fistulas to other loops of bowel, bladder, vagina or skin Extraintestinal – erythema nosdosum, large jt. arthritis, mouth ulcers, liver disease, renal calculi, uveitis, anemia, elevated WBC & ESR Erythema Nodosum  Diagnosis Findings from history & physical (poor growth and delayed maturation) Lab data – CBC, ESR, C-reactive protein, total protein, albumin, zinc, magnesium, vitamin B12, fat soluble vitamins & pANCA Stools – blood, leukocytes & infectious agents Upper GI series with small bowel follow through, CT scan & Endoscopy of upper & lower bowel, & mucosa biopsies  Goals Control inflammatory process & reduce or eliminate symptoms Obtain long term remission Promote normal growth & development Allow as normal lifestyle as possible  Medical Treatment Corticosteroids – mediate & control inflammation Aminosalicylates – sulfasalizine (Azulfidine) & mesalamine (Asacol & Pentasa) – antinflammatory Immunodulators – 6-mercaptopurine, azathioprine, methotraxate & cyclosporine – induce and retain remission who are steroid resistant or dependent and to treat chronic draining fistulas Antibiotics – adjunct therapy or for complications  continued Anti-TNF – infleximab (Remicade) Adalimumab (Humira) anti–TNF-α antibody, was approved by the US Food and Drug Administration (FDA) for children aged 6 years or older with moderately to severely active Crohn disease who have had an inadequate response to corticosteroids or immunomodulators.  Nutrition Primary component of treatment High calorie, high protein Multivitamins, iron & folic acid supplements Enteral formulas by mouth or NG feedings TPN  Surgery *Not curative *Drain abscesses, close fistulas, remove short segments of diseased bowel, repair perforations, relieve obstructions or widen strictures *Toxic megacolon – fever, acute abdominal pain & abdominal distention  Prognosis No cure Outcome influenced by severity of GI involvement, the regions of bowel affected & appropriate therapeutic management Colon cancer long term complication  Nursing Home dietary management Coping with factors that increase stress Good mouth care Adjust to disease of remissions & exacerbations Prepare for possible surgery NG or TPN instruction Importance of continued drug therapy Crohn’s and Colitis Foundation of America