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Pediatrics > Exam 2: GI > Flashcards

Exam 2: GI Flashcards

1
Q

Hirshprung’s Disease

A
  • also known as congenital aganglionic megacolon
  • Mechanical obstruction caused by inadequate motility of part of the intestine
  • Lack the ganglion that are necessary for peristalsis
  • Due to this aganglionic portion, you end up having an accumulation of stool proximal to the portion of the large intestine that is affected by the Hirshprung’s
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2
Q

Areas affected by Hirshprung’s Disease

A

Usually includes rectum and proximal portion of the large intestine

  • 15-20% of children can have it spread to the rest of the colon
  • ~10% of children can have it spread to the entire intestines
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3
Q

Incidence of Hirshprung’s Disease (6)

A
  1. ¼ of all neonatal obstruction but may not be diagnosed until later in infancy or childhood
  2. Is usually diagnosed at/around birth
  3. More common in children with Downs Syndrome
  4. 4x more common in males
  5. 1 in 5,000 births
  6. Familial component/genetic predisposition → if you have a child with Hirshprung’s then your next child has a slightly increased likelihood of getting it too

EXACT ETIOLOGY IS UNKNOWN

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4
Q

Pathophysiology of Hirshprung’s Disease (4)

A

1st: Absence of ganglionic cells in one or more segments of the colon
2nd: Results in absence of propulsive movements (peristalsis) leading to accumulation of intestinal contents and distention of bowel proximal to defect (megacolon)
3rd: Internal anal sphincter fails to relax
4th: Intestinal distention and ischemia of bowel wall which leads to enterocolitis (inflammation of small bowel and colon) which is leading cause of death in children with Hirshprungs (worry about this if patient can’t have surgery)

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5
Q

Number one complication of Hirshprung’s

A

Entercolitis then Peritonitis

Entercolitis: inflammation of intestine and colon

Peritonitis: perforation of bowel wall that will occur second to entercolitis

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6
Q

Symptoms of Peritonitis (6)

A
  1. severe abdominal pain,
  2. very rigid and tender abdomen,
  3. distended abdomen,
  4. fever,
  5. dyspnea,
  6. no bowel sounds upon auscultation
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7
Q

Newborn Signs and Symptoms of Hirshprung’s (4)

A
  1. Failure to pass meconium (first stool) within 24 to 48 hrs. after birth
    - -Meconium is black and tarry and difficult to clean
    - -Failure to pass means you need further evaluation to see if the patient has Hirshprung’s
  2. Reluctance to ingest fluids
  3. Bile-stained vomitus
  4. Abdominal distention
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8
Q

Infancy Signs and Symptoms of Hirshprung’s (7)

A
  1. Failure to thrive
  2. Constipation due to lack of peristalsis
  3. Abdominal distention
  4. Episodes of diarrhea and vomiting
  5. Explosive watery diarrhea
  6. Fever
  7. Severe exhaustion
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9
Q

Childhood Signs and Symptoms of Hirshprung’s (6)

A
  1. Constipation
  2. Ribbon-like, foul-smelling stool that leaks around where the mega-colon is
  3. Abdominal distention
  4. Visible peristalsis in abdomen
  5. Fecal masses easily palpable
  6. Poorly nourished child and anemic

Very rare!

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10
Q

Diagnosing Hirshprung’s (4)

A
  1. Rectal exam –> tight internal sphincter and absence of stool
  2. Barium enema
  3. Anorectal manometry
  4. Definitive diagnosis is rectal biopsy; there will be a lack of nerve fibers with Hirshprung’s disease
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11
Q

Therapeutic Managment of Hirshprung’s

A
  1. At birth, total surgery correction where they remove the diseased portion of the bowel and reinastimose the healthy parts (
  2. At 9kg pull through procedure and colostomy closed
    * Depending on age of child, may have to do temporary ostomy after removal of aganglionic portion and once mega-colon area gets back to normal shape they reinastimose the healthy parts
  3. Outcome of surgery is very good; 65-85% end up achieving normal bowel function
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12
Q

Enterocolitis

A

Inflammation of intestine and colon; the biggest concern of pre-op patient’s with Hirshprung’s

*Will need to assess for signs and symptoms of perforated bowel (peritonitis)

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13
Q

Assessing for Signs of Perforated Bowel (7)

A
  1. Vital signs – looking for shock; tachycardia, increased RR, high fever, may have hypotension
  2. Absent bowel sounds
  3. Abdominal distention and tenderness
  4. Vomiting
  5. Irritable
  6. Fever – DO NOT DO RECTAL TEMPS
  7. Dyspnea and cyanosis
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14
Q

Post-Op Care of Hirshprung’s

A
  1. Colostomy care
  2. Prevent contamination of wound with urine
  3. Impaired skin integrity due to incontinence
  4. NPO until bowel sounds return or flatus passed – IV fluids
  5. Pain control
  6. Strict I&O
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15
Q

Gastroesophogeal Reflux

A

Very common, could be due to/in conjunction with something else such as a treatment

  • Dysfunction of lower esophageal sphincter (LES)
  • Delayed gastric emptying
  • Poor clearance of esophageal acid
  • Susceptibility of esophageal mucosa to acid injury
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16
Q

Etiology of Gastroesophogeal Reflux (9 with most common cause)

A
  1. Prematurity
  2. Tracheal-esphogeal atresia
  3. Neurological disorders; delay in the message from the brain to the sphincter to close after eating
  4. Scoliosis
  5. Asthma
  6. Cystic Fibrosis
  7. Partial or incomplete swallowing dysfunctions
  8. Theophylline and caffeine
  9. Increased abdominal pressure
  10. Infants with short LES; Immature sphincter
    • **This is the most common cause!
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17
Q

Tracheal-Esophogeal Atresia

A

When esophagus ends with a blind pouch; no connection to stomach

  • Will have a fistula that is connected to a trachea
  • When you try feeding them, they will present with cough, congestion, respiratory distress because the feed is going into the fistula then into trachea
  • Surgical repair of this can put a child at risk for developing reflux
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18
Q

Incidence of Gastroesophogeal reflux (3)

A
  1. 3% of all newborns, but rare to see it in the newborn period
  2. Peaks between 1-4 months of age, usually resolves by 6-12 months of age
    * **This is because regurgitation/irritability incidence decreases since they begin to sit up and are beginning to eat solids
  3. Boys affected 3x more than girls
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19
Q

Signs and Symptoms of Gastroesophageal Reflux (10)

A
  1. Vomiting/may be constantly regurigtaing
  2. Weight loss
  3. Failure to thrive (may not be gaining weight)
  4. Very Irritable because the mucosa is getting excoriated; every time they reflux it’s very painful (May increase after eating)
  5. Respiratory illness
  6. Coughing, choking, apnea, bradycardia (May be aspirating)
  7. Hiccups
  8. Recurrent weight loss
  9. Heme (+) stools; blood in stool from bleeding in esophagus
  10. Sandifer’s syndrome
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20
Q

Apnea with Gastroesophogeal Reflux

A

Aspiration and regurgitation stimulates mucous production in the throat which can lead to apnea or bradycardia
*Near life threatening event: apneic episode at home and they need resuscitation

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21
Q

Sandifer’s Syndrome

A

Neuro-behavioral syndrome; will see child arching and turning head to side

  • While/after eating, they will have episodes where they exhibit this
  • Baby will be irritable, trying to wiggle around and/or arch
  • Similar traits could also be seen in patients with neurological disorders, such as seizure disorder; if you see a child exhibit this behavior, you may think something else is going on and may incorrectly give an anticonvulsant
  • Very important to keep this in the back of your mind that it could be reflux
22
Q

Diagnostic Tests for GER (4)

A
  1. Upper GI series to rule out something else like pyloric stenosis
  2. Radionuclide tests
  3. 24 hour esophageal ph monitoring
  4. Endoscopy & esophageal biopsy; want to look and see if there is damage or inflammation in the esophagus
23
Q

24 hour esophageal pH monitoring test

A

This is the gold standard for diagnosing GERD

  • *Will pass an NG tube with a monitor at the bottom that will assess different things such as
    1. pH of acid,
    2. How many episodes of reflux in 24 hours
    3. How long does it take for acid to clear
24
Q

Management of GER (two types)

A

Depends on the severity!!

  1. Thriving infant without respiratory complications:
    A. Small frequent feedings
    B. Thickened feedings with rice cereal; only time you’ll put rice cereal in the bottle
    C. Positioning with HOB elevated
  2. Failure to Thrive infants with severe reflux, who failed to respond to medical therapy or have an anatomic abnormality contributing to symptoms:
    A. NG feedings and/or surgery (Nissen Fundop)
25
Q

Nissen Fundoplication

A

Tx of severe GER

Take the fundus of the stomach, wrap it around the lower part of the esophagus, and try to prevent the refluxing of food back into the esophagus

  • Not done unless necessary due to complications, such as:
    1. Obstruction
    2. Gas bloat syndrome; unable to burp and belch
26
Q

GERD Medications (3)

A
  1. Antacids or H2 blockers (very rare to use antacids)
  2. PPIs (better than H2 blockers)
  3. Prokinetics
27
Q

Antacids or H2 Blockers for GERD (3)

A
  1. cemetidine(Tagamet)
  2. ranitidine (Zantac); Approved for children under age 1
  3. famotidine (Pepcid); Approved for children under age 1
    * It’s very rare to use antacids; not the choice of meds for children; can use H2 blockers
28
Q

PPIs for GERD (2)

A
  1. omeprazole (Prilosec)
  2. lansoprazole (Prevacid); Approved for children under age 1, but should mainly be 1 and above
    • *This is the drug of choice!
    • *Give prevacid about 30 minutes before eating
  • PPIs are better at healing than H2 antagonists
  • Less of developed tolerance than with H2 antagonists
29
Q

Prokinetics for GERD (2)

A
  1. metoclopramide (Reglan)
    • *First choice in this category
    • *Give it 30 minutes before meal
    • *Give if they have decreased gastric emptying
  2. bethanecol (Urecholine)

**Decreased gastric emptying makes reflux worse; if they have decreased gastric emptying they will be on a prokinetic!!

30
Q

Nursing Diagnosis with Reflux (6)

A
  1. Risk for aspiration
  2. Impaired swallowing
  3. Acute pain
  4. Imbalanced nutrition
  5. Knowledge deficit (Major one)
  6. Parental anxiety (Major one)
    • *Major one since it’s a near life threatening event if resuscitation is necessary
    • *Always teach the parent to do CPR before they leave the hospital
    • *May need to use APNEIC MONITOR for first 6 months which helps with parental anxiety
31
Q

Crohn’s Disease

A

A chronic inflammatory Disease

  • Can occur in any part of GI tract from mouth to anus, with ileum, colon & rectum most common affected areas
  • Transmural involving all 3 layers of mucosa

Inflammation and ulceration of colon mucosa

*There are healthy areas between the affected areas (“skip areas”)

32
Q

Crohn’s Disease Etiology (7)

A
  1. Unknown exact cause
  2. May be a genetic factor
  3. Triggers
    - -Viral & infectious agents
    - -Food allergies
    - -Increased intestinal permeability and immunological dysfunction
  4. Stress
  5. More common in whites, 3-6x more common in Jewish descent
  6. Occurs equally in men and women
  7. Runs in families
33
Q

Signs and Symptoms of Crohn’s (7)

A
  1. Abdominal pain with cramps
  2. diarrhea
  3. weight loss & poor growth
    * Can have delayed physical and sexual growth
  4. Fever,
  5. anorexia,
  6. rectal bleeding,
  7. perianal discomfort and fissures or fistulas to other loops of bowel, bladder, vagina or skin
34
Q

Extraintestinal Signs and Symptoms of Crohn’s (8)

A
  1. Erythema nosdosum (Red papular nodules on the legs)
  2. Large jt. arthritis
  3. Mouth ulcers
  4. Liver disease
  5. Renal calculi
  6. Uveitis; inflammation of uvea (vascular area in eye beneath the sclera)
  7. Anemia; Due to blood loss from the bleeding that can occur with Crohn’s
  8. Elevated WBC & ESR & CRP (all indicating inflammation)
35
Q

Diagnosing Crohn’s (6)

A
  1. Lab data
  2. History and physical; make sure nothing else is causing the symptoms
  3. Stools – blood, leukocytes & infectious agents
  4. Upper GI series with small bowel follow through
  5. CT scan & Endoscopy of upper and lower bowel
  6. Mucosa biopsies
36
Q

Lab Data to check with Crohn’s

A
  1. CBC
  2. ESR
  3. C-reactive protein
  4. pANCA
  5. Measure all of the below because the disease is causing poor absorption; they may need to be on supplementation
    - Total protein
    - Albumin
    - Zinc
    - Magnesium
    - Vitamin B12
    - Fat soluble vitamins
37
Q

pANCA

A

Done to decipher between ulcerative colitis and Crohn’s disease because the symptoms can be very similar

  • Will see a dramatic increase in pANCA in patient’s with ulcerative colitis
  • Will only have a minor increase in patient’s with Crohn’s disease
38
Q

Upper GI series with small bowel follow through

A

Used to dx Crohn’s

  • Looking for bowel wall thickening or any complications that are occurring in the bowel from Crohn’s
  • Also looking for abscesses that can occur with the ulcerations
39
Q

Goals of Crohn’s Management (4)

A
  1. Control inflammatory process & reduce or eliminate symptoms
  2. Obtain long term remission
  3. Promote normal growth & development
  4. Allow as normal lifestyle as possible
40
Q

Treatment of Crohn’s (4)

A

Some can be controlled on diet alone, but some need medications

  1. Corticosteroids
  2. Aminosalicylates
  3. Immunomodulators
  4. Antibiotics (adjunct)
41
Q

Corticosteroid Treatment of Crohn’s (with 8 side effects)

A

Used to mediate and control inflammation; can be oral, IV, or rectal
*Enema of corticosteroid may decrease urgency of stools

Side effects of corticosteroids:

  1. Infection
  2. Metabolic problems such as temporary hyperglycemia
  3. Moon face
  4. Acne
  5. Hurstism (hair in places they aren’t normally)
  6. Aggressive behaviors
  7. Osteopenia
  8. If a patient is on long term corticosteroids and needs surgery, their cortisol would go up because they are stressed but due to the corticosteroid their body won’t elevate cortisol
    • *Long term corticosteroids → body isn’t producing cortisol, this is why you wean people off of corticosteroids in order to give their adrenal glands time to start making cortisol
      * *Will need IV pre, during, and post doses of corticosteroids if they are having surgery
42
Q

Aminosalicylates tx for Crohn’s

A
  1. sulfasalizine (Azulfidine)
  2. mesalamine (Asacol and Pentasa)
  • antinflammatory
  • Asacol and Pentasa are preferred
  • Tell patients that they are going to need extrafolic acid because these interfere with absorption of folic acid
  • Also causes an increase in sun sensitivity; may burn if out in the sun
43
Q

Immunomodulator tx for Crohn’s

A
  1. 6-mercaptopurine,
  2. azathioprine,
  3. methotraxate
  4. cyclosporine

*enhance effect of steroids

  • Methotraxate is used during chemo
  • Major concern is suppression of the bone marrow/immune system
  • Monitor WBC levels
  • Helps enhance the effects of steroids, may not need to be on it if they’re not on steroids
44
Q

Antibiotics with Crohn’s

A

Used as adjunct therapy for complications such as abscesses

Most commonly prescribed: Flagyl

45
Q

Other treatments for Crohn’s

A
  1. Anti-TNF – infleximab (Remicade)
  2. Interleukin 10; helps reduce inflammation
  3. Budesonide (Corticosteroid with fewer side effects than Prednisone)
  4. Zinc (Helps remove free radicals that can contribute to inflammation)
46
Q

Anti-TNF tx for Crohn’s

A

infleximab (Remicade)
Used if the other medications are not working (last resort)

  • *TNF a protein that ends up getting produced by the immune system causing inflammation
  • *Remicade binds with TNF and excretes it in urine to help decrease inflammation
  • Has a lot of side effects
  • Need to come in once a month for monitoring
  • Only for children 6 and older
47
Q

Crohn’s Nutrition (4)

A

Primary component of treatment!!; May not be on any meds but just diet management because due to issues of absorption they need a specific diet

  1. High calorie, high protein
  2. Multivitamins, iron & folic acid supplements
  3. Enteral formulas by mouth or NG feedings
    * *These formulas are formulas that the protein is broken down into it’s simplest forms; it can be completely absorbed in the small intestine
    * *These formulas also help reduce remission
  4. TPN
48
Q

TPN Treatment for Crohn’s

A
  1. Occurs when you can’t maintain weight or nutrition
  2. Will be on intermittent TPN liquids for nutrition and weight maintenance
  3. Broviac: central line that goes into the right atrium; used if child has Crohn’s and needs TPN treatment
  4. Portocath is another option for this; acts as a tube that goes right into right atrium
    - These are considered central lines and are used for nutrition/TPN if necessary
49
Q

Surgery for Crohn’s

A

*Not curative

Drain abscesses, close fistulas, remove short segments of diseased bowel, repair perforations (reduce risk of peritonitis and enterocolitis), relieve obstructions or widen strictures

Due to inflammation that occurs in bowel, these patients can develop enterocolitis then are at risk for peritonitis
*Toxic megacolon: fever, acute abdominal pain and abdominal distention

50
Q

Prognosis of Crohn’s (4)

A
  1. Depends on how much of the bowel is involved, medication adherence, etc.
  2. No cure
  3. Outcome influenced by severity of GI involvement, the regions of bowel affected & appropriate therapeutic management
  4. Main worry is colon cancer, which a long term complication
    - –> Children with Crohn’s will be getting colonoscopies in their teenage years to monitor this!!
51
Q

Nursing Care for Crohn’s (8)

A
  1. Home dietary management
  2. Coping with factors that increase stress
  3. Good mouth care
    * Important because they can develop oral ulcerations
    * Normal saline rinses
    * If ulcerations are very painful, use magic mouth wash (Nalox base with Benadryl and lidocaine)
    * Be careful with lidocaine because it can cause seizures
    * Sucking on ice also helps decrease the pain
  4. Adjust to disease of remissions & exacerbations
  5. Prepare for possible surgery, especially if they are on corticosteroids
  6. NG or TPN instruction
  7. Importance of continued drug therapy
  8. Inform patients about Crohn’s and Colitis Foundation of America

Pediatrics (13 decks)

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