Altered Gastrointestinal Function I

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What is the normal functioning of the gastrointestinal system?: 1. Digestion and absorption
2. Elimination
3. Fluid/Electroylte balance
4. Secretion of digestive substances
Growth & Development of the gastrointestinal system:: - fetus swallows and ingests amniotic fluid
- GI system IMMATURE at birth
- No voluntary control over swallowing (approximately 6 weeks of age)
- newborn has small stomach capacity
- cardiac sphincter relaxed - regurgitation
- intestinal mobility (faster in newborns)
- more frequent BMs
- babies need to be fed a lot
- infants are deficient in carb, protein and fat enzymes (Amylase, Lipase, and Trypsin) - 4-6 months should have full amounts of enzymes
- Liver function immature (impact on digestion and jaundice)
- GI system and bladder control fairly complete by 2 YEARS (stomach capacity increases to accommodate 3 meals per day)
Common consequences of GI dysfunction:: 1. Malabsorption
2. Malnutrition
3. Impaired growth (organic, inorganic, and idiopathic failure to thrive) *nonorganic FTT is related to more than 1 cause
4. Fluid/electrolyte imbalances
What are S&S of GI disorders?: 1. Failure to thrive (organic, inorganic and idiopathic)
2. Spitting/regurgitation/vomiting
3. Constipation
4. Diarrhea
5. Pain/Colic
6. Abdominal distention
7. GI bleeding
8. Jaundice
Assessment of the gastrointestinal system: 1. History:
- change in eating habits
- food allergies
- bowel changes (it can be normal for a person to go a few days without a BM but if there is a change in frequency, color or consistency, there can be a problem)
2. Physical Exam:
- Height
- Weight
- I&O
- lab values
- abdominal exam
3. Diagnostic Procedures:
- Stool testing
- radiography
- biopsy
- enzyyme analysis
- pain
How is gastric decompression achieved?: - N/G tubes
- Gastrostomy tube

**decompress: allowing fluid or air to be released from the stomach
**bilious vomiting (means obstruction further down in the GI tract and bile and air backs up; needs to be decompressed)
Enteral feedings are accomplished through:: 1. N/G tubes
2. Gastrostomy tubes
3. Jejunostomy tubes
What is Parenteral Nutrition?: - TPN (Total Parenteral Nutrition) and Lipids (Hyperalimentation: procedure in which nutrients and vitamins are given in liquid form through a vein)
- provided when GI tract is nonfunctional and when feeding is held for a long period of time
What are the long-term complications of TPN?: - IV acces
- infection
- thrombosis
- liver dysfunction
What medications are taken for the gastrointestinal system?: 1. Antiemetics
2. Laxatives / stool softeners
3. Antibiotics
What are 4 disorders of gastrointestinal motility?: 1. Constipation
2. Diarrhea
3. Hirshsprung disease
4. Gastroesophageal reflux
What is constipation?: - alteration in frequency, consistency, or ease of stool passage
- Chronic constipation: may be due to environmental or psychological factors
What are some causes of constipation?: - inadequate fluid and fiber intake
- not enough exercise
- issues with motility
- long term opioid use
- pregnancy
- metabolic conditions
- formula fed infants
Newborn issues with constipation:: - 1st meconium should be passed within 24-36 hours; if not, assess for:
1. Hirschsprung disease (congenital disease; blockage of large intestine due to improper muscle movement (due to missing nerves) in the bowel
2. Hypothyroidism (thyroid gland does not produce enough thyroid hormone)
3. Meconium plug (a little plug that is similar to the consistency and color of the umbilical cord
4. Meconium ileus (CF) - meconium that is thickened and congested in the ileum (related to cystic fibrosis)
Infancy issues related to constipation:: - usually related to DIET (ex. iron)
- constipation from exclusively breastfed infants is very uncommonly (infrequent stool may occur because of minimal residue from digested breast milk
- formula fed infants (may develop constipation) - harder to digest, stays in system longer, could be related to how powder is diluted
How is constipation managed?: 1. Glycerin suppositories / mineral oil
2. Alterations in diet (change formula, increase fiber, increase fluid, eliminate binding foods)
3. Establish regular schedule for defecation
4. DO NOT encourage laxatives with children
What is diarrhea?: - frequent, watery, loose stools
- increased intestinal motility (results in impaired absorption & electrolyte imbalance
- a SYMPTOM (not a disease)
- acute or chronic, inflammatory or non-inflammatory, viral or bacteria (ex. rhodovirus, norwalk virus, adenovirus, e.coli, salmonella)
What are some causes of diarrhea?: - respiratory or intestinal infection
- colon disease or trauma
- food intolerance / sensitivity
- medication
- surgery
- stress
Statistics of diarrhea in children:: - acute diarrhea (#1 cause of illness in children LESS than 5 years)
- 20% of deaths in developing countries related to diarrhea and dehydration
**can lead to dehydration, electrolyte imbalance, hypovolemic shock, and death (*need to be able to distinguish between mild, moderate and severe)
What is mild dehydration? (5% weight loss): ***5% of body weight LOSS
- slight increased HR (tachycardia)
- decreased tear production
- dry mucous membranes
- slight oliguria

**50 ml/kg replacement needed
What is moderate dehydration? (10% weight loss): ***10% body weight loss
- moderate increased HR (tachycardia)
- dry mucous membranes
- decreased skin turgor
- sunken eyes/fontanelles
- prolonged capillary refill

*100 ml/kg replacement needed
What is severe dehydration? (15% weight loss): ***15% body weight loss
- severe tachycardia
- HYPOTENSION
- MOTTLED skin (discoloration of skin in irregular patches)
- absence of tear production
- anuria (absence of urine output)
- decreased LOC (level of consciousness)

*at least 20 ml/kg of NS as RAPID BOLUS (ABSOLUTELY need IV)
How is diarrhea managed?: - fluid / electrolyte assessment
- oral rehydration
- fluid therapy
- 1 dose of Ondansetron (Zofran)?
- reintroduction of adequate diet
What is the composition of various drinks and oral rehydration fluids?: - Apple Juice (Na: 3, C: 124, O: 730)
- Ginger Ale (Na: 3, C: 90, O: 540)
- Chick. Broth (Na: 250, C: 0, O: 450)
- Gatorade (Na: 45, C: 60, O: 300)
- Pedialyte (Na: 45, C: 25, O: 250)
- WHO ORS (Na: 90, C: 20, O: 310)

***More of a balance for Gatorade and Pedialyte - Carbs help the Na across the gut membrane
***Gatorade is similar to Pedialyte but children like it better
What are some concepts of oral rehydration?: - Rehydration solution of 70-90 mEq of Na+/L
- Give 40-50 ml/kg (over first 4 hours)
- Maintain hydration with solution of 40-60 mEq Na+/L
- Daily volume of maintenance hydration (LESS than or EQUAL to 150 ml/kg/day)
How is diarrhea prevented?: - most diarrhea is spread by the fecal-oral route (teach hygeine)
- clean water (prevent contamination - ex. e. coli)
- careful food preparation
What is Hirschsrpung disease? (AKA Congenital Aganglionic Megacolon): - AKA congenital aganglionic megacolon
- mechanical obstruction from inadequate motility of intestine (innervation to a portion of bowel is not functioning properly - usually lower portion [approx. 1-2 feet] near rectum)
- becomes distended and thins (then inflammed)
- ABSENCE of GANGLION cells in colon
- 1 in 5000 live births
- more common in MALES & in DOWN SYNDROME
What are the S&S of Hirschprung disease (aka congenital aganglionic megacolon)?: - aganglionic segment usually includes RECTUM and PROXIMAL COLON
- distention (accumulation of stool)
- failure of INTERNAL ANAL SPINCHTER to relax
- ENTEROCOLITIS (may occur) - inflammation of the colon and small intestine
What are the S&S of Hirschprung disease in NEONATES (newborn to 28 days)?: - no passage of meconium for 24-48 hours
- FEVER
- BILIOUS emesis (bile [green color] in vomit)
- DISTENDED abdomen
- explosive diarrhea (when fluid and stool slip by)
What are the S&S of Hirschprung disease in a CHILD?: - CONSTIPATION
- DIARRHEA & VOMITING
- FEVER
- Ribbon-like, FOUL smelling stools
- Visible peristalsis
- Malnutrition
How is Hischprung disease diagnosed?: 1. Xray (Barium enema)
2. Anorectal manometric exam (measure nerve impulses)
3. Rectal biopsy (confirm diagnosis by observing for nerve cells)
How is Hirschprung disease managed?: - Surgery with 2 STAGES (to remove non-innervated portion of bowel) *nerves can\'t be replaced
STAGE 1:
- temporary colostomy proximal (nearest) to innervated bowel
STAGE 2:
- \"pull through\" procedure at 8-12 MONTHS, and closure of colostomy
What are preoperative nursing considerations for Hirschprung disease?: - IVF (IV fluids)
- NPO (12 hours before)
- Gastric decompression
- Measure abdominal girth (compare to postop)
- I&O
- possible enema
- routine operative prep
What are postoperative nursing considerations for Hirschprung disease?: - NPO
- IVF (IV fluids)
- gastric decompression
- dressing changes
- foley catheter
- monitor ostomy drainage
What is Gastroesophageal Reflux (GER)?: - transfer of gastric contents into the esophagus
- exact cause unknown
- frequency & persistency may make it abnormal
- may occur without GERD (disease)
- majority of babies will grow out of it (usually related to immature spinchter)
What are the S&S of Gastroesophageal Reflux (GER)?: - Vomiting
- Weight loss, FFT (failure to thrive)
- Irritability
What are potential complications of gastroesophageal reflux (GER)?: - apnea (suspension of external breathing)
- cyanosis (blue or purple in color)
- aspiration pneumonia
- esophagitis (inflammation of esophagus)
- bleeding
- Gagging or go off color with feeding
How is gastroesophageal reflux (GER) diagnosed?: - feeding assessment (monitor and track feeds)
- pH Probe (insert probe [like NG] and sensor can detect the amount of pH; baby is fed during test and they can determine how much reflux)
- Barium swallow and upper GI series
- Endoscopy (looking inside with a small flexible tube that has a camera attached)
- Manometry of esophageal sphincter pressure (observe innervation)
How is gastroesophageal reflux (GER) managed?: - nutritional support (small, frequent, thickened feeds with frequent burping)
- Positioning during feeding (upright as long as possible [up to 30 mins after]; do not put them in carseat after feeding - puts pressure on the abdomen) **for infant with SEVERE GERD - position prone with HOB elevated - only when monitored (prone position is related to SIDS)
- daily weight
- Medications (H2 receptor blockers - decrease gastric secretions ex. Ranitidine; Proton pump inhibitors - inhibit gastric secretions)
- Monitor for apnea, cyanosis, respiratory distress
- Surgery: NISSEN FUNDIPLICATION (most common) - fundus is wrapped around the lower part of the esophagus
*in SEVERE cases, may have gastrostomy tube for 6-8 WEEKS after surgery
What is Malabsorption Syndrome?: - Charcterized by CHRONIC DIARRHEA and MALABSORPTION of NUTRIENTS
- may result in FTT (failure to thrive) - insufficient weight gain or inappropriate weight loss
- related to DIGESTIVE, ABSORPTIVE, or ANATOMIC defects
- short bowl syndrome is related to malabsorption
What is Short Bowel Syndrome (SBS)?: Decreased mucosal surface area resulting from structurally or functionally absent bowel
What are the causes of Short Bowel Syndrome (SBS)?: 1. Congenital:
- Intestinal atresia - a narrowing or absence of a portion of the intestine
- Midgut Volvulus - condition in which bowel becomes twisted as a result of malrotation during fetal development
2. Neonatal:
- NEC (Necrotizing Enterocolitis) - death of intestinal tissue
- Intestinal malrotation - rotation of the midgut during fetal development
- tumors
3. Childhood:
- Intussusception - part of the intestine invaginates into another section of the intestine (ex. similar to the pieces of a telescope)
- Crohns - Chronic inflammation of the gastrointestinal tract
- Accidental injury
What are the S&S of Short Bowel Syndrome (SBS)?: - Intractable (hard to control) diarrhea
- Fluid / Electrolyte imbalances
- Gastric hypersecretion
- Steatorrhea (fat in stool; problems with fat absorption)
- poor growth and development
How is Short Bowel Syndrome (SBS) diagnosed?: 1. Medical / Surgical History
2. Abdominal Xray
3. Labs: CBC and Electrolytes
4. Laparotomy - surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as celiotomy
How is Short Bowel Syndrome (SBS) managed?: - Nutritional support (TPN and Enteral Feeding)
- Monitor hydration and for infection
- Medications
- long term management
What is Celiac Disease (AKA Gluten-Induced Enteropathy & Celiac Sprue)?: - intestinal intolerance to GLUTEN causes TOXIC substances to DAMAGE mucosal villi
- decreased absorptive capacity of intestine (especially foods containing GLUTEN of WHEAT, RYE, OATS, and BARLEY)
- higher incidence in Canada & Europe
- Celiac can be triggered by stressors
- gluten can be toxic to the system
What are the S&S of Celiac Disease?: - Steatorrhea (excess fat in stool)
- Diarrhea
- Anorexia, FTT (failure to thrive: insufficient weight gain or inappropriate weight loss)
- Muscle wasting (affects growth)
- S&S usually develop at 1-2 YEARS of AGE
- range of severity of malabsorption
- BREASTFEEDING (PROTECTIVE against Celiac)
How is Celiac Disease diganosed?: - Mucosal biopsy
- Symptomatic improvement with gluten-free diet
**Lab:
- Steatorrrhea (excess fat in stool), - - - Anemia
- HYPOalbuminemia (low protein in blood)
- low serum VITAMIN D & A
- low calcium
- PROLONGED prothrombin time

**resembles many other problems
How is Celiac disease managed?: - Gluten-free diet
- encourage CORN, RICE, SOY, POTATO FLOUR, FRESH FRUIT
- supplemental vitamins and iron (*can develop osteoporosis if it continues for a long period of time)

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