Transcript Lect.08 - Gastrointestinal Alterations in Children

Chapter 19
The Child with a
Gastrointestinal Alteration
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Anatomic and Physiologic
Differences in the Gastrointestinal Tract
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Swallowing is not under voluntary control until
6 weeks of age
Infants have minimal saliva
Stomach lies transversely and is horizontal in
infants’ abdomens
Infants and children have less stomach
capacity
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Slide 2
Pediatric Gastrointestinal Anatomy
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Anatomic and Physiologic
Differences in the Gastrointestinal Tract
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Gastric secretions are less acidic in the infant than in
older children or adults
Hydrochloric acid concentration is low until school
age
Human milk has properties that partially compensate
for decreased digestive function and optimize
nutrition
Formula or milk can increase alkalinity of gastric
secretions
Cardiac sphincter of stomach is relaxed at birth,
allowing mild, occasional regurgitation of stomach
contents
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Slide 4
Anatomic and Physiologic
Differences in the Gastrointestinal Tract
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Peristaltic waves may reverse in infancy,
causing regurgitation and vomiting
Peristalsis tends to be faster, with food
remaining in the stomach for a shorter period
Conditions such as fever and diarrhea can
increase the rate of propulsion and peristalsis
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Slide 5
Anatomic and Physiologic
Differences in the Gastrointestinal Tract
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Infants have a deficiency of the following
enzymes: amylase, lipase, and trypsin
Enzymes are not present in sufficient
quantities to aid digestion until 4 to 6 months
of age
Liver function is immature; gluconeogenesis,
plasma protein, ketone formation, vitamin
storage, and deamination remain immature
during the first year
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Slide 6
Nursing Assessment of the
Gastrointestinal Tract
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History
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Urine specific gravity
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Vomiting episodes? If so,
amount, color, and consistency
of emesis
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Episodes of apnea or
respiratory distress?
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Pain?
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Bowel sounds
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Abdominal circumference
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Calorie count
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Electrolyte status
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Hydration status
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Diarrhea (frequency, amount,
color, consistency of stools)
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Daily weights
(plot progress on growth chart)
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Vital signs
(including quality of respirations)
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Intake and output
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Skin integrity (especially in
perianal and rectal areas)
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Slide 7
Diagnostic Tests
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Complete blood count, erythrocyte
sedimentation rate, electrolytes
Liver enzymes, absorption tests
Stool-reducing substances, pH, fat, trypsin,
occult blood
Stool culture, ova and parasites
Upper gastrointestinal tract, colonoscopy,
small bowel follow through, barium enema,
gastric emptying, pH probe
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Slide 8
Malabsorption Syndromes:
Celiac Disease
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Gluten breaks down into gliadin in the small
intestine
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Intestine is unable to digest gliadin
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Accumulation of glutamine causes toxic effect
on the mucosal cells
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From here either the villi of the intestine will
atrophy, leading to malabsorption of fat
calories, carbohydrates, and vitamins, or
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The child will go into celiac crisis, which
causes severe dehydration and diarrhea
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Slide 9
Celiac Disease
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Malabsorption Syndromes:
Short Bowel Syndrome
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Decreased ability to digest and absorb a
regular diet because of a shortened intestine
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Extent and location of the involved bowel
determine the severity of the disorder
Causes include:
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Necrotizing enterocolitis
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Inflammatory disorders
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Intestinal malrotation
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Atresia
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Congenital bowel anomalies
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Slide 11
Malabsorption Syndromes:
Gastroesophageal Reflux
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The return of gastric contents into the esophagus from
a relaxation of the lower esophageal sphincter
Occurs at any time and is not necessarily related to
having a full stomach
Regurgitation increases in frequency and often results
in delayed growth
More common in premature infants and in children
with neurologic impairments
Often resolves without surgical intervention by 12 to
18 months of age
Reflux of stomach contents can lead to aspiration,
resulting in frequent bouts of pneumonia, respiratory
airway disease, color changes during feeding, apnea,
or hematemesis
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Slide 12
Malabsorption Syndromes:
Gastroesophageal Reflux
Therapeutic management depends on severity
of symptoms:
 Diet
 Positioning
 Medications
 Surgery
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Slide 13
Nursing Considerations
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Frequently monitor the child’s condition
Assess hydration status frequently
Take vital signs often
Monitor intake and output
Monitor urine output
(should have a minimum of 1 to 2 mL/kg per
hour)
Administer oral and intravenous fluids safely
Monitor child’s weight
Observe infection control procedures
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Slide 14
Nursing Considerations
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Provide emotional support
Promote rest and comfort
Good handwashing
Good Skin care
Ensure adequate nutrition: oral rehydration
therapy, CRAM diet (complex carbohydrates,
rice and milk)
Family and child education for home care
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Slide 15
Motility Disorders: Congenital Aganglionic
Megacolon (Hirschprung Disease)
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Congenital anomaly in which
inadequate motility causes
mechanical obstruction of
the intestine.
Caused by absence of
autonomic parasympathetic
ganglion cells in the colon,
which prevents peristalsis at
that portion of the intestine
Causes accumulation of
intestinal contents and
abdominal distention
Occurs more commonly
in boys
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Obstructive Disorders: Pyloric Stenosis
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Occurs when the circular areas
of muscle surrounding the pylorus
hypertrophy
Results in stenosis of the
passage between the stomach
and the duodenum, partially
obstructing the lumen of the
stomach
Lumen becomes inflamed and
edematous, which narrows the
opening until the obstruction
becomes complete
Cause unknown
Affects firstborn children and
males most often
Symptoms occur 2 to 4 weeks
after birth
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Obstructive Disorders: Intussusception
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Telescoping of part of the
intestine into an adjacent
distal portion of the intestine
Usually occurs around
6 months, rare after 3 years
Abrupt onset of acute
abdominal pain, vomiting,
and passage of brown stool
alternating with periods of
comfort
Develops “current jelly”–like
stools
Palpable mass may be
present in right upper
quadrant or mid to upper
abdomen
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Obstructive Disorders:
Malrotation and Volvulus
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Caused by abnormal rotation of the intestine
around the superior mesenteric artery during
embryologic development
May present in utero or may be asymptomatic
throughout life
Is the most serious type of intestinal
obstruction because if the intestine
undergoes complete volvulus, compromise
of the blood supply will result in intestinal
necrosis, peritonitis, perforation, and death
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Slide 19
Obstructive Disorders:
Necrotizing Enterocolitis
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Inflammatory disease of the intestinal tract
that primarily occurs in premature infants
Is potentially life threatening and has a 40%
mortality rate
Can be caused by several factors:
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Intestinal ischemia
Bacterial or viral infection
Immaturity of the gut
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Slide 20
Nursing Considerations
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Depends on underlying cause
Prevention of dehydration/hydration
maintenance
Oral care to prevent effects of hydrochloric
acid on teeth
Nothing by mouth order if blockage or
obstruction is suspected
Family teaching: see dehydration
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Slide 21
Defects in Physical Development that
Affect the Gastrointestinal Tract
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Cleft lip
Cleft palate
Tracheoesophageal fistula or atresia
Imperforate anus
Umbilical hernia
Diaphragmatic hernia
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Slide 22
Tracheoesophageal Fistula or Atresia
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Malformation that results from failure of
esophagus to develop as a continuous tube
during the fourth to fifth weeks of gestation
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Slide 23
Types of Esophageal Atresia and
Tracheoesophageal Fistula
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Slide 24