Week 2-Fluids, GI, Abdominal Assessment PDF

**Gastrointestional Disorders in Children


** **Hirshprung's Disease (congenital aganglionic megacolon)** - Mechanical obstruction caused by inadequate motility of part of the intestine - Congenital, diagnosed in utero - No nerve fibers in aganglionic portion to have sensation of bowe...

**Gastrointestional Disorders in Children


** **Hirshprung's Disease (congenital aganglionic megacolon)** - Mechanical obstruction caused by inadequate motility of part of the intestine - Congenital, diagnosed in utero - No nerve fibers in aganglionic portion to have sensation of bowel movement o Accumulation of stool proximal to aganglionic portion -\> creates megacolon - ¼ of all neonatal obstruction but may not be diagnosed until later in infancy or childhood - More common in children with Downs Syndrome o Also T1D, congenital HD, leukemia - 4x more common in males - 1 in 5,000 births - Should have meconium within 24-48 hours of birth -\> indicates this - 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 - Failure to pass meconium within 24 to 48 hrs. after birth - Reluctance to ingest fluids - Bile-stained vomitus - Abdominal distention o Firm and distended o Track abdominal girth -  - failure to thrive o Not growing or gaining weight - constipation - abdominal distention - episodes of diarrhea and vomiting - fever - severe exhaustion - - Constipation - Ribbon-like, foul-smelling stool o Stool leaks - Abdominal distention - Visible peristalsis o Above area of megacolon - Fecal masses easily palpable - Poorly nourished child and anemic  - Rectal exam - tight internal sphincter and absence of stool - Barium enema-contrast enemas should be avoided if patient has enterocolitis - Anorectal manometry o Catheter passed into rectum, inflate balloon -\> if nerve fibers are there -\> internal anal sphincter will relax - Definitive diagnosis is rectal biopsy o Confirms diagnosis - Irrigation of colon before surgery - Surgery to unlock colon and preserve bowel control - Remove aganglionic area between rectosigmoid and rectum just above anal canal (2 cm above pectinate zone) - Healthy intestine is connected to rectum o 30% of pts will still have colitis and irrigations are still needed until healthy colon overcomes pressure of anal canal (takes months to years) - May need to do temporary ostomy before connecting bowel  - Inflammation of intestine & colon o Most common cause of death - Asses for signs of perforated bowel o vital signs -- shock - absent bowel sounds, distention & tenderness o vomiting - irritable, dyspnea & cyanosis - fever -- NO RECTAL TEMPS - 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: o 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. - Colostomy care o Protect skin breakdown, infection - Prevent contamination of wound with urine - Impaired skin integrity due to incontinence o May have incontinence after surgery - NPO until bowel sounds return or flatus passed -- IV fluids - Pain control - Strict I&O **
Gastroesophageal Reflux
** - Dysfunction of LES - Delayed gastric emptying - Poor clearance of esophageal acid - Susceptibility of esophageal mucosa to acid injury - If reflux continues over a year -\> will become gastroesophageal reflux disease - Prematurity, tracheal-esphogeal atresia, neurological disorders, scoliosis, asthma, CF o Scoliosis due to position and pressure from spine - Tracheal-esphogeal atresia: esophagus does not connect to stomach, but connects to trachea - Signs: choking - Can diagnose in utero - Will have surgery to fix -\> surgery will place them at risk for reflux - Partial or incomplete swallowing dysfunctions - Theophylline & caffeine - Increased abdominal pressure - Infants with short LES - 3% of all newborns - Peaks between 1-4 months of age - Usually resolves by 6-12 months of age o They can sit up more, start to eat solids - Boys affected 3x more than girls - Vomiting or frequent regurgitation - Most common symptom - Weight loss, FTT (failure to thrive) - Irritable o Especially after eating o Discomfort from heartburn - Respiratory illness - Coughing, choking, apnea, bradycardia o Can lead to cardiac arrest - Hiccups - Recurrent weight loss - Heme (+) stools o Streaks of blood in stool from ulcers - Sandifer's syndrome o Children with reflux have extension of head o Almost looks like seizure - Would conduct an ECG and esophageal ph monitoring o Looks like exaggerated Moro reflex o Also looks like infantile spasm o GI and neurological - Acid reflux and torticollis movements (spine arches back, arms reach out for 1-3 minutes) - Radionuclide tests o Barium swallow to rule out other causes of vomitting - 24 hour esophageal ph monitoring o Ng tube placed - Endoscopy and esophageal biopsy - Depends on severity o Thriving infant w/o respiratory complication - Small frequent feedings - Thickened feedings with rice cereal - Positioning with HOB elevated - Failure to Thrive infants with severe reflux, who failed to respond to medical therapy or have an anatomic abnormality contributing to symptoms o NG feedings and/or surgery (Nissen Fundoplication) Nissen Fundoplication - For severe cases of reflux - Wrap stomach around part of esophagus - Can cause small bowel obstruction - Can cause inability to burp  - H2 blockers -- cemetidine (Tagamet), famotidine (Pepcid) o After 1, switch to PPI - Proton pump inhibitors - omeprazole (Prilosec), lansoprazole (Prevacid) o Better for healing o Cannot develop a tolerance to these o Give 30 mins before meal - Prokinetic -- metoclopramide (Reglan) o Do not use unless absolutely necessary o Increases gastric emptying, but has a lot of SE o Given 30 mins before eating Nursing - Risk for aspiration o Can be misdiagnosed for sids - Impaired swallowing - Acute pain - Imbalanced nutrition - Knowledge deficit - Parental anxiety - 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  - 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 - 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 - 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 - 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. - Primary component of treatment - High calorie, high protein - Multivitamins, iron & folic acid supplements - Enteral formulas by mouth or NG feedings - TPN - 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 **Pediatric Abdominal Assessment** 1. Newborns have a very ineffective gastrointestinal system because of its' immaturity at birth 2. Newborn's stomach capacity is only 10 to 20 ml and reaches adult capacity of 2,000 to 3,000 ml by late adolescence. 3. Peristalsis is greater in the infant than the older child with emptying time going from 2 to 3 hours in the newborn to 3 to 6 hours by 1 to 2 months of age. 4. Infants have a faster metabolic rate than an adult's requiring approximately 100 calories/kg compared to 30 to 40/kg for an adult. 5. Regurgitation is common in the infant because the lower esophageal sphincter tone in decreased or relaxed. 6. The length of the small intestine is proportionately greater in an infant than an adult and the large intestine is proportionately shorter than an adult's. These two characteristics, more secretions (small intestine) and less absorption (large intestine) are responsible for the soft frequent stools of infants. 7. Infant's liver function is immature. 8. The liver and spleen are proportionally larger than an adults'. 9. The stomach is round and lies more horizontally until 2 years of age. 10. Infants are deficient in digestive enzymes until 4 to 6 months of age (amylase, lactase and lipase). 11. Infants intestines are more permeable to proteins than the adult allowing passage into the bloodstream of cow's milk protein and other potential food allergens. - Family history - Past medical history related to GI system - Feeding habits, nutritional history and current diet - Changes in appetite - Bowel habits - Constipation and/or diarrhea - Vomiting - Presence of pain (onset, location, type, quality and aggravating and alleviating factors). - Food intolerance and/or allergies (what food, symptoms and treatment) - Weight loss or weight gain Assessment- Inspection - Best to inspect the abdomen in supine position when the infant is calm and not crying - Shape: Infants and young children have less well developed abdominal musculature so the abdomen is more protuberant and round. - Children up to 4 years of age can have potbellied appearance while supine of standing due to lordosis of spine. - Distended: can indicate intestinal obstruction, a mass organomegaly or ascites. - Scaphoid: can indicate malnutrition or displaced abdominal organs. - Note contours, symmetry, skin texture, color, and integrity - Skin in infants contains a fine, superficial venous pattern that is more visible on lightly pigmented children up to adolescence - Asymmetry may indicate a mass, organomegaly, or hollow organ distention (such as stomach or intestine) - Note any lesions, rashes, pigment variations, or scars - Observe for any pulsations (normal to see pulsations in epigastric area of a young infant or very thin child) - Respirations are abdominal - Assess for signs of pain: facial grimacing, high pitched cry, inability to console, and drawing knees up toward chest. - Inspect umbilical cord for redness or swelling and presence of umbilical hernia. - Inspect for umbilical vessels (2 arteries 1 vein) - Usually detach by 10th day of life, but can take up to 3 weeks. - Careful attention to keeping the umbilical stump clean to prevent infection -   - As with adults, listen to each quadrant with a stethoscope - Bowel sounds indicate peristalsis and movements of contents through the bowels - Normal bowel sounds are heard every 10-20 seconds and of low intensity - High pitched and frequent sounds: peritonitis, diarrhea and intestinal obstruction Absent sounds are associated with paralytic ileus - No vascular sounds should be heard! - Loud gurgles or stomach growling are normal in children - Percuss infant's abdomen same as you would with adult. - Greater tympanic sounds in infant due to infant's propensity to swallow air - Useful for determining size of organs and abdominal masses - Distract the child during abdominal palpation - Bend the knees and take deep breaths, best if it can be done on inspiration and expiration. - Start with light palpation, if areas of tenderness are detected (and guarding) then examine those last. - Note if abdomen soft or hard and if it is tense and rigid. - Liver: 1 to 2 cm below right costal margin. Enlarged liver (3cm below coastal margin) is determined better by percussion. - Start gently palpating low in abdomen and moving upwards with your fingers - Spleen: may be felt 1 to 2 cm below the left costal margin in infants and young children. Only gently palpate because it is very vascular - Spleen is soft with a sharp edge and projects downward like a tongue from under the left costal margin. - Palpation of kidney is difficult in infants due to deep position in the abdominal cavity. In toddlers and older children, palpation of kidneys is the same as in adults - Hallmark symptom: projectile, nonbilious vomiting - Upon examination, a firm olive-shaped mass can be palpated in the upper abdomen, slightly right of the midline visible after vomiting. - - Sudden onset, inconsolable cry, drawing up of knees to chest, bilious vomiting, current jelly stools and palpable sausage-shaped mass palpated in right upper quadrant. -  - Most common cause for abdominal surgery in adolescents - Presenting symptoms may be vague and poorly localized - Pain generally starts in the periumbilical area and localizes in the right lower quadrant (RLQ) - Followed by anorexia and nausea without vomiting - Rebound tenderness: pain on deep palpation with sudden release - Rovsing sign: tenderness in the RLQ that occurs during palpation or percussion of other abdominal quadrants.