Gastrointestinal Tract Disorders

1. DR. Areefa Albahri Gastrointestinal Tract Disorders By DR. Areefa Albahri (Alkasseh) Assistance Prof. of MCH Islamic University of Gaza

2. Main function GI is turning food into nutrients which can be absorbed by the human body to provide energy needed for survival • Accessory organs that assist the GI tract by secreting enzymes to help break down food into its component nutrients (salivary glands, liver, pancreas and gall bladder)

3. Gastrointestinal Tract: Assessment • Health history: • Gestational age and birth weight • Nutritional history (length of breast feeding, introduction of solid food). • Neonatal & infancy GI problems • Family factors (life style, hereditary problems) • Present changes in child’s life (start schooling, new sibling or death in the family) • Assessment of the digestive function in a 24hr (food intake and elimination)

4. Gastrointestinal Tract: Physical Exam • Physical parameter (Wt and Ht) • Skin Color • Inspection of oral cavity • S & S of dehydration • Abdominal and rectal assessment • Peristalsis • Abdominal Tenderness • Distended abdomen • Displaced heart (diaphragmatic hernia) • Hair (loss of pigment or brittle)

7. Cleft Lip & Cleft Palate • incomplete fusing of soft and hard tissues of lip and palate (top of mouth) respectively. May occur together or separately, one side or both. • Among the most common facial anomalies • Genetic basis is present (family history for presence of the defect in other siblings) • Incidence rate of cleft lip is 1:7800 • Incidence rate of cleft palate alone in 1:2000 • May result in communication between the nasal and oral cavities • Cleft lip may be unilateral or bilateral • Cleft lip may be accompanied with cleft palate • Cleft palate may be present without cleft lip (non-visible): early sign is dripping milk from nose

9. Assessment should be focused on; • In newborn: compromised sucking ability • Respiratory status • Family reaction Complication Feeding problem Hearing problem Speech difficulties Social • Management: • Surgical repair for cleft lip during the first few weeks of life • Initial repair for cleft palate during 4-6 months of age and the surgical correction between 6-18 months

10. Nursing care Provide adequate nutrition and prevent aspiration and infection (otitis media) During feeding Upright position Feed slowly Burp frequently

11. After the surgical operation: • Restrains may be necessary to prevent disturbance of the surgical site • No tooth brushing • Prevent infection • Follow-up assessment of • Growth • Speech • Teeth development. • Nursing diagnosis: • Altered nutrition R/T physical defect / difficulty eating • Risk for aspiration • Risk for infection • Risk for impaired verbal communication • Altered family process

12. Hypertrophic Pyloric Stenosis An overgrowth of the circular muscle of the pylorus, results in obstruction/ partially / narrowing of the pyloric sphincter Cause is unknown, however there is a hereditary component The stomach contractions increase in frequency and force to empty the stomach content. Usually develops in the first few weeks of life

13. CM: • Regurgitation small amounts of milk immediately after feeding • Projectile vomiting • Vomiting may occur during feeding or shortly after feeding • Vomitus contain NO bile • Gastritis due to prolonged stay of stomach content • Wt loss and dehydration • Metabolic alkalosis( blood pH above 7.45, levels of other blood components, including salts like potassium, sodium, and chloride, fall below normal ranges. The level of bicarbonate in the blood will be high, usually greater than 29 mEq/L. Urine pH may rise to about 7.0 in metabolic alkalosis. • Failure to thrive • Dehydration

14. Assessment: • Olive-like mass at right epigastrium under the edge of the liver • Peristaltic waves can be noted after feeding moving from left to right • Ultrasoundgraphy • Treatment is by surgery: to allow better passage of milk • Nursing Care: • Monitor intake and output • Assess vomitus • Prevent dehydration • Monitor Wt and Ht

15. Intussusception

16. Is an invagination of part of the intestine into an adjacent distal portion of the intestine. • Occurs in healthy infants around 6 months of age and rarely occur before 3 months or after 3-years of age • More common in male infants • The cause is unknown. • The most common type is near the ileocecal valve pushing into the cecum and onto the colon. • The involved intestine become inflamed and edematous with bleeding from the mucosa • Untreated intussusception can lead to intestinal gangrene, peritonitis and death • Diagnosis by barium enema ( if there is intraperitoneal air from a bowel perforation thus enema is contraindicated)

18. Assessment is focused on: • Stool inspection (currant-jelly stools) • CM such as Pain • Abdominal palpation • Early symptoms: • Crampy abdominal pain and a drawing up of the knees to the chest • Periods of apathy • Poor feeding and vomiting • Late symptoms: • Worsening vomiting, becoming bilious • Abdominal distension/ Palpable abd. Mass (sausage-shaped) • Heme positive stools • Followed by “currant jelly” stools: Jelly stools due to leaking of blood and mucus into the intestinal lumen as a result of venous engorgement • Dehydration • If untreated, necrosis and perforation are possible

19. Treatment: • Supportive therapy (Fluid; Antibiotics) • Hydrostatic barium • Operation • Manual • Resection and reanastamosis

21. Hirschsprung’s Disease (aganglionicmegacolon) A congenital anomaly resulting from an absence of ganglion cells in the colon (lack of nerve ending in the sigmoid colon) Autosomal dominant genetic mutations More common in male & children with down syndrome peristalsis cannot occur

22. CM: • Newborn: • Failure to pass meconium after birth (during the firs t 24 hr) • Poor feeding and spitting up • Visible bowel loops • Bile-stained vomitus • Abdominal distention • Infancy: • Failure to thrive • Constipation & Abdominal distention • Diarrhea & vomiting/ Explosive watery stool • Fever

23. Childhood (more chronic): • Constipation • Ribbon-like & foul smelling stools • Abdominal distention • Palpable fecal masses • Poorly nourished • Lethargy, nausea and anorexia • Treatment by surgery (removal of non-motile part) • Colostomy/ileostomy care after surgery • After surgery high fiber diet is established • Prevent enterocolitis

24. Celiac Disease • A disease of malabsorption & abnormal immune reaction to gluten • Celiac disease is a hereditary intolerance of gluten (protein found in wheat, oats, rye) • Gluten protein (gliadin) causes inflammation and damages villi in the small bowel • Enzyme insufficiency (peptidase) causes accumulation of toxic gluten peptide • Gluten toxicity results from alteration in immunologic response • It is the second cause of malabsorption after CF

27. CM: (related to malabsorption and malnutrition) • Problem starts after the introduction of solid food • Diarrhea; Steatorrhea (stool is bulky, fatty foul smelling) • Wt loss • Weakness • Abdominal pain & distention • Bone & joint pain • Anemia (malabsorption of iron) • Vit. Deficiency • Failure to thrive ( without S&S of GI problems) • Behavioral changes: irritability, apathy and uncooperative

28. Anti-tissue transglutaminase antibodies (tTGA) or anti- endomysiumantibodiesCBCSerum protein

29. Dietary management a gluten-free diet In acute phase; Corticosteroid Fluid replacement N/G to decrease the distention

30. Complications: (if not treated) • Iron deficiency anemia • Osteoporosis • infertility or recurrent miscarriage • depression or anxiety • tingling numbness in the hands and feet • seizures

31. Inflammatory bowel diseases: Ulcerative Colitis & Crohn’s Disease • Inflammatory bowel disease (IBD) refers to chronic conditions that cause inflammation in some part of the intestines. • The intestinal walls become swollen, inflamed, and develop ulcers • IBD can cause discomfort and serious digestive problems • Symptoms depend on which part of the digestive tract is involved • Causes of the inflammation in IBD involves a complex interaction of several factors: • The genes the patient has inherited, • The environment and the immune system. antigens in the environment may cause of the inflammation or they may stimulate the body's defenses to produce inflammation

32. Symptoms of IBD: • The symptoms of ulcerative colitis and Crohn's disease are similar: • Abdominal pain or cramping • Diarrhea multiple times per day • Bloody stools • Weight loss • Mouth sores and skin problems • Arthritis • Eye problems that affect vision

33. Inflammatory bowel diseases: Crohn’s disease • Crohn's Disease is characterized by a chronic inflammatory process that may affect any segment of the gastrointestinal tract, from mouth to anus. • The inflammatory process usually extends through all layers of the intestinal wall • Skip lesions • Treated by medication to decrease inflammation and usually control the symptoms but does not provide a cure

34. Inflammatory bowel diseases: Ulcerative Colitis • Ulcerative Colitis is characterized by continuous inflammation confined to the large intestine. • Inflammation is limited primarily to the mucosa and does not extend through all layers. • Treated by: • The primary treatment options are medications that decrease the abnormal inflammation in the colon lining and control the symptoms.. • Ulcerative colitis is potentially curable if the colon is removed

35. Inborn errors of metabolism • Galactosemia • Phenylketonuria • Congenital hypothyroidism

36. Galactosemia: • Lack of galactose-1-phosphate uridyl-transferase enzyme. • Inherited as autosomalrecessive. • Failure of conversion of galactose to glucose, accumulation of galactose leads to damage of the liver & brain. • Should be suspected in any infant who vomits, refuses feeds, fails to thrive & become jaundiced in the first week • Long term effect: ovaries damage, speech delay, learning difficulties • Treatment may include stopping BF & replacement by a special low-lactose milk.

37. Phenylketonuria: • Autosomal recessive genetic disorder causing mutation of the gene that producing phenylalanine hydroxylase enzyme that is necessary to metabolize the amino acid phenylalanine to tyrosine. • Phenylalanine is converted into phenylketone which is detected in the urine • The disease may present clinically with • Seizures • Excessively fair hair and skin • "Musty Odor" to the baby's sweat and urine • Early cases of PKU were treated with a low-phenylalanine diet. • Children with PKU must adhere to a special diet low in Phe for optimal brain development. • The diet requires severely restricting or eliminating foods high in Phe, such as meat, chicken, fish, eggs, nuts, cheese, milk & dairy products. • If PKU is left untreated, it can cause problems with brain development, including mental retardation, brain damage and seizures.

39. Appendicitis: • Inflammation of the appendix Caused by an obstruction. • Fecalith (hard feces) • Lymphoid obstruction • Infection • Swelling of the appendix reduces blood flow causing • Ischemia • necrosis • Perforation (rupture) may occur which may cause peritonitis, sepsis or abscess

40. CM: • PAIN (pain is the first sign) • Starts around the belly and moves to the lower right quadrant of the abdomen • Right lower quadrant localized tenderness • Right lower quadrant rebound tenderness • Fever, nausea, vomiting & diarrhea • WBC over 15,000 • Elevated C-reactive protein • CMIn neonate (non specific) • Irritability/ lethargy • Abdominal distention & abdominal mass • Vomiting

41. In infants and older children • Vomiting & diarrhea; Pain & fever • S & S of appendix perforation: • Fever • Sudden relief from pain • Subsequent increase in pain and rigidity guarding of the abdomen • Progressive abdominal distention • Tachycardia, rapid-shallow breathing • Pallor , chills and irritability