GI Peds

When does the risk of colorectal cancer begin with IBDs?

10 years after diagnosis. Surveillance colonoscopy with multiple biopsies should begin approximately 10 years after diagnosis of ulcerative colitis or Crohn disease

When can formula or breastfeeding be initiated after a pyloromyotomy?

24 hours

When do feedings begin postoperatively (after a pyloromyotomy)?

4-6 hours with small frequent feedings of an electrolyte solution such as Pedialyte.

What are 5-ASAs used for with IBDs?

5-Aminosalicylates (5-ASAs) are effective in the induction and maintenance of remission in mild-to-moderate ulcerative colitis. Mesalamine, olsalazine, and balsalazide are now preferred over sulfasalazine because of reduced side effects (headache, nausea, vomiting, neutropenia, and oligospermia).

The absence of ganglion cells in the affected bowel results in what?

A lack of enteric nervous system stimulation, which decreases the ability of the internal sphincter to relax.

What is revealed during a diagnostic evaluation of intussusception?

A rectal examination reveals mucus, blood, and occasionally a low intussusception itself.

What is Meckel's diverticulum?

A remnant of the fetal omphalomesenteric duct, which connects the yolk sac with the primitive midgut during fetal life.

What is the most effective diagnostic testing for M.D.?

A technetium-99 pertechnetate scan (Meckel scan).

Clinical manifestations of M.D.?

Abdominal Pain • Similar to appendicitis • May be vague and recurrent Bloody Stools • Painless • Bright or dark red with mucus (currant jelly-like stools) • In infants, bleeding sometimes accompanied by pain Sometimes • Severe anemia • Shock

What are the classic triad of intussusception symptoms?

Abdominal pain Abdominal mass Bloody stools

Pathophysiology of EA and TEF?

Anomalies involving the trachea and esophagus are caused by defective separation, incomplete fusion of the tracheal folds after this separation, or altered cellular growth during embryonic development.

Where can Crohn's disease be found?

Any part of the GI tract from the mouth to the anus.

Preoperative care for a child who is malnourished and suffering from Hirschsprung disease?

Because a child who's malnourished may not be able to withstand surgery until their physical status improves, they receive symptomatic treatment with enemas; and a low-fiber, high-calorie, high-protein diet.

Why is Meckel's diverticulum often referred to by the "rule of twos"?

Because it occurs in 2% of the population, Has a 2 : 1 male-to-female ratio, Is located within 2 feet of the ileocecal valve, Is commonly 2 cm in diameter and 2 inches in length, Contains two types of ectopic tissue (pancreatic and gastric), and is more common before 2 years of age

What is a serious sign during the course of Hirschsprung? And How do you measure this sign?

Because progressive distention of the abdomen is a serious sign, the nurse measures abdominal circumference with a paper tape measure, usually at the level of the umbilicus or at the widest part of the abdomen. The point of measurement is marked with a pen to ensure reliability of subsequent measurements.

What is the most common problem in Meckel's diverticulum?

Bleeding Bleeding, which is the most common problem in children, is caused by peptic ulceration or perforation because of the unbuffered acidic secretion.

What are the 3 main complications of Meckel's diverticulum?

Bleeding, obstruction, and inflammation.

What tests/exams can be used to investigate complications of M.D.?

CT, MRI, and mesenteric angiography.

Clinical Manifestations of Intestinal Obstruction?

Colicky abdominal pain: From peristalsis attempting to overcome the obstruction Abdominal distention: As a result of accumulation of gas and fluid above the level of the obstruction Vomiting: Often the earliest sign of a high obstruction; a later sign of lower obstruction (may be bilious or feculent) Constipation and obstipation: Early signs of low obstructions; later signs of higher obstructions Dehydration: From losses of large quantities of fluid and electrolytes into the intestine Rigid and boardlike abdomen: From increased distention Bowel sounds: Gradually diminish and cease Respiratory distress: Occurs as the diaphragm is pushed up into the pleural cavity Shock: Caused by plasma volume diminishing as fluids and electrolytes are lost from the bloodstream into the intestinal lumen Sepsis: Caused by bacterial proliferation with invasion into the circulation

This is a long term complication of IBD.

Colorectal cancer

What are Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)?

Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) are rare malformations that represent a failure of the esophagus to develop as a continuous passage and a failure of the trachea and esophagus to separate into distinct structures.

(Hirschsprung's) The Hx is an important part of diagnosis and typically includes a chronic pattern of what?

Constipation

Clinical manisfestations of Hirschsprung Disease in childhood?

Constipation; Ribbonlike, foul-smelling stools; Abdominal distension; Visible peristalsis; Easily palpable fecal mass; Undernourished, anemic appearance.

What are corticosteroids used for with IBDs?

Corticosteroids such as prednisone and prednisolone are indicated in induction therapy in children with moderate-to-severe ulcerative colitis and Crohn disease. These drugs inhibit the production of adhesion molecules, cytokines, and leukotrienes.

Which IBD disorder is more disabling?

Crohn disease is more disabling, has more serious complications, and is often less amenable to medical and surgical treatment than is ulcerative colitis. Because ulcerative colitis is confined to the colon, a colectomy may cure ulcerative colitis.

What type of diet is a safe and potentially effective primary therapy for patients with Crohn's disease?

Elemental diet

Preoperative care for an older child who is suffering from Hirschsprung disease?

Emptying the bowels with saline enemas and decreasing bacterial flora with oral or systemic antibiotics and colonic irrigations using antibiotic solution.

What is the most serious complication of Hirchsprung disease?

Enterocolitis

What is the major nursing concern for an infant with EA?

Establishment and maintenance of a patent airway.

Why is it important to stress continued drug therapy for IBDs?

Even after remission of symptoms, discontinued usage can cause an exacerbation.

These signs should alert the nurse that an infant may have an EA or TEF.

Excessive amount of frothy saliva Difficulty with secretions Unexplained episodes of apnea, cyanosis, or oxygen desaturation

Clinical manisfestations of Hirschsprung Disease in newborns?

Failure to pass meconium within 24 to 48 hours after birth; Refusal to feed; Bilious vomiting; Abdominal distention.

Clinical manisfestations of Hirschsprung Disease in infancy?

Failure to thrive; Constipation; Abdominal distension; Episodes of diarrhea and vomiting; Signs of enterocolitis: explosive, watery diarrhea; fever; appears significantly ill.

When are feedings usually instituted after surgery for HPS?

Feedings are usually instituted within 12 to 24 hours postoperatively, beginning with clear liquids and advancing to formula or breast milk as tolerated. Observation and recording of feedings and the infant's responses to feedings are a vital part of postoperative care. Care of the operative site consists of observation for any drainage or signs of inflammation and care of the incision.

When is HPS usually diagnosed?

First 2-5 weeks of life

When is Hirschsprung diagnosed?

First few months of life.

Emergency preoperative care of Hirschsprung includes what?

Frequent monitoring of vital signs and blood pressure for signs of shock; monitoring fluid and electrolyte replacements and plasma or other blood derivatives; and observing for symptoms of bowel perforation such as fever, increasing abdominal distention, vomiting, increased tenderness, irritability, dyspnea, and cyanosis.

Preoperative considerations for M.D.?

Frequent monitoring of vital signs, including blood pressure and recording the approximate amount of blood lost in stools. Pain management.

Why are immunomodulators used with IBDs?

To induce and maintain remission in children with IBD who are steroid resistant or steroid dependent and to treat chronic draining fistulas.

What is the most dangerous form of colitis

Toxic megacolon is the most dangerous form of severe colitis.

T/F A colostomy for Hirchsprung disease is usually temporary?

True

T/F Crohn disease lesions may pierce the walls of the small intestine and colon, creating tracts called fistulas between the intestine and adjacent structures such as the bladder, anus, vagina, or skin.

True

These procedures are an integral part of diagnosing IBD?

Upper endoscopy, and colonoscopy with biopsies.

When is surgery indicated for ulcerative colitis?

When medical and nutritional therapies fail to prevent complications.

When is a well-balanced, high-protein diet recommended for peds with IBDs?

When the symptoms do not prohibit an adequate oral intake.

Is symptomatic M.D. recoverable?

Yes, if it's diagnosed and treated early.

What is Hirschsprung's disease?

congenital anomaly that results in mechanical obstruction (which leads to back up of materials and an enlarged colon (megacolon)) from inadequate motility of part of the intestine.

Therapeutic management of patients with EA and TEF?

maintenance of a patent airway, prevention of pneumonia, gastric or blind pouch decompression, supportive therapy, and surgical repair of the anomaly.

Which gender is Hirschsprung's disease more common in?

males (4x more common)

Why are antibiotics used for IBDs?

metronidazole and ciprofloxacin used to treat perianal disease and/or bacterial infections

What is intussusception?

the slipping of a length of intestine into an adjacent portion usually producing obstruction.

Clinical Manifestations of tracheoesophageal fistula?

• Excessive salivation and drooling • Three C's of tracheoesophageal fistula: • Coughing • Choking • Cyanosis • Apnea • Increased respiratory distress during feeding • Abdominal distention

What are the clinical manifestations of intussusception?

• Sudden acute abdominal pain • Child screaming and drawing the knees toward the chest • Child appearing comfortable during intervals between episodes of pain • Vomiting • Lethargy • Passage of red, currant jelly-like stools (stool mixed with blood and mucus) • Tender, distended abdomen • Palpable sausage-shaped mass in upper right quadrant • Empty lower right quadrant (Dance sign) • Eventual fever, prostration, and other signs of peritonitis

How is the diagnosis of Hirschsprung confirmed?

Rectal biopsy

When are any persistent respiratory difficulties after removal of secretions reported?

Reported to the surgeon immediately.

Other nursing interventions for EA and TEF?

Respiratory assessment Airway management Thermoregulation Fluid and Electrolyte management PN support

Preoperative care for a newborn who is suffering from Hirschsprung disease?

Since their bowels are relatively sterile, no additional preparation may be necessary.

Nursing interventions for IBD?

Successful interventions include involving the child in meal planning; encouraging small, frequent meals or snacks rather than three large meals per day; serving meals around medication schedules when diarrhea, mouth pain, and intestinal spasm are controlled; and preparing high-protein, high-calorie foods such as eggnog, milkshakes, cream soups, puddings, or custard (if lactose is tolerated). Using bran or a high-fiber diet for active IBD is questionable. Bran, even in small amounts, has been shown to worsen the condition.

The majority of peds with Hirschsprung disease require what form of therapy?

Surgery

Standard treatment for symptomatic M.D.?

Surgical removal of the diverticulum. Extra Info ((When severe hemorrhage increases the surgical risk, interventions to correct hypovolemic shock such as blood replacement, IV fluids, and oxygen may be necessary. Antibiotics may be used before surgery to control infection. If intestinal obstruction has occurred, appropriate preoperative measures are used to reverse electrolyte imbalances and prevent abdominal distention.))

Pathophysiology of hypertrophic pyloric stenosis?

The circular muscle of the pylorus thickens as a result of hypertrophy. This produces severe narrowing of the pyloric canal between the stomach and the duodenum, causing partial obstruction of the lumen (Fig. 41.4, A). Over time, inflammation and edema further reduce the size of the opening, resulting in complete obstruction. The hypertrophied pylorus may be palpable as an olive-like mass in the upper abdomen.

What description given by the infant's parents is a significant sign of intussusception?

The description of the child's severe colicky abdominal pain combined with vomiting is a significant sign of intussusception.

How are the IBD disorders diagnosed?

The diagnosis of ulcerative colitis and Crohn disease comes from the history, physical examination, laboratory evaluation, and other diagnostic procedures. Laboratory tests include a CBC to detect anemia and an erythrocyte sedimentation rate (ESR) or CRP to assess the systemic reaction to the inflammatory process.

Crohn's often involves what?

The disease involves all layers of the bowel wall (transmural) in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation may result in ulcerations; fibrosis; adhesions; stiffening of the bowel wall; stricture formation; and fistulas to other loops of bowel, bladder, vagina, or skin.

What are the goals of nutritional support for IBDs?

The goals of nutritional support include (1) correction of nutrient deficits and replacement of ongoing losses, (2) provision of adequate energy and protein for healing, and (3) provision of adequate nutrients to promote normal growth. Nutritional support includes both enteral nutrition and parenteral nutrition (PN).

What are the 4 goals of therapy for IBDs?

The goals of therapy are to (1) control the inflammatory process to reduce or eliminate the symptoms, (2) obtain long-term remission, (3) promote normal growth and development, and (4) allow as normal a lifestyle as possible.

When EA with a TEF is suspected, what is the FIRST intervention?

The infant is immediately deprived of oral intake, IV fluids are initiated, and the infant is positioned to facilitate drainage of secretions and decrease the likelihood of aspiration.

What position should the infant with EA and TEF be placed in?

The infant's head is kept upright to facilitate removal of fluid collected in the pouch and prevent aspiration of gastric contents.

What is usually seen with the diagnosis of HPS?

The olive-like mass is easily palpated when the stomach is empty, the infant is quiet, and the abdominal muscles are relaxed. Vomiting usually occurs 30 to 60 minutes after feeding and becomes projectile as the obstruction progresses. Emesis is nonbilious in the early stages. These infants may become dehydrated and appear malnourished if an early diagnosis is not established.

A common, serious complication in patients with IBD?

Growth failure Growth failure is characterized by weight loss, alteration in body composition, restricted height, and delayed sexual maturation. Malnutrition causes the growth failure, and its etiology is multifactorial.

What is the diagnosis of M.D. usually based upon?

History and physical; radiographic studies, xrays, CT, wireless capsule endoscopy, lab work to evaluate bleeding

What is hypertrophic pyloric stenosis?

Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. This produces an outlet obstruction and compensatory dilation, hypertrophy, and hyperperistalsis of the stomach. This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding. If the condition is not diagnosed early, dehydration, metabolic alkalosis, and failure to thrive may occur.

What is Inflammatory Bowel Disease (IBD)?

IBD is a term used to refer to two major forms of chronic intestinal inflammation: Crohn disease (CD) and ulcerative colitis (UC).

Postoperative considerations with M.D.?

IV fluids and an NG tube for decompression and evacuation of gastric secretions; Signs of return of normal bowel function should be monitored in the postoperative period.

Since vomiting is common during the first 24 - 48 after a surgery for HPS, what is a nursing intervention for this?

IV fluids are administered until the infant is taking and retaining adequate amounts by mouth.

Therepeutic management of intussusception?

IV fluids, NG decompression, and antibiotic therapy may be used before hydrostatic reduction is attempted. If these procedures are not successful, the child may require surgical intervention.

In ulcerative colitis the inflammatory process affects what?

Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema. Thickening of the bowel wall and fibrosis are unusual, but long-standing disease can result in shortening of the colon and strictures. Extraintestinal manifestations are less common in ulcerative colitis than in Crohn disease.

Patho of intssusception

Intussusception occurs when a proximal segment of the bowel telescopes into a more distal segment, pulling the mesentery with it. The mesentery is compressed and angled, resulting in lymphatic and venous obstruction. As the edema from the obstruction increases, pressure within the area of intussusception increases. When the pressure equals the arterial pressure, arterial blood flow stops, resulting in ischemia and the pouring of mucus into the intestine. Venous engorgement also leads to leaking of blood and mucus into the intestinal lumen, forming the classic currant jelly-like stools.

Several mechanisms may cause obstruction in Meckel's diverticulum?

Intussusception or entaglement of the small intestine.

Why is Meckel's diverticulum called a "true diverticulum"?

It includes all layers of the intestinal wall.

In ulcerative colitis, where is the inflammation found?

It is limited to the colon and rectum.

Pathophysiology of hirchsprung?

It is related to the absence of ganglion cells in the affected areas of the intestine, which results in a loss of the rectosphincteric reflex and an abnormal microenvironment of the cells of the affected intestine.

In Hirschsprung's what will you usually find upon examination of the rectum?

It will be empty of feces and the internal sphincter will be tight.

Decrease of the ability of the internal sphincter to relax leads to what?

Leads to an inability to properly pass a bowl movement, which in turns leads to an enlarged colon. ((In Hirschsprung's disease, the internal sphincter does not relax.))

Which gender is more likely to suffer from EA and TEF?

Males

What is malnutrition related to? (IBDs)

Malnutrition occurs as a result of inadequate dietary intake, excessive GI losses, malabsorption, drug-nutrient interaction, and increased nutritional requirements. Inadequate dietary intake occurs with anorexia and episodes of increased disease activity. Excessive loss of nutrients (protein, blood, electrolytes, and minerals) occurs secondary to intestinal inflammation and diarrhea. Carbohydrate, lactose, fat, vitamin, and mineral malabsorption as well as vitamin B12 and folic acid deficiencies occur with disease episodes, with drug administration, and when the terminal ileum is resected. Finally, nutritional requirements are increased with inflammation, fever, fistulas, and periods of rapid growth (e.g., adolescence).

What are a few serious complications of ulcerative colitis?

Malnutrition, growth failure, and bleeding.

What ages is intussusception most common? And what gender is most affected?

Most common cause of intestinal obstruction between the years of 3 months and 3 years. Males

Is there a cure for IBD?

No known cure

What do you see in a neonate that can be a signal of Hirschsprung's disease?

No meconium, which can lead to bilious vomiting and abdominal distension. [Meconium is usually passed in the first 48 hours of life.]

Passage of what, indicates that the intussusception has reduced itself?

Normal brown stool

When assessing vital signs in an infant with HPS, what are you looking for and why?

Observations also include assessment of vital signs, particularly those that might indicate fluid or electrolyte imbalances. These infants are prone to metabolic alkalosis from loss of hydrogen ions and to potassium, sodium, and chloride depletion. Assess the skin, mucous membranes, and daily weight for alterations in hydration status.

How are EA and TEF diagnosed?

On the basis of clinical symptoms, and the exact type is based upon radiographic studies.

Postoperative care of Hirschsprung's disease includes what?

Ostomy care, daily anal dilations, and skin care around stoma.

The most common clinical presentation in children with M.D.?

Painless rectal bleeding, abdominal pain, or signs of intestinal obstruction. Bleeding, which may be mild or profuse, often appears as dark red or "currant jelly" stools; it may be significant enough to cause hypotension.

What is present in the maternal hx that is usually found with EA and TEF?

Polyhdramnios

What is the preoperative focus for an infant with HPS?

Preoperatively, the emphasis is placed on restoring hydration and electrolyte balance. Infants are usually given no oral feedings and receive IV fluids with dextrose and electrolyte replacement based on laboratory serum electrolyte values and clinical appearance.

Why is stool examined for IBD?

Presence of blood, leukocytes, and infectious organisms.

Clinical manifestations of HPS?

Projectile vomiting • May be ejected 3 to 4 feet from the child when in a side-lying position, 1 foot or more when in a supine position • Occurs shortly after a feeding but may not occur for several hours • May follow each feeding or appear intermittently • Nonbilious vomitus that may be blood tinged Infant hungry, avid feeder; eagerly accepts a second feeding after vomiting episode No evidence of pain or discomfort except that of chronic hunger Weight loss Signs of dehydration Distended upper abdomen Readily palpable olive-shaped tumor in the epigastrium just to the right of the umbilicus Visible gastric peristaltic waves that move from left to right across the epigastrium

What is the standard surgical procedure to relieve HPS?

Pyloromyotomy