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Transcript
GASTROINTESTINAL SYSTEM G ASTROINTESTINAL T RACT Begins in the mouth- terminates at anus Mouth Esophagus Gastroesophageal (cardiac) Sphincter- between esophagus and stomach Stomach Fundus Body Antrum Pyloric Sphincter- between stomach and small intestine Small Intestine- 20 ft long, most digestion occurs here Duodenum Jejunum Ileum Large intestine- joins with small intestine with ileocecal valve Cecum (appendix) Ascending colon Transverse colon Descending colon Sigmoid colon Rectum D IGESTION Process by which food is prepared for use by the body Mechanical- teeth, saliva, stomach churning, peristalsis Chemical- actions of enzymes that act to breakdown fat, carb, protein HCl in stomach, Pancreatic enzymes: Amylase, trypsin, chymotrypsin, carboxypeptidase- protein Lipase- fat Amylase- starch A SSESSMENT OF GI S YSTEM Ask about: Weight loss/gain and over what period of time Bowel Function Laxative Use Appetite Dysphasia, N/V/D, indigestion, blood in vomit or stool, Mental State P HYSICAL E XAM Inspection Auscultation Palpation (gentle) Percussion Ask pain D IAGNOSTIC T ESTING Abdominal X-ray Ultrasound- may be NPO- fat free diet to accumulate bile in gallbladder CT- NPO 6-8 hours MRI- soft tissues, ask about metallic implants Upper GI- Post Procedure- Monitor stool- must make sure stool passes- Barium can set up in stool and cause obstruction Stop Glucophage 2 days before test with barium b/c liver damage Lower GI- barium enema- Monitor for passion of Barium after procedure Endoscopy- EGD- conscious sedation (Demerol and Versed)- Withhold food and fluids until gag reflex returns NPO 6-8 hours Proctoscopy- exams the rectum Sigmoidoscopy- exams the rectum and the sigmoidoscopy Colonoscopy- exams entire large intestine Gastric Analysis and histamine test- gives acidity of the stomach contents- NPO after supper and have test in morning. NG tube extracts stomach contents, no gum or smoking. Stool/fecal analysis Manometry- measure pressure Lab studies CEA (carcinoembryonic antigen)- can detect cancer cells, suggestive but not diagnostic Labs to evaluate nutritional status Albumin Pre-albumin Transferrin Urine urea nitrogen to assess protein balance E NTERAL F EEDING Can be any location in GI tract- usually stomach, duodenum or jejunum Preferred alternative to normal eating NG tubes Nasoduodenal or Nasojejunal tubes Gastrostomy- potential complications Displacement Perforation of the mucosa Reflux of stomach contents can lead to skin breakdown Can obstruct pyloric outlet and lead to n/v Feedings can be bolus or continuous, continuous have less complications due to slower infusion Head of Bed needs to be at least 30 degrees Always check placement before feeding and at least once per shift Can cause diarrhea due to high osmolarity of formula, may decrease rate or dilute formula Complications are more prevalent in the elderly Always flush NG tubes with 20-30 mL before and after feedings and PRN to keep tube patent C ASE S TUDY You are the 1st shift LPN in a LTC facility. You are caring for Mr. George Toobe. Mr. Toobe has a PEG tube and is receiving full-strength formula at 50 mL/hour continuously via Kangaroo pump. What should your routine assessment consist of? Lung sounds Bowel sounds Site care Tube placement The nursing assistant tells you that Mr. Toobe has had several diarrhea stools this am, you know that he was recently started on his continuous feedings. What action should you take? Call the physician as he may slow the rate or dilute the formula It is important that all the CNA’s caring for Mr. Toobe know: Keep the HOB raised to 30 degrees and put pump on hold when HOB must be lowered. GI M ANIFESTATIONS OF I LLNESS Anorexia Nausea- subjective Vomitingobjective, usually proceeded by nausea but projectile not (brain tumors, aneurism, increased intercranial pressure, pyloric Stenosis), can be caused by many factors, measure amount and document appearance, color, odor prolonged can lead to electrolyte and acid-base balance and dehydration, puts elderly at risk for cardiac arrest and renal insufficiency Maintain fluid and electrolyte balance and prevent aspiration Prevention- deep, slow breaths Fluids as tolerated, avoid spicy and greasy foods, may need IV or NG for gastric decompression Meds- usually make them drowsy, Phenergan, Zofran, Compazine Diarrhea- increased frequency and excessive water content Secretory- due to abnormal increase in the production of intestinal secretion, high volume and high sodium, inflammation of the GI mucosa and infections Osmotic- poor water Reabsorption of the large intestines, pull in of water by contents with High osmolarity, antibiotics, surgical procedures that speed contents through the GI tract- High Potassium content Mixed- increased intestinal motility and combination of secretory and osmotic factors Consequences depend on cause and severity Fluid and electrolyte imbalance Irritation of the perianal skin Assess color, consistency, amount, odor Stool samples (C-diff, parasites) Interventions to control cause and symptoms, prevent complications, and increase comfort Anti-diarrhea Meds-Lomotil or Imodium Fluid and electrolyte replacement, barrier creams to prevent skin breakdown Constipation- decrease in frequency of BM for what is normal for the patient Lack of mobility, iron, antidepressants, pain meds, laxative abuse, poor diet Intervention depends on cause, usually lifestyle change is best Fecal Incontinence- involuntary passage of stool Impaction, neurological injuries, injury to the perianal area, diarrhea Skin breakdowns Bowel training, biofeedback Indigestion- dyspepsia, not necessarily pathologic but can be a result of disease GI S URGERY Incision into the thoracic cavity (thoracotomy), abdominal cavity (laparotomy) or both Pre-op nursing care Teaching, provide support, relieve anxiety Cleansing enema, antibiotics Post operative Turn, cough, deep breath and incentive spirometer Routine vitals Observe for abdominal distention, bowel sounds, n/v, observe for passing gas or stool I&O’s Paralytic ileus- no peristalsis Gastric decompression by NG to prevent atelectasis At risk for Fluid and electrolyte imbalance Bleeding Leaking of fluid into interstitial spaces C OMPLICATIONS OF GI S URGERY Fluid/electrolyte imbalances Bleeding Peritonitis Infection Immobility Risks C OLOSTOMY Removal of part of the colon May be done for: Cancer Inflammatory bowel disease Trauma Perforated diverticulum Enteric Fistula Intestinal obstruction Preoperative psychological support Can be any part of the intestine- commonly cecum, transverse, descending or sigmoid Amount and character of stool depends on location of colostomy in intestine Care: Change appliance ever 3-4 days- can go to 5-7 days after stoma shrinks Empty pouch when ½ to 1/3 full Watch for skin irritation/breakdown Well-pouched stoma should not cause odor Stoma will shrink for about 6-8 weeks Healthy stoma- red/moist I LEOSTOMY Distal end of the ileum is used as stoma, entire colon is removed Fecal output: early very loose to liquid- 1800-2000 mL per day May thicken up over time and output decreases to 500-1000 mL/day Dehydration, electrolyte imbalance More problems with skin breakdown due to increased acid S TOMAS End Stoma- created by cutting bowel and brings it up the proximal (functioning) through the surface of the skin and is single stoma. This is for permanent placement. Bowel is removed Double-barreled stoma- usually temporary Both proximal and distal ends brought to surface Proximal end is functioning Distal end is called mucous fistula Loop stoma- Loop of bowel brought to surface, Opening in anterior wall for fecal drainage, posterior wall intact, bridge can be removed after 7-10 days and is usually temporary S TOMATITIS Inflammation of the oral cavity Cause: vitamin deficiency, infection, drugs, viral disease (burning sensation pain, fever) T HRUSH candidiasis fungus candida albicans: can be infected while coming through the birth canal O RAL C ANCER Predisposing factors: smoking, smokeless tobacco Metastasize early More common in men Treatment- surgery, radiation, or both Leukoplakia- sign of oral cancer on tongue or cheek, white patches E SOPHAGITIS - INFLAMMATION OF THE ESOPHAGUS Common causes: chemical irritants, smoking, reflux of gastric acids, exposure to radiation therapy S&S: burning pain, dysphasia, can lead to ulceration and stricture of the esophagus Diagnosis: symptoms, endoscopy Treatment: relief of symptoms and removal of the cause G ASTRITIS - INFLAMMATION OF THE STOMACH Acute- caused by irritation by drugs (aspirins, steroids, alcohol) Anorexia Epigastric pain Treatment: antacids, remove cause, Karafate (Sucralfate) Chronic- elderly, atrophy of gastric mucosa, Poor appetite Nausea Epigastric pain Bleeding Treatment: avoid irritants, small, frequent, bland meals, B12 supp H IATAL H ERNIA Can be called hiatus hernia or diaphragmatic hernia, protrusion of the stomach into the diaphragm Symptoms Heartburn, epigastric pain Can feel like chest pain n/v stomach distention Risk factors Obesity Pregnancy aging Diagnosis EGD Barium swallow Interventions Small frequent meals Avoid foods that cause and smoking Should not wear tight fitting clothes Avoid straining with bowel movements HOB elevated G ASTROESOPHAGEAL R EFLUX D ISEASE - GERD Lower esophageal sphincter- stomach contents flow back into the esophagus (associated with Hiatal hernia) Risk factors Smoking Coffee Alcohol Chocolate Peppermint Pregnancy Obesity Fatty foods Symptoms: Heartburn after eating Mid sternal pain may be mistaken for MI Complications Esophageal stricture and ulceration Esophagitis Barrett’s esophagus (pre-malignant) Treatment: Minimize foods that can irritate the mucosa Avoid tight clothing Elevate HOB Avoid eating close to bedtimes Small, frequent, bland meals Proton pump inhibitors Diagnosis Esophageal pH testing Upper GI Endoscopy Surgery- Fundoplication Wraps the fundus around the lower esophagus to tighten the esophagus to prevent reflux P EPTIC U LCER D ISEASE erosion of the lining of the upper GI tract- as deep as muscle layer down to the abdominal cavity Usually duodenum, stomach, lower esophagus Affects 10% of the population- usually not in children, but duodenal more common in men between 30-50 yrs. Stomach ulcers more prevalent In women over 60 H. Pylori Helocobactor Pancreatic tumors produced Can be caused by pancreatic cancer Patients that have chronic severe illness and burns will have increased risk. Chronic stress causes parasympathetic response that increases gastric juices. Complications: Obstruction, usually pyloric sphincter or gastric outlet Bleeding- either slow (coffee grounds vomitus) or severe bleed (bright red vomitus), IV volume expanders, NG tube, blood transfusion, reduce acid, prevent nausea, iced saline lavage for severe vomiting Perforation- ulcer erodes the wall of the stomach or intestine and the GI contents leach into the peritoneal cavity- EMERGENCY- surgery needed. Surgery washes the cavity with antibiotics to keep infection down. Symptoms Dull, boring pain Pain occurs between meals and early in the morning N/V Anemia if bleeding Diagnosis Upper GI Endoscopy Stool specimen for occult blood Histamine test for pH Tests to confirm H. Pylori Treatment Healing can take from 4-8 weeks Diet modification Medication- antacids and Anticholinergics, histamine blockers Antibiotics if H. Pylori Small, frequent, bland meals Surgery Gastrectomy- removal of part of the stomach Bilroth I- connect stomach to the duodenum Bilroth II- connect stomach to the jejunum NG tube 24-48 hours after surgery for decompression, do not remove without MD order For total gastrectomy, will need 12 injections for rest of life for intrinsic factor Dumping syndrome- nausea, weak, faint, (food moves too fast through the GI tract and makes the chyme more hypertonic causing water to be pulled from the blood stream) Vagotomy- resection of the vagus nerve to reduce stimulation of acid production Antrectomy- remove a large part of the stomach, usually the antrum Pyloroplasty – enlargement of the pyloric sphincter G ASTROENTERITIS Inflammation of stomach and intestines- occurs in conjunction with other diseases and usually caused by virus or from bacterial infection from food Primary Symptoms Diarrhea, cramping, vomiting Will start within a few hours after eating bad food Diagnostic- stool samples and cultures Treatment Treat dehydration Contact precautions I RRITABLE B OWEL S YNDROME Signs and Symptoms Abdominal pain Bloating Alternating bouts of diarrhea and constipation DOES NOT INVOLVE AN INFLAMMATORY PROCESS Cause: stress, chocolate, milk, alcohol, caffeine NO BLEEDING FEVER OR WEIGHT LOSS I RRITABLE B OWEL D ISEASE Group of chronic disorders in the small and large intestines that cause inflammation or ulceration Affects approximately 2 million people in the US. Caused by genetic and environmental factors. Infectious agents, food additives, birth control pills, stress exacerbations. Crohn’s Disease Ulcerative Colitis Specific cause unknown, may be food allergies or autoimmune. One of the most serious diseases. Periods of remission and exacerbation. May be passing 20-30 stools a day. Ulcers form on the lining of the intestine that may bleed leading to anemia. Can be a slow bleed or severe hemorrhage. Nutritional and Vitamin deficiencies Colonoscopy with biopsy, stool specimens, history and physical for diagnosis Interventions: physical and psychological rest, fluid and electrolyte management, control inflammation, prevent infection Pharmacology: manage inflammatory response at the mucosal level; amino salicylates, steroids, sulfasalazine, Mesalamine, olsalazine Chronic, persistent inflammation, almost always presents before the age of 30. Fibrosis and narrowing of bowel lumen Begins in the rectum and spreads through the colon Frequent diarrhea, bloody, mucoid May have mild cramping pain in left lower quadrant- often relieved by defecation Cancer can be complication Diagnosis: stool specimen, colonoscopy, Upper GI Anti-diarrheal can cause toxic mega colon Treatment: TPN, improve nutritional and fluid levels, psychological support Surgery: total colectomy with ileostomy Crohn’s Disease Chronic, progressive Can affect any part of GI tract, but usually small intestine. Terminal ileus and anus usually involved. Lesions in patches with patches of normal lymphoid tissue. Abdominal Pain- most common symptom. Diarrhea Young adults- higher incidence among Jews Requires ongoing therapy, but rarely surgery Prone to abscess and fistula formation, anal fissure, perianal abscesses, and partial bowel obstruction Often results in disability and incapacity Associated with complications in other parts of body- arthritis, kidney stones, gallstones, cutaneous manifestations (pyoderma gangrenousum) and inflammation of eyes Stool may be fatty and have foul odor Milk, fatty foods, emotional upsets, stress, other physical illness can bring on attack Diarrhea not as severe as ulcerative colitis, but may have urgency and flatus Diagnosed by x-rays, upper GI, barium enemas, colonoscopy will have high risk of perforation Complications: lesions of the rectum and anus, fissure, ulcers, fistulas and abscesses. Treatment: supportive, aimed at obtaining remission, anti-diarrheal, anti-inflammatory, immunosuppressant agents. Mesalamine Pg 448 good chart for manifestations and complications of UC and CD A PPENDICITIS Inflammation of the vermix appendix, fills and empties frequent, but because narrow it is easily obstructed and can cause infection- E. Coli. Distention can cause rupture. Can abscess and cause peritonitis Risk of fatal complications increase with delay of treatment Pain in the right lower quadrant- McBurneys point (halfway between the umbilicus and anterior iliac crest- rebound tenderness Always surgical intervention before rupture (clean). If removed after rupture it is called dirty appendectomy. Di bit administer laxatives or enemas or apply heat to the abdomen because these measures may cause perforation of the appendix. P ERITONITIS Inflammation of the peritoneum and the abdominal cavity. Can be a complication of a bacterial, fungal, or viral infection. Can come from female reproductive or GI contents in the peritoneum Signs and symptoms: severe abdominal pain. Will lie on back or side with flexed knees to try to alleviate pain. Any movement is painful. N/V/D. paralytic ileus. Abdominal distention and tenderness. High white cells. Can progress to septic shock. Every patient who has GI surgery is at risk. Interventions: antibiotics, fluid and electrolyte replacement, resolve paralytic ileus, pain control. NPO, NG. Usually in ICU. H ERNIA Projection of a loop of an organ, tissue, or structure, through a congenital and acquired defect. Usually in the abdomen Umbilical- weakness in the abd wall at the umbilical ring. Can see when baby cries or strain. Usually resolve on their own. 3-5 years before surgery. Femoral- where femoral artery passes into the femoral canal. More common in women. Inguinal- part of the intestine projects through the inguinal canal. More common in men Incisional- from wound Reducible- if they can be gently manipulate them back into the cavity Incarcerated- not able to be reduced Strangulated- when blood supply is reduced, will have to do emergency surgery to prevent necrosis Hernias are usually not painful unless blood supply is disrupted. Most hernias for adults are repaired surgically. Hernioctomy- removal. Hernioplasty- repair Fluid, fiber rich diet, stool softeners, small frequent meals, no heavy lifting, avoid constipation I NTESTINAL O BSTRUCTION Can be partial or complete but is always serious. Partial can resolve on its own, but may require surgical intervention Occurs when any condition exists that prevents the passage of bowel contents through the intestine. Causes: strangulated hernia, twisting of the bowel, cancerous lesions, postoperative adhesions, usually occurs in the small intestine. Vomiting, decreased electrolytes, can also lead to decreased HCl, metabolic alkalosis, the higher the obstruction the earlier and more acute the symptoms, wave like pain, will vomit gastric contents and then will have fecal content from above the obstruction. Lower obstruction, no vomiting but blood mucus. Abdominal distention- must measure girth and strict I&O’s Symptoms of hypovolemic shock Death can result in hours from complete obstruction NG tube for decompression, may need intestinal decompression, NPO, monitor vital, HOB elevated 20-30 degrees D IVERTICULAR D ISEASE Diverticulum- pouch or sac arising from any tubular structure. Low fiber diet contributes to development of this disease. Diverticulosis- multiple diverticulae scattered through the colon Diverticulitis- fecal matter fills the diverticulum and leads to inflammation Mild to severe pain often in LLQ. May have fever and increased WBC. If rupture can cause peritonitis, septicemia, and septic shock. Treatment: high fiber diet unless having inflammation symptoms. Avoid seeds, nuts, and corn. If inflammation, low fiber diet. IV fluids, antibiotics, gastric decompression H EMORRHOIDS Dilated veins similar to varicose veins. Thrombosed- blood clot in veins Factors: straining with bowel movements, heavy lifting, pregnancy, prolonged constipation Symptoms: awareness of a mass in the rectum, constipation, bleeding, bright red blood that is not mixed with feces, If thromobosed, severe pain. Usually resolve without treatment, but if much discomfort can instruct warm compresses or sitz baths. Analgesic ointments, stool softeners, steroid suppositories, can be surgically excised or can be injected with saline solution. Pain relief main issue post op C ANCERS Small Intestine- not seen as often as other areas, symptoms are intestinal obstruction, bleeding and upper abdominal pain. Prognosis: poor- metastasizes early to the liver and lymph node Colorectal cancer- most prevalent intestinal cancer in US. Equal in men and women. Prognosis: earlygood. Risk: ulcerative colitis, diverticulitis, low fiber diet. Symptoms: rectal bleeding, alternating constipation and diarrhea, excessive flatus, cramping lower abd, abd distention. If tumor is in transverse colon, obstruction will be likely. ¾ can be detected with colonoscopy and recommended for pts. Over 50. May do radiation and chemo pre and/or post op. Curative is always surgery. May have colostomy. ACCESSORY ORGANS C HOLECYSTITIS Inflammation of the gallbladder- more common in women Four F’s 1. Fat 2. Female 3. Fair 4. Over 40 Causes: obstruction, gallstone or tumor. Usually gallstones. Bile can’t leave the gallbladder, water is absorbed and becomes more concentrated irritating the gallbladder, causing inflammation, and thickening. Possible rupture and gangrene. Acute Attack: Biliary Colic: sudden onset of nausea and vomit. Pain RUQ. Fatty foods with indigestion and heartburn. Fever, Jaundice. Diagnosis/Treatment: Abd. X-ray and ultrasound. EKG to rule out cardiac. Oral cholecystogram. IV fluid, electrolyte replacement, IV antibiotics, cholecystectomy (usually after acute attack is over) Cholelithiasis- gallstones, more common in women. Pregnancy increases risk. Made of cholesterol, Bilirubin, and calcium. Fat intolerance. Treatment: analgesics, HOB 45-60 degrees raised with knees flexed. Laparoscopic surgery. P ANCREATITIS Inflammation of the pancreas caused by release of pancreatic enzymes which causes auto-digestion of pancreatic tissue Most caused by gallstones, alcoholism Acute: abd pain radiating to back, N/V, bowel sounds decreased or absent, abd. Tenderness and fever, WBC high, serum amylase elevated 2- 2 ½ above normal. Pleural effusion, abscesses or pseudocyst in pancreas, tachycardia and hypotension and can progress to shock. Treatment: pain meds, surgical drainage, Chronic: chronic pain that waxes and wanes from day to day in upper abdomen radiating to the back, can become addicted to narcotics for pain, pancreatic calcifications, fatty stools, diabetes, Acute interventions: reduce pancreatic activity, maintain fluid and electrolyte imbalance, NG, total Parenteral nutrition, if cause is gallstones, then remove gallbladder Chronic interventions: pancreatic enzyme injections, insulin, nerve block. L IVER Largest accessory organ Metabolism of carbohydrates, fats, proteins Regulation of blood glucose by storing as glycogen and releasing as glucose as needed Removal of ammonia Breakdown fats for energy Converts to fat Synthesis of proteins for ketone bodies Vitamin storage- Vitamin K and other fat soluble vitamins Detoxification D ISORDERS OF THE L IVER Viral Hepatitis- diffuse inflammatory reaction that can cause liver cells to degenerate and die. A- source primarily human feces- spread by fecal/oral route B- most commonly transmitted via blood- can progress to chronic liver disease C- Parenteral transmission- drug abusers, health care workers, one of leading causes of liver transplant D- Delta virus- can transform Hep B into severe, chronic hepatitis E- primarily in developing countries- fecal/oral All can cause chronic liver disease Labs: AST, ALT elevated; PT will be prolonged. Alkaline phosphatase will be elevated Assessment- mild or sever symptoms- anorexia, fatigue, n&v, chills, headache, fever, jaundice (not always) No specific therapy; rest and encourage PO fluids, good nutrition PREVENTION C IRRHOSIS Chronic Diffuse destruction and regeneration of liver cells causing an accumulation of fibrous connective tissue that obstructs the biliary channels in the liver More common in men middle aged or older 7th leading cause of death by disease in the US Causes: chronic hepatitis; cystic fibrosis; blockage of the bile ducts; severe reactions to drugs and environmental toxins; alcoholism causes Laennec’s and is the most common type in the US, repeat bouts of CHF can cause also Develops slowly usually over a period of years Liver cells become infiltrated with fat- the liver size increases Liver function decreases- unable to metabolize protein normally- leads to increased ammonia levels in the blood Early signs and symptoms: anorexia, indigestion, nausea, flatulence, bowel habit changes, dull, heavy feeling in RUQ, gynecomastia (enlargement of the breast in men), nosebleed, bleeding gums Progressive: jaundice, spider angiomas on the face, trunk, and neck, anemia, thrombocytopenia, peripheral neuropathy Late: portal hypertension, ascites, hypoalbunemia, collateral circulation resulting in esophageal varices, hemorrhoids, decreased renal blood flow Hepatic coma or hepatic encephalopathy- terminal complication due to increased ammonia Interventions: Manage symptoms- no cure Diet Daily weights Skin care Mouth care Diuretic therapy- Spironalactone (Aldactone) Potassium sparing diuretic Lactulose- traps ammonia to be expelled in the feces Leveen shunt- shunts the fluid from the abdomen back into the circulatory system- can cause the blood to be too dilute Sengstaken-Blakemore tube to tamponade esophageal varices PEDIATRIC GI C LEFT L IP Characterized by fissure or opening in upper lip More in boys One or both sides of the lip May be accompanied by cleft palate Common congenital abnormalities Treatment- surgical repair- usually about 2 months old Surgery improves sucking and appearance Watch for oral or systemic infection, before and after until suture heals may be fed with syringe with rubber tip, Haberman feeder, or medicine dropper. Logan’s bow- helps immobilize the upper lip while healing ***NEED TO AVOID SUCKING MOTIONS UNTIL SUTURES HEAL**** Should avoid crying until sutures heal Should be kept off of their abdomen, and need to gently cleanse suture line, Need to let the parents know that they can hold, and comfort infant C LEFT P ALATE Failure of hard palate to fuse at midline- forms passageway between nasopharynx and nose Feeding complications Increased risk of respiratory and middle ear infections, speech difficulties Surgical treatment Can predispose babies to emotional problems because of difficult feeding times. May not have regular tooth eruptions, drooling, and late speech. Will be fed liquids by cup and then advance to soft diet. Avoid hot foods and liquids. No straws. Ear aches and dental problems are complications P YLORIC S TENOSIS Narrowing and obstruction of lower end of stomach. Overgrowth of circular muscles of pylorus or spasms of pyloric sphincter 2-3 weeks old- more boys Projectile vomiting Most common surgical condition of the digestive tract in infants Olive-shaped mass in the RUQ Constant hunger, dehydration, malnourishment Surgical treatment to enlarge the opening of the pyloric muscle Will try thickened formula pre-op to help prevent vomiting, place on right side in Fowler’s after feeding, feed slowly and burp often H IRSCHPRUNGS D ISEASE Absence of ganglionic innervations to the muscle of a segment of bowel Chronic constipation- Ribbon like stools More in boys and incidence higher in children with Down’s syndrome Watch for failure to pass meconium, abdominal distention, vomiting, and failure to thrive. Colon can be distended increasing surface tension, do not give tap water enema as will over absorb. Treatment: surgical, may have to have temporary colostomy. I NTUSSESCEPTION Telescoping of one part of intestine into another part just below it- frequently at the ileocecal valve Leads to intestinal obstruction and strangulation and may burst causing peritonitis Occurs more in boys May have spontaneous reduction, if treated in 24 hours, good prognosis. Barium enema Sudden, severe pain, vomiting, Currant Jelly stools, fever, signs of shock, EMERGENCY, may feel sausage shaped mass in the RUQ G ASTROENTERITIS Inflammation of stomach and intestines Treatment focuses on identifying and eradicating disease (sorbitol) Hydration- Pedialyte V OMITING Common Persistent or projectile- investigate Can lead to dehydration- electrolyte imbalance Causes- improper feeding, increased intercranial pressure, viral infections Constant vomiting can lead to alkalosis, aspiration, and aspiration pneumonia Document time, amount, color, consistency, if projectile, measure to rehydrate G ASTROESOPHAGEAL R EFLUX Many infants have May have esophagoscopy, barium swallow, pH monitoring ordered Treatment- depends on severity of symptoms Severe- vomiting, weight loss, failure to thrive Avoid over feeding, place in Fowler’s after eating, may do antacid meds, surgery is last resort, fundoplication D IARRHEA Sudden increase in stools with fluid consistency, may have mucous, blood, or greenish color Acute- sudden, d/t inflammation, infection, medication, Chronic- lasts more than 2 weeks and can be indicative of malabsorption Infectious- rotavirus, E. Coli, salmonella, C-diff Isotonic vs. hypotonic- if patient has lost equal amounts of fluid and electrolytes are lost is isotonic (shock), more electrolytes than fluid hypotonic (water intoxification), hyper tonic, more fluid than electrolytes (dehydration) Treatment- BRAT diet make sure the kidneys are working before giving potassium to IV fluids C ASE S TUDY Dee Hydration is 1 year old who presents with hypotonic dehydration- What is she at risk for? Water intoxication P INWORMS (E NTERBIASIS ) Most common worm infection Comes out at night to lay eggs Oral entry Scotch tape test Vermox-Povan All family members treated R OUNDWORMS (A SCARIASIS ) Can be asymptomatic- may cause abdominal pain Caused by unsanitary disposal of feces and poor hygiene Eggs ingested- can survive for weeks in the soil Chronic cough with no fever Vermox-Povan