GI Rounds 2

Intussusception


Most frequent cause of intestinal obstruction in children. One portion of the bowels telescopes into another
Peaks 3-9 months, more common in boys
Idiopathic, no clear cause
3months to 5 years
Possible causes polyp, foreign body, viral infection

Pathophysiology
Bowel telescopes into another, walls of the bowel press against each other cutting of blood and lymph flow, causing inflammation , edema, obstruction
Causes blood and mucous in stool
Obstruction
Abdominal distention
Vomiting
Necrosis and perforation

Clinical manifestations:
Colic
Intermittent abdominal pain
Crying , drawing legs up to abdomen
Vomiting
Currant jelly stools

Onset –
Severe intermittent abdominal pain
Nonbilious vomiting, later bile stained
Currant jelly stools
Tender abdomen
Sausage shaped mass right upper quadrant
Listless, lethargic, shock

Diagnosis
Definitive test barium or air contrast enema
Abdominal ultrasound reliable

Treatment:
Nonsurgical reduction using barium, air or water soluble contrast
Air insuflation and water soluble contrast, safer with less perforation
90% success with air, 65-85 with contrast
Prompt surgical intervention if unsuccessful or for perforation

Nursing management:
Caregivers need reassurance
Demonstration of telescope or glove
NPO
NG suction
IV fluids
Passage of normal stool can indicate resolution
Reoccurrence possible

Family Teaching:
Observe for S&S of recurrence


Case study: Intussusception

Julisa presents to the local clinic complaining of severe abdominal pain. She is 5 years old. She appears in obvious distress. Her pulse is slightly elevated as is her temperature at this time; her respirations are shallow. The nurse notices she is doubled over with her legs drawn up to her abdomen. Occasionally she will relax for a while. Mother states she has had infrequent vomiting which now just looks like bile and no bowel movements. She states she has done this all day but that the pain will occasionally will go away for a while. The doctor on call sends her to the ER.
Why might the doctor decide to send a ‘stomach ache’ to the ER?
What are these signs and symptoms indicative of?
What other information may you want to assess?
The child has quieted for the moment but states she is very thirsty. Mother states she will get her a coke on the way to the ER. Is this a good idea? Why or why not?
When the diagnosis is later made in the ER, the nurse pulls out a glove to demonstrate what has happened to the mother. Why? What does she do with it?
The mother of the child says she is confused. The doctor said Julisa would have to have surgery but then another doctor said a test might help. The mother wants to know what they are talking about, “Cause I just want the test that will help, not surgery, I just don’t want her to have to have surgery…” What tests is she talking about? What is the likelihood that it will help?





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Hirschsprung’s Disease (HD)
Congenital aganglionic megacolon
Most common cause of distal bowel obstruction in the newborn
*A helpful mnemonic may be to think of a 'sprung' rubber band. It no longer has the elasticity to perform its job, similar to the distal bowel's lack of ganglion cells to help with peristalsis.

Incidence/Etiology
Males affected 3-4 xs more often than females
Not hereditary but strong predisposition, family history in 10%
Other associated conditions imperforate anus, urinary tract abnormalities, cardiac defects, seizure disorders, Downs

Pathophysiology:
Absence of parasympathetic ganglion cells in the colon
Affected bowel unable to transmit peristaltic waves to move feces
Thus bowel becomes enlarged and hypertrophied
Distention and ischemia = enterocolitis

Clinical manifestations:
Failure to pass meconium in first 24-48 hours after birth
Abdominal distention
Episodes of explosive passage of stools
Inadequate weight gain
Ribbon like foul smelling stools
Vomiting
Palpable fecal mass
Complication – enterocolitis (inflammation of small intestine and colon)
May rapidly progress to perforation (major cause of death 30%)

Diagnosis:
Diagnosed in 15% at birth
60% third month
80% by one year
History chronic constipation
Rectal exam absence of feces, internal sphincter tight
Barium enema, definitive with rectal biopsy for absence of ganglionic cells

Treatment:
Abnormal section of colon removed
Pull through one step surgery most common
Two stage abnormal colon removed, colostomy
Then normal colon anastomosed to rectum

Nursing Management:
Preop
NPO
IV
NG suctioning
Bowel cleaning
Oral antibiotics, antibiotic enemas

Postop
No rectal temperatures! axillary
NG
Abdominal distention
Incision site care
Return of bowel sounds
Ostomy appliance fitting

Explanation and teaching about colostomy, skin care, appliance application
S&S of complcations, enterocolitis, leaks, strictures= abdominal distention, irritability, constipation, vomiting, diarrhea




Case Study: Hirschsprungs Disease


At 36 hours old with no meconium stool, William is transferred to a more advanced hospital to assess his colon. After a barium enema and a rectal biopsy, William is diagnosed at 4 days old with Hirschsprung’s disease and is scheduled for surgery. Before he can have the pull through surgery, he contracts enterocolitis. Now emergency surgery is performed and a temporary colostomy is in place.


What are some immediate nursing diagnoses, nursing interventions and nursing outcomes, which can be anticipated at this time? Preoperatively? Postoperatively?


The grandparents are visiting and the parents are exhausted. They have asked you to explain what Hirschsprung’s disease and enterocolitis is to the grandparents. What is your explanation?


The grandparents main concern is when “will they fix that hole in his stomach?” What is your answer?


Barring emergencies such as Williams, what is the current treatment of choice and why?


Is it possible William will have any residual effects? If so what might they be?


The real William - A picture of the initial presentation at birth







This video is an example of the continued care and management needed after correction.





Liver:

Hepatitis A, B and C


Hepatitis with a vowel comes from the bowel.
Hepatitis A from food inflames liver but resolves. Vaccine.
Hepatitis B from blood and bodily fluids. Vaccine
Hepatitis C from blood and bodily fluids. No vaccine
Hepatitis D can get if already have B
Hepatitis E from food usually seen in Asia, Africa and Mexico

Symptoms:
Fatigue, fever, nausea, vomiting, dark urine, jaundice, yellow eyes, joint pain, clay colored stools
Can result in Liver damage, scarring or cirrhosis of the liver. lose function, muscle wasting because using protein from own body, fluid (ascites), mental confusion, bleeding.

Avoid:
High fat diet
Extra iron
Alcohol
Excess anti inflammatory agents, Tylenol.

Hepatitis


Biliary Atresia

Biliary atresia is a chronic, progressive liver problem, evident shortly after birth.
Tubes in the liver, called bile ducts, normally allow a liquid produced by the liver called bile to drain into the intestines and kidneys.
Bile aids in digestion and carries waste products from the liver to the intestine and kidneys for excretion.
In biliary atresia, bile ducts in the liver are blocked.
When the bile is unable to leave the liver through the bile ducts, the liver becomes damaged and many vital body functions are affected.

The cause of biliary atresia is unknown.
Biliary atresia does not seem to be linked to medications the mother took, or illnesses the mother had. Not a genetic link known for biliary atresia.
Biliary atresia is the most common cause of liver transplantation in children living in the U.S.
Biliary atresia occurs once in every 10,000 births and is more common in girls than in boys.
Asian populations and African-American newborns are more frequently affected than Caucasian newborns.

Biliary atresia causes liver damage and affects numerous processes that allow the body to function normally. Biliary atresia is a life-threatening disease and is fatal without treatment.

Symptoms

May appear healthy at birth. Symptoms develop between two weeks and two months of life, and include:
Jaundice
Dark urine
Light colored stools
Distended abdomen
Weight loss

Encopresis
Voluntary or involuntary passage of stool of near normal consistency.
Occurs once per month for 3 months.
Primary when 4 years of age and has not achieved fecal continence.
Secondary over 4 and occurs after period of continence.
Main causes:
Constipation but can be due to digestive tract difficulties such as Hirschsprungs, rectal prolaspe, anorectal lesions or hypothyroidism, hypokalemia, hypercalcemia, lead intoxification, myelomeningocele, cerebral palsy, MD or IBS. Therapeutic Interventions:
Dietary changes, lubricants, toilet ritual. Education.


S&S Appendicitis Nursing diagnosis:






Appendicitis:


Ulcerative Colitis:




Crohn's Disease


Celiac Disease:



Gluten free diet


Parasites
Pin Worms:


Test for child with gastrointestinal system dysfunction


Circle the correct response:


T. F. 1. Infants and young children are less susceptible to dehydration than older children and adults, since infants have less fluid intake and output relative to size.


T. F. 2. The extracellular fluid compartments in infants until age 2 are larger than in the older child or adult.


Match the corresponding answers:


3. _ Congenital aganglionic megacolon __A. Intussusception

4. _ Intestine prolapses into itself ___B. Hirschsprung Disease


Circle the one, best answer:


5. Weight can indicate fluid loss or gain in infants and children generally:


A. 1 ounce = 1 milliliter of body fluid

B. 1 ounce = 10 milliliters of body fluid

C. 1 gram = 1 milliliter of body fluid

D. 1 gram = 10 milliliters of body fluid



6. This is one of the major causes for gastroenteritis among children under two years of age causing 70% to 80% of all infectious diarrheas in developed nations.


A. Salmonella

B. C. Difficile

C. E. Coli

D. Rotavirus



7. The most common cause of emergency abdominal surgery in children is:


A. Acute appendicitis

B. Trauma

C. Intussusception

D. Foreign body ingestion



8. A history of maternal polyhydramnios is present in 50% of all cases of which GI anomaly?


A. Esophageal atresia

B. Biliary atesia

C. Hypertrophic pyloric stenosis

D. Umbilical hernia



9. Probable diagnosis for a malnourished infant with an olive-like mass in the upper abdomen who exhibits nonbilious, projectile vomiting 30 to 60 minutes after each feeding is:


A. Hirschsprung disease

B. Gastroesophageal reflux

C. Biliary atresia

D. Hypertrophic pyloric stenosis



10. Abrupt, intermittent colicky pain, accompanied by vomiting, dehydration, fever, abdominal distention and later red, currant jelly stools are signs of what G.I. disorder?


A. Acute appendicitis

B. Intussusception

C. Hirschsrung disease

D. Acute gastroenteritis



On questions 11 and 12 select all answers that apply.


11. Circle all the signs and symptoms of biliary atresia that apply:


A. Jaundice

B. Frothy saliva

C. Constipation

D. Light colored stools

E. Failure to thrive

F. Dark urine



12. Circle all the causes of Short Bowel Syndrome:


A. Congenital anomalies

B. Hirschsprung disease

C. Trauma

D. Ischemia

E. Vascular injury

F. Biliary atresia



Fill in the blanks with the appropriate answer:


13. Dehydration can be classified as:

1. _

2. _

3. _



14. The three Cs of a tracheoesophageal fistula are:

1.__

2.__

3.__


Complete the following 2 essay questions in the space provided being sure to include the prompted material:


15. A 18 month old has been admitted to the unit with dehydration due to acute gastroenteritis. Name at less 3 nursing concerns/diagnosis’s with appropriate nursing interventions in the space provided. Be specific in your care. You may use a concept map to answer this question if desired. Continue on next page if needed.







16. A couple has just had their first baby. He was born with a cleft lip and palate. The parents are distraught. The infant is otherwise healthy and robust. The doctors have decided to schedule the infant for surgery for his lip but correction of the palate will wait. Is this the norm? What types of care will this family need? Write at least two nursing diagnosis’s with appropriate nursing interventions in the space provided. Focus on the immediate needs.







Questions 17 and 18 relate to the case study below:


Kennedy has been complaining of a stomachache for two days. She has a fever and has been vomiting. She guards her abdomen and complains each time her wheelchair bumps anything. She is pale, tachycardic and will not stand up straight when she gets to the room. Her mother states that she put a heating pad on her daughter’s stomach and she had stopped complaining for a while and now she is worse.


17. What is the likely diagnosis?


A. Appendicitis

B. A ruptured appendix

C. Intussusception

D. Severe gastroenteritis



18. What is the likely management? Refer to case study.


A. Surgery, IV management, antibiotics and observation until the child stabilizes, then the child can go home.

B. Emergency surgery, IV therapy, antibiotic therapy for 7-10 days, possibly a penrose drain and nasogastric suctioning until GI activity returns.

C. Administration of a barium enema and continued observation to ensure the nonsurgical reduction was successful.

D. IV replacement therapy with continued monitoring of I&Os, stool cultures, possible antibiotic therapy with steady improvement.




Utilize the picture below to answer Hot-Spot questions for 19 and 20.


hirschsprungs.pngpyloric_stenosis.png


19. Place an X on the drawing of pyloric stenosis in the area of dysfunction.


20. Circle the drawing of Hirschsprung disease in the area of dysfunction.


Multiple-choice questions with clinical practice framework:


21. While caring for a child hospitalized with acute diarrhea you weigh the child without the diaper but need to assess the amount of fluid loss in the diaper so you weigh the diaper also knowing that:


A. 1 ounce = 30 mls and normal output is 1-2 mls/kg/hr

B. 1 gram = 30 mls and normal output is 1-2 mls/kg/hr

C. 1 ounce = 1 ml and normal output is 1-2 mls/kg/hr

D. 1 gram = 1 ml and normal output is 1-2 mls/kg/hr



22. For the infant needing minimal therapeutic management of gastroesophageal reflux (GER) parental teaching may include:


A. Small frequent feedings of thickened formula, infant positioning counseling and medication therapy information.

B. A change in formula, a prone position during sleeping, and medication therapy information.

C. There is no need for teaching at this time; just reassurance since the GER is minimal and the child will likely outgrow it.

D. Signs and symptoms of possible complications, feeding strategies, medication information.



23. A child has been admitted through the ER with Intussusception. At this time he is out of pain and wants to eat. The nurse knows that:


A. This is acceptable as the intussusception has corrected itself and is unlikely to reoccur.

B. This child could require surgery; consequently eating or drinking is not a good idea.

C. Clear liquids and ice chips are permissible.

D. B & C



24. Postoperative care of the infant who had a pyloromyotomy includes:


A. I&O, NPO, incision care, continuous IV therapy for 24 hours

B. I&O, incision care, slow small feeding by 4 -6 hours post-op, mother involved

C. I&O, NPO, IV maintenance, continuous GI suctioning, parental visitation.

D. Immediate small feeding on return from OR, monitor tolerance and I&Os.



25. The prognosis for children with short bowel syndrome has improved. The most important nursing considerations for these children involves:


A. The administration and monitoring of pharmocologic therapy.

B. Assisting the family with pallatative home care.

C. Minimizing the risk of complications related to the central venous access.

D. Diet, activity and home care education.


Answers:
1. F
2. T
3. B
4. A
5. C.
6. D
7. A.
8. A.
9. D.
10. B.
11. A, D, F
12. A, C, D, E
13. Isotonic, Hypotonic, Hypertonic
14. Coughing, Choking, Cyanosis
15.
16.
17. B.
18. B.
19.
20.
21. D.
22. A.
23. B.
24. B.
25. C.


References:

Daigneau, C. V. (2005). The child with gastrointestinal dysfunction. In M. Hockenberry, D. Wilson & M. Winkelstein (Eds.), Wong's essentials of pediatric nursing (7th ed., pp. 839-889). St. Louis, Missouri: Elsevier Mosby.

Ellett, M. L. (2009). Chapter 24: The child with gastrointestinal dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 813-860). St. Louis, MO: Mosby Elsevier.

Videos:

Intussusception by Dr.
Larry Mellick
https://youtu.be/OZOCcoD5a5c

Intussusception by expatdoctormom1
https://youtu.be/B9C5BHTX-dA

Intussusception by Digestible Donut
http://youtu.be/MDl7iySivFg

Hirschsprung's Disease by Minion79
http://youtu.be/PFiJfkr5Dl0

Hirschsprung's Disease by Avera Medical Minute
http://youtu.be/v2ZpXxhuxQg

Hepatitis A, B and C
https://youtu.be/U-PE-5jTwzI

S&S of Appendicitis
https://youtu.be/4VVbOjBX5ew

Appendicitis
https://youtu.be/r2zsbdPBhGY

Celiac Disease
https://youtu.be/gZeliSjhkpg

Ulcerative Colitis:
https://youtu.be/JMApMBY0CfQ

Chrohns Disease
https://youtu.be/k0kRSF80PJ0

Pin Worms by Healthy Kid Tips

http://youtu.be/eplTQau7ZtY