4gastrointestinal Disorder

Gastrointestinal Disorders
Copyright © 2018 Wolters Kluwer · All Rights Reserved

DIARRHEA
• Acute diarrhea usually associated with
infection.
• Chronic diarrhea is more likely related to a

malabsorptive or inflammatory cause.

Assessing Disorders of Fluid, Electrolyte, and
Acid–Base Imbalance

Assessing Common Disorders of the Stomach
and Duodenum
• Gastroesophageal Reflux
– In infants, history of effortless vomiting; pH of gastric secretions;
endoscopy or esophagography; esophageal manometry
– In adolescents, history of heartburn; if severe, endoscopy is needed.
• Pyloric stenosis
– Vomit immediately after feedings; sour-smelling vomitus without bile;
dehydration; alkalosis; hypopnea; round, firm sphincter.

Assessment
• Upper GI series to look for anatomical abnormalities
such as intestinal malrotation.
• pH probe (catheter inserted through the nose into the

lower esophagus) to calculate the amount of acidic
reflux into the esophagus in a 24-hour period.
• Esophageal manometry to assess esophageal motility

to ensure there is normal esophageal peristalsis.
• Endoscopy to obtain biopsies to assess the degree of

esophagitis.

Therapeutic Management
• Therapeutic management options for

gastroesophageal reflux in infants include
conservative treatment, medication, and
surgery.
• In infants, gastroesophageal reflux is usually

a self-limiting condition.

– To prevent reflux, the child should avoid lying
down until 3 hours after a meal and should sleep
at night with their upper body elevated on a foam
wedge or extra pillow.
– Avoid acidic foods such as tomato products,

citrus fruits, or spicy foods.
– Avoiding foods that delay gastric emptying such

as fatty foods, chocolate, or alcohol.

PYLORIC STENOSIS
• If hypertrophy or hyperplasia of the muscle

surrounding the sphincter occurs, it is difficult
for the stomach to empty, a condition called
pyloric stenosis.
• The exact cause is unknown, but

multifactorial inheritance is the likely cause.

Pyloric stenosis
• Fluid is unable to
pass easily
through the
stenosed and
hypertrophied
pyloric valve.

Assessment - Pyloric Stenosis
• With this condition, at 4 to 6 weeks of age, infants
typically begin to vomit almost immediately after
each feeding.
• The vomiting grows increasingly forceful until it is

projectile, possibly projecting as much as 3 to 4 ft.

– Treatment is surgical or laparoscopic correction
(a pyloromyotomy)
– If dehydration and starvation have occured

corrected by administration of IV fluid.
– For surgical correction, the muscle of the pylorus

is split down to the mucosa, allowing for a larger
lumen.

Hepatitis A - Infectious Hepatitis
• Causative agent: a picornavirus, hepatitis A virus
(HAV) Incubation period: 25 days on average
• Period of communicability: highest during 2 weeks
preceding onset of symptoms
• Mode of transmission: in children, ingestion of
fecally contaminated water or shellfish
• Immunity: Natural immunity: one episode induces
immunity for the specific type of virus.
– Active artificial immunity: HAV vaccine (recommended for
all children 12 to 23 months of age, workers in day care
centers, and certain international travelers)
– Passive artificial immunity: immune globulin

Assessment
– No matter which virus is involved, acute hepatitis
is a generalized body infection with specific and
intense liver effects.
– All hepatitis viruses cause liver cell destruction.
– Hepatitis A is an acute self-limited illness and

spread via the fecal–oral route. Symptoms
include headache, fever, and anorexia. Jaundice
occurs as liver function slows.

Intestinal Disorders
• INTUSSUSCEPTION
– The invagination of one portion of the intestine

into another.
– The point of the invagination is generally at the

juncture of the distal ileum and proximal colon.

Intestinal Disorders - INTUSSUSCEPTION

Assessment
– Children with this disorder suddenly draw up their
legs and cry as if they are in severe pain, and
they may also vomit.
– After the peristaltic wave that caused the

discomfort passes, they are symptom free and
play happily.
– In approximately 15 minutes, however, the same

phenomenon of intense abdominal pain strikes
again.
Assessment
– The stool is described as having a “red currant
jelly” appearance due to the blood and mucus it
contains.
– Frank or occult blood is seen in the stool.
– The abdomen becomes distended as the bowel

above the intussusception distends.
– Presence of the intussusception is confirmed by

an abdominal X-ray, or ultrasound.

• The condition is a surgical emergency.
• Reduction of the intussusception must be

done promptly by either:
– instillation of a water-soluble solution
– barium enema, or air (pneumatic insufflation) into
the bowel
– surgery to reduce the invagination before
necrosis of the affected portion of the bowel
occurs.
NECROTIZING ENTEROCOLITIS
• Necrotic areas develop in the bowel that

interfere with digestion and can lead to
paralytic ileus, perforation, and peritonitis.
• The necrosis appears to result from ischemia

or poor perfusion of blood vessels in the
entire bowel or in isolated sections of the
bowel.

Therapeutic Management - NEC
– As soon as the condition is recognized,
breastfeedings or formula feedings are
discontinued.
– Antibiotic may be given to limit secondary
infection.
– Surgery to remove that portion of the bowel.
– Prognosis is guarded until the infant can again

take oral feedings without bowel complications.

APPENDICITIS
– Appendicitis (inflammation of the appendix) is the
most common cause of abdominal surgery in
children.
– Fecal material apparently enters the appendix,

hardens, and obstructs the appendiceal lumen.

Assessment
– Symptoms: anorexia, pain or tenderness in the
right lower quadrant, nausea or vomiting,
elevation of temperature, and leukocytosis.
– The point of sharpest pain is often one third of

the way between the anterior superior iliac crest
and the umbilicus (McBurney’s point).
– Fever is a late symptom.

Assessment
• Rebound tenderness is a phenomenon in which a
child feels relatively mild pain when the area over the
appendix is palpated, but, once an examiner’s hand is
withdrawn, the child experiences acute pain caused by
abdominal contents shifting.
• This is diagnostic for appendicitis.
• If, on auscultation, bowel sounds are reduced

(hypoactive), this suggests peritonitis or that the
appendix has already ruptured.

• Therapy for appendicitis is surgical removal

of the appendix by laparoscopy before it
ruptures.

CELIAC DISEASE (MALABSORPTION SYNDROME,
GLUTEN-INDUCED ENTEROPATHY, CELIAC SPRUE)
– Celiac disease is an immune-mediated abnormal

response to:
– gluten
– wheat
– rye
– barley
– oats

Celiac Disease
• If the disease goes undiagnosed, children

develop:
• steatorrhea (bulky, foul-smelling, fatty stools)
• failure to thrive and malnutrition.
• The classic picture of a child with celiac

disease—a thin child with a distended
abdomen.

• Treatment is to continue the gluten-free diet

for life.

Disorders of the Lower Bowel
• CONSTIPATION
– Functional constipation, or constipation without
an underlying medical disease, is a very common
problem in childhood, often starting in the first
year of life.
– As passing stool is painful, the child represses

the next urge to defecate to avoid pain.

• Treatment of chronic constipation is aimed at

softening stool so it will pass painlessly.
• A stool softener such as polyethylene glycol is

prescribed daily.
• Children should be encouraged to sit on the

toilet after meals to attempt defecation.

INGUINAL HERNIA
• Inguinal hernia is a protrusion of a section of

the bowel into the inguinal ring.
• If it fails to close, intestinal descent into it

(hernia) may occur at any time when there is
an increase in intra-abdominal pressure.

• Treatment of inguinal hernia is laparoscopy

surgery.
• The bowel is returned to the abdominal cavity

and retained there by sealing the inguinal
ring.

HIRSCHSPRUNG DISEASE (AGANGLIONIC
MEGACOLON)
• An absence of ganglionic innervation to the

muscle of a section of the bowel—in most
instances, the lower portion of the sigmoid
colon just above the anus.
• The absence of nerve cells means there are

no peristaltic waves in this section to move
fecal material through the segment of
intestine.

Aganglionic megacolon (Hirschsprung disease)
• The distal portion of

the bowel lacks
nerve innervation.
• Because there is no
peristalsis in this
narrowed segment,
the bowel proximal
to it distends
markedly.
Assessment
– Aganglionic megacolon generally do not become
apparent until 6 to 12 months of age.
– Children appear thin and undernourished.
– Have a history of not having a bowel movement

more than once a week of ribbonlike or watery
stools.

INFLAMMATORY BOWEL DISEASE: ULCERATIVE
COLITIS AND CROHN DISEASE
• Ulcerative colitis (UC) affects only the

mucosal lining of the colon, whereas Crohn
disease (CD) can affect any part of the GI
tract from the mouth to the anus.
• The area most commonly involved in CD is

the last part of the small intestine known as
the terminal ileum.

Ulcerative Colitis
• Crampy abdominal pain, urgency, tenesmus,

and frequent bloody stools. Anemia and
hypoalbuminemia due to losses in the stool
may be present.
• If it does not respond to medical therapy,

surgery to remove the colon is performed.

Crohn Disease
– Abdominal pain, diarrhea with or without blood,
and weight loss may be present.
– The inflamed area may become narrowed

causing a stricture of the bowel, and a bowel
obstruction may develop.
– Surgery may be necessary to remove strictures

or repair fistulae.

– Oral medications are usually sufficient to control
the symptoms.
– Vitamin and mineral deficiencies should be
corrected.
– Bowel surgery is always a serious step, but

because it reduces the possibility of the child
developing colon cancer in association with UC,
it may be necessary in children whose disease is
running a long-term,

CD and UC

IRRITABLE BOWEL SYNDROME
– (IBS) is a functional bowel disorder that typically
causes symptoms of abdominal pain and altered
bowel habits with no underlying organic cause.
– The cause is unknown.
– The onset of loose stools can follow an infection

and may be due to an alteration in the intestinal
flora.

IBS
• Antidepressants - Stress
• Antibiotics that work to reduce bacteria in the

gut such as rifaximin may be prescribed to
treat the symptoms of IBS.

Question #1
A 3-year-old male is diagnosed with intussusception. Which
symptom reported by the parents would have led the nurse to
suspect this diagnosis?
A. Projectile vomiting
B. Right lower quadrant pain
C. Bloody mucus stool
D. Rebound tenderness

Answer to Question #1
C. Bloody mucus stool
Rationale: The “currant jelly” stool is a classic

sign of intussusception. It is the presence of
blood with mucus in the bowel movements as the
digested food is blocked from advancing past the
point where the bowel is telescoped.

Question #2
A school-age boy has an emergency appendectomy. Which
assessment should the nurse report to his physician if noticed
in the immediate postoperative period?
A. Abdominal pain
B. A feeling of “tugging” at the incision line
C. Thirst
D. A rigid abdomen

D. A rigid abdomen
Rationale: One of the first symptoms of

peritonitis (infection of the peritoneal cavity) is
a tense, rigid abdomen.

Question #3
The nurse discovers that an infant is developing necrotizing
enterocolitis. Which is the best action?
A. Institute NPO status.

B. Insert a glycerin suppository.
C. Count respirations.
D. Dilute next formula feeding to 13 calories per ounce.

A. Institute NPO status.
Rationale: The damaged bowel is not able to

process food, so keeping it free of food to rest is
important.

END

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Gastrointestinal Disorders

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Chronic diarrhea is more likely related to a

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• pH probe (catheter inserted through the nose into the

• Esophageal manometry to assess esophageal motility

• Endoscopy to obtain biopsies to assess the degree of

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Therapeutic management options for

• In infants, gastroesophageal reflux is usually

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– Avoid acidic foods such as tomato products,

– Avoiding foods that delay gastric emptying such

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• If hypertrophy or hyperplasia of the muscle

• The exact cause is unknown, but

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• The vomiting grows increasingly forceful until it is

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– If dehydration and starvation have occured

– For surgical correction, the muscle of the pylorus

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– All hepatitis viruses cause liver cell destruction.

– Hepatitis A is an acute self-limited illness and

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– The invagination of one portion of the intestine

– The point of the invagination is generally at the

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– After the peristaltic wave that caused the

– In approximately 15 minutes, however, the same

– The abdomen becomes distended as the bowel

– Presence of the intussusception is confirmed by

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• The condition is a surgical emergency.

• Reduction of the intussusception must be

• Necrotic areas develop in the bowel that

• The necrosis appears to result from ischemia

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– Surgery to remove that portion of the bowel.

– Prognosis is guarded until the infant can again

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– Fecal material apparently enters the appendix,

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– The point of sharpest pain is often one third of

– Fever is a late symptom.

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• This is diagnostic for appendicitis.

• If, on auscultation, bowel sounds are reduced

Copyright © 2018 Wolters Kluwer · All Rights Reserved

• Therapy for appendicitis is surgical removal

Copyright © 2018 Wolters Kluwer · All Rights Reserved

– Celiac disease is an immune-mediated abnormal

Copyright © 2018 Wolters Kluwer · All Rights Reserved