Interventions

● these pre-interventions are focused on ensuring

CHILDREN WITH PHYSIOLOGIC DISORDERS
proper feeding and nutrition. The other one
Topic D: Pediatric Gastrointestinal Disorders
postoperative interventions assures establishing the
airway, preventing complications (such as
● The GI system involves an alimentary canal with hemorrhage), and ensuring nutrition as well.
numerous organs seen in the photo. Because it is so
long and diverse, a multitude of disorders can occur. I. PRE-OPERATIVE
This is either congenital or acquired. Since this A. Feed upright.
system is responsible for our cells’ nutrients, any B. Burp frequently.
problem can quickly affect other body systems too. If C. Use large-holed nipple, but if unable to suck,
not adequately treated it can affect overall health drip formula into side of mouth.
and especially growth and development. D. Provide small, frequent feedings.
● Vomiting and diarrhea are common symptoms of GI E. Finish feeding with water.
problems both in children and adults. Box 45.2 also II. POST-OPERATIVE
shows other bodily findings in a child with an altered A. Maintain patent airway.
GI function. B. Assess color, monitor amount of swallowing
to detect hemorrhage.
PEDIATRIC GASTROINTESTINAL DISORDERS C. Do not place in prone position or with
pressure in cheeks.
1. Cleft Lip and Palate D. Avoid straining, such as crying.
2. Esophageal Atresia and Tracheoesophageal E. Use elbow restraints, if needed.
Fistula F. Provide liquid diet initially, then soft, then
3. Gastroesophageal Reflux normal.
4. Pyloric Stenosis ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL
5. Omphalocele FISTULA
6. Gastroschisis
➔ Esophageal atresia is when esophagus ends in a
7. Hiatal Hernia
blind pouch, with no entry route to stomach.
8. Inguinal Hernia
➔ Tracheoesophageal fistula is an open connection
9. Appendicitis
between esophagus and trachea.
10. Celiac Disease
➔ Atresia means close, fistula means open.
11. Hirschsprung’s Disease
➔ These two birth defects often appear together
12. Kwashiorkor
resulting from an abnormal intrauterine
13. Marasmus
development. It is not inherited. However, they are
often seen when babies have other birth defects.
CLEFT LIP AND PALATE Such as trisomy 21, diaphragmatic hernia, and some
➔ Openings or splits in the upper lip, the roof of the congenital heart diseases.
mouth, or both.
➔ Results from non-union of the tissue and bone of the ASSESSMENT:
upper lip and hard and soft palate during embryonic Esophageal Atresia
development. ● Inability to pass a gastric tube.
➔ These birth defect occur when the facial structures ● Increased drooling and salivation.
that are developing in the unborn do not form ● Immediate regurgitation of undigested formula and
properly. milk when fed.
SURGICAL REPAIR Tracheoesophageal Fistula
● this will be the treatment. ● Normal swallowing, but some food or mucus crosses
● surgery is important before speech development fistula, causing choking and intermittent cyanosis.
occurs. At the minimum, one surgery is needed to ● Distended abdomen from inhaled air crossing fistula
repair the lip and the separate surgery to repair the into stomach.
palate. However, several surgeries may be needed ● Aspiration pneumonia from reflux of gastric
to make the lip appear as normal as possible. secretions into trachea.
MANAGEMENT:
1. Cheiloplasty – cleft lip repair (3 months) ● surgery will fix the problem while awaiting repair
2. Palatoplasty – cleft palate repair (10-12 months) interventions are focus on ensuring feeding which is
1
 gastrostomy and prevention of aspirations thru ● If medical therapy is ineffective, a laparoscopic or
esophagostomy. surgical myotomy procedure to narrow the
● corrective therapy is thru anastomosis which esophageal sphincter must be done.
connects the normal parts together. If there is
insufficient tissues for two ends to be attached, a all of these interventions prevents the reflux of gastric
part of the child’s colon may be used to connect. contents and ensure normal passage of foods and fluids
● Palliative down the alimentary canal.
○ Gastrostomy for feeding.
○ Esophagostomy to drain secretions. PYLORIC STENOSIS
● Corrective ➔ Narrowing of the pylorus, the lower part of the
○ End-to-end anastomosis to restore normal stomach through which food and other stomacH
anatomy. contents pass to enter the small intestine.
○ Colon transplant for defects where there is ➔ When an infant has pyloric stenosis, the muscles in
insufficient tissue for an end-to-end the pylorus have become enlarged to the point
anastomosis. where food is prevented froM emptying out of the
stomach.
GASTROESOPHAGEAL REFLUX ➔ Occurs less frequently in breastfed infants than in
➔ Regurgitation of stomach secretions into the formula fed infants. In formula fed infants these
esophagus through the gastroesophageal or cardiac typically begins at approximately 4 weeks of age.
valve. While in breastfed infants, symptoms begin at about
➔ Occurs mainly in infants and adolescents. 6 weeks of age. The curd of breastmilk is smaller
➔ Caused by relaxed cardiac sphincter or than that of cows milk so it passes through a
overdistention of stomach by gas or overfeeding. hypertrophy muscle more easily.

ASSESSMENT: ASSESSMENT:
these conditions may also be associated with the the diagnosis of pyloric stenosis is made primarily from the
development of esophageal cancer later in life. history. If a child is vomiting or spitting up, these certain to
get full description on its (1) duration, which begins at about
● Vomiting appears effortless and is not projectile. 6 weeks. (2) intensity, it is usually projectile vomiting. (3)
● Irritable child with periods of apnea. description which is sour but contains no bile.
● Acidic gastric secretions of pH < 7.0 into esophagus.
● In adolescents, heartburn 30 to 60 minutes after ● At 4 to 6 weeks of age, infants begin to vomit almost
meals. immediately after each feeding, and is projectile.
● Esophageal manometry shows less strength of ● With sour, non-bile vomitus.
esophageal sphincter. ● Usually hungry immediately after vomiting because
● Fiberoptic endoscopy or esophagography with they are not nauseated.
barium swallow shows involved sphincter and reflux ● May have signs of dehydration, alkalosis, hypopnea,
of stomach contents into the esophagus. and electrolyte imbalances.
MANAGEMENT: TREATMENT:
● Feed infants formula thickened with rice cereal, 1 ● The definitive treatment of pyloric stenosis is surgical
tbsp of cereal per 1 oz of formula or breast milk. or laparoscopic pyloromyotomy known as
● Position head upright, elevated 30o to 45o during Ramstedt's procedure. It divides the muscle of the
and 1 hour after feeding. pylorus to open up the gastric outlet. This is a
● Give small, frequent feedings with adequate burping. relatively straightforward surgery that can possibly
● Give H2 receptor antagonist such as ranitidine be done through:
(Zantac) or proton pump inhibitor such as 1. Single incision, usually 3–4 cm long)
omeprazole (Prilosec) to reduce possibility of 2. Laparoscopically, through several tiny
stomach acid contents irritating the esophagus. incisions
● If problem does not disappear as child grows, Surgery must be performed before electrolyte imbalance
botulinum toxin may be injected into lower from the vomiting or hypoglycemia from lack of food occurs.
esophageal sphincter to temporarily relieve In this scenario, if surgery is performed early, prognosis for
symptoms of obstruction. infants is excellent. For the surgical corrections, the muscle
of the pylorus is split down to the mucosa allowing for a
larger lumen. Although the procedure sounds very simple, it
2
is technically difficult. There is also a high risk of infection DIAGNOSIS:
afterwards because the abdominal incision is near the diaper ● History; Ultrasound or barium swallow
area. ● This will locate the abnormal anatomical position.
MANAGEMENT:
OMPHALOCELE ● Keep baby in upright position.
➔ A birth defect of the abdominal wall where the ○ this will prevent the condition from recurring.
neonate’s intestines, liver, or other abdominal organs ● Administer medications to reduce acid secretions.
stick outside of the belly through the umbilicus. ○ such as H2 blockers and antacids.
➔ The organs are covered in a thin, nearly transparent ○ If the condition now has not corrected itself
sac that hardly ever is open or broken. by the time the child is 6 months old, even in
➔ Repair is performed in the following ways if maintaining an upright position most of the
omphalocele is small and involves only the day…
intestines: ● Perform laparoscopic surgery to reduce the
1. Right after birth, a silo plastic pouch or a stomach’s ability to protrude through the diaphragm.
mesh-type of material is used to contain the
organs. INGUINAL HERNIA
2. The pouch or mesh is then attached to the ➔ This is the protrusion of a section of the bowel into
baby’s abdomen. the inguinal ring.
3. Every 2 to 3 days, the pouch or mesh is 1. In boys, as the testes descend from the abdomen
gently tightened to push the organs back into the scrotum late in fetal life, a fold of peritoneum
inside. also descends, this forms a tube from the abdomen
➔ If omphalocele is big and involves other organs to the scrotum.
including liver, an open surgery is needed to place 2. In girls, the round ligament extends from the uterus
back the protruded organs into its normal anatomic into the inguinal canal to its attachment on the
position. The surgeon will then close the opening in abdominal wall.
the abdominal wall.
◆ In this case, in omphalocele the most ASSESSMENT:
common concern is the risk for infection. ● Appears as a lump in left or right groin
Nurses must then take measures to prevent ○ This is very apparent when the child is
such complications. crying and with increase activity. As when
intra or abdominal pressure increases.
GASTROSCHISIS ● Generally painless
➔ This birth defect is very similar to omphalocele in ○ A painful inguinal hernia only means that the
almost all aspects, the only difference is that there is intestines have been confined in the sac.
no covering membrane over the protruded organs. This may then require immediate action or
➔ Cause is generally unknown but associated with surgery to prevent bowel obstruction or
some genetic conditions and environmental factors ischemia.
during pregnancy. MANAGEMENT:
➔ Management is also similar to omphalocele, but ● Treatment of inguinal hernia is laparoscopy surgery.
there is more risk for infection. ● The bowel is returned to the abdominal cavity and
retained there by sealing the inguinal ring.
1. After surgery, keep the suture line dry and
HIATAL HERNIA
free of urine or feces to prevent infection.
➔ This is the intermittent protrusion of the stomach up a. infant may need frequent diaper
through the esophageal opening in the diaphragm. changes and good diaper area care.
➔ When this occurs, the volume of the stomach is 2. Assess circulation in the leg on the side of
suddenly restricted. This leads to periodic vomiting the surgical repair to be certain that edema
similar to that of GERD or gastroesophageal reflux. of the groin is not compressing blood
That is why there is pain in vomiting and shortness vessels.
of breath. a. this will assure that there is no
obstruction or obstructing blood flow
to the legs.
ASSESSMENT:
● Pain with vomiting; Shortness of breath

3
 APPENDICITIS respirations, and increased
➔ Inflammation of the appendix which prevents mucus temperature.
from passing into cecum.
➔ It is the most common cause of abdominal surgery in CELIAC DISEASE
children. The appendix is a blind end pouch attached ➔ A sensitivity or abnormal immunologic response to
to the cecum. It may become inflamed because of protein, particularly the gluten factor in grains such
upper respiratory or other body infections. as wheat, rye, oats, and barley.
➔ When gluten is ingested, damage occurs in the small
What Happens? intestine and interferes with absorption of nutrients
1. In most instances, fecal material apparently enters from food.
the appendix, hardens and obstructs the ◆ Because the intestines main function is
appendiceal lumen. absorption. This disease is both a disease of
2. Inflammation and edema develop, leading to malabsorption meaning nutrients are not
compression of blood vessels and cellular absorbed properly and its also a disease of
malnutrition. an abnormal immune reaction because
3. Necrosis and pain result. these children cannot tolerate gluten.
4. If the condition is not discovered early enough, the
necrotic area will rupture and fecal material will spill ASSESSMENT:
into the abdomen, causing peritonitis, a potentially ● Abdominal bloating and pain
fatal condition. ● Chronic diarrhea
a. We do not wait for it to rupture. ● Vomiting
ASSESSMENT: ● Pale, foul-smelling, or fatty stool
Among all these findings the localized pain distinguishes ● Weight loss
appendicitis from that of acute gastroenteritis. The all these GI findings is because of the immune reaction to
abdominal pain in appendicitis usually starts diffusing, but gluten causing malabsorption of nutrients. These are
gradually it localized to the right lower quadrant. The point of noticeable between 6-18 months of age.
sharpest pain is often 1/3 of the way between the anterior DIAGNOSIS:
superior iliac crest and the umbilicus this is called the ● Serum analysis of antibodies against gluten, IgA
McBurney’s point. antigliadin antibodies
● Diffuse pain at lower right quadrant, McBurney’s ● Biopsy of the intestinal mucosa done by endoscopy,
point establishes typicaL changes in intestinal villi
● Nausea and vomiting ● Oral glucose tolerance test, reveal poor absorption
● Guarding of abdomen, rebound tenderness ● Stool may be collected to test for fat content, which
● Decreased bowel sound is increased
● Fever MANAGEMENT:
DIAGNOSTIC TESTS ● The only treatment for celiac disease is a gluten-
1. Increased WBC at 10,000 to 18,000/mm3 free diet. To stay well, people with celiac disease
2. Elevated ketone in urine as a symptom of starvation must avoid gluten for the rest of their lives.
from poor intestinal absorption ○ In the photo, it shows a variety of foods to
3. Ultrasound or CT Scan reveals swollen appendix be avoided in celiac disease. This includes
MANAGEMENT breads, cakes, cereals, pasta, daily products
● Administer antipyretics or analgesics as ordered. and even alcoholic beverages.
● No enema or heating pads, this may perforate ○ Administer water-soluble forms of Vitamins
appendix. A and D.
● Therapy is appendectomy by laparoscopy. This must ○ Give iron and folate to correct anemia.
be done before it ruptures.
○ With Rupture: HIRSCHSPRUNG’S DISEASE
■ Position semi-fowler’s to so infected ➔ Aganglionic megacolon is the absence of ganglion
drainage from cecum flows down cells in a section of the bowel, usually in the lower
instead of going to lungs. portion of the sigmoid colon just above the anus,
■ Administer IV fluid for hydration. caused by abnormal gene on chromosome 10.
■ Start antibiotics pre-operatively. ➔ The absence of these nerve cells mean that there is
■ Watch out for signs of peritonitis no persitalsic waves in this section of the bowel. So
such as rigid abdomen, shallow moving of fecal material or movement of fecal
4
 material through that segment of intestine is ● Edema.
impossible. ○ This results from the hypoproteinemia. This
➔ It is common in males and incidnce is 1 in 5000 live causes a shift of body fluid from the
births. intravascular to the interstitial space. This
causes ascites as shown in the photo. It
ASSESSMENT: tends to be dependent, so it is first noted in
● Because newborn stools soft, symptoms generally the lower extremities.
do not show until 6 to 12 months. ● Severe wasting of muscles.
● However, if extensive section is involved, even ○ This is masked by edema. They may not
meconium at birth cannot pass. appear light in weight until the edema is
○ Chronic constipation relieved.
○ Ribbonlike stools as it pass through a small, ● Generally irritable.
narrow segment ○ Children is uninterested in their
○ Portion of bowel proximal to obstruction surroundings.
dilates, so abdomen becomes distended ● Zebra sign.
○ The photo shows that the distal part of the ○ Hair shafts with stripped appearance of
bowel lacks nerve innervation because of brown and white. This shows a period of
the absence of the ganglion cells and good protein intake then poor protein intake
because there is no peristalsis in the area, then good protein intake again and so on
the bowel proximal to it distends. and so forth.
Treatment ● May have diarrhea, iron-deficiency anemia, and
consists of surgical removal or resection of the abnormal enlarged liver.
section of the colon, followed by re-anastomosis. There used ○ This conditions will compound the problem.
to be two steps used to achieve this goal.
1. The first stage used to be a colostomy. This ➔ Without treatment, kwashiorkor is fatal. For therapy,
temporarily allows bowel contents to be discharged a diet rich in protein is essential.
outside in a bag, while awaiting surgery. ◆ However, if corrected later on this may still
a. with colostomy the large intestine is cut off result in failure of children to reach their full
and an opening is made thru the abdomen. potential of intellectual and psychological
This allows the bowel contents to be development.
discharged into a bag.
2. Later, when the child’s weight, age, and condition is MARASMUS
right, usually at 12 to 18 months, a pull-through ➔ Malnutrition.
procedure is performed. ➔ Caused by a deficiency of all food groups, and
a. this procedure involves dissection and basically a form of starvation.
removal of the affected intestine with ➔ These children are most commonly younger than 1
anastomosis or connecting of the involved year.
bowel. This will correct the condition. ➔ They have many of the same symptoms as children
with kwashiorkor, including growth failure, muscle
KWASHIORKOR wasting, irritability, iron-deficiency anemia, and
➔ A disease caused by protein deficiency, occurring diarrhea.
after weaning, when children change from breast ➔ While children with Kwashiorkor is anorectic, these
milk to a diet consisting mainly of carbohydrates. children with Marasmus are invariably hungry. They
➔ Hypoproteinemia occurs most frequently in children Page 6 of 6 starve, they may suck at any object such
ages 1 to 3 years, because this age group requires a as finger or clothing.
high protein intake. ➔ Treatment is a diet rich in all nutrients.

ASSESSMENT:
● Growth failure.
○ This is a major symptom. Children fall
behind other children of the same age also
in terms of motor development.