GIT DISORDERS IN INFANTS

The first step of digestion: Chewing

1. Cleft Lip

2. Cleft Palate

3. Tracheoesophageal Fistula

4. Gastroesophageal Reflux

5. (Pylorus) – Pyloric Stenosis

6. (Small Intestine) - Intussusception

7. (Large Intestine) - Hirschsprung

8. Imperforate Anus

CLEFT LIP

• Failure of the maxillary & median nasal process to fuse
• Congenital deformity. Common among males
• Several staggered suture line to minimize notching

SIGNS & SYMPTOMS

• Difficulty in feeding
• Mouth breathing - air & infxn

SURGICAL TREATMENT: Ideal is 6 - 12weeks old

• Surgical Readiness: 10 wks old, 10 g of Hgb, at least 10 lbs., <>
• Procedure: close the defect called Cheiloplasty

PRE-OP

• Feeding Technique: Dropper with SAP

POST-OP

• Position: SUPINE never Prone (No head control)
• Promote Arm & Elbow Restraint
• Prevent Tension on suture lines: Anticipate the needs to avoid crying. Use of Logan’s Device (Bow / Bar)
  
• Anticipate Respiratory distress due to swelling of post-op area.
• Clean the suture line after feeding: sterile water or CBW

CLEFT PALATE

• Midline Fissure on the HARD PALATE. Most common in FEMALES.
• SURGICAL TREATMENT: Done before speech development begins
• Procedure: Palatoplasty

PRE-OP

• Feeding: flange nipple, lamb’s nipple, Brecht Feeder
• Breastfeeding method: With use of Palatar prosthesis

POST-OP

• Feeding device and Diet: Breast milk (by breast), commercial nipple, or from a cup. Never use a Straw because it can hit suture. Use blender for soft diet.
• Position: Prone (Abdomen or side) to promote natural drainage of secretion.
• Observe for bleeding: frequent swallowing.
• Use of elbow restraint to protect suture lines (cardboard on elbow → avoid flexion).

GASTRO ESOPHAGEAL REFLUX (GER) / CHALASIA

• Movement of gastric (acidic) contents to the esophagus
• Thicken milk
• Positioning: Upright position when feeding.
• Burp after feeding to eliminate air bubbles in stomach.
• If position is supine: Turn Right Lateral ( semi-upright ) - promote absorption by the Small Intestine (SI).
• H2 antagonist given to reduce acid & prevent esophagitis.
• Proton pump inhibitor, Omeprazole, Lansoprazole : blocks acid production
  If not resolved within One (1) year, Cardiac Sphincter surgery is done.
• Wrapping (tighten, 360 degrees) of Fundal part of the stomach to the distal esophagus.
• This surgery is called: NISSEN FUNDOPLICATION
  

PYLORIC STENOSIS
There is a narrowing or tightening of the Pyloric Sphincter. Food is blocked → Small Intestine → Food is regurgitated back to esophagus. It occurs around 1- 10 weeks of age. Most common in Males.

SIGNS & SYMPTOMS:

• Abdominal distention (visible peristalsis)
• Vomiting (non-bile stained)
• Projectile vomiting (4 – 6 weeks)
• Palpable olive shaped mass in RUQ.
• Constipation

DIAGNOSIS:

• Barium Swallow: X-ray reveals a String Sign or appearance

SURGICAL TREATMENT

• PYLOROMYOTOMY: The procedure is called FREDET – RAMSTEDT PROCEDURE
  a. Involves first a LAPAROTOMY
  b. Next is LAPAROSCOPY

PRE-OP

• Correct the existing Fluid & Electrolyte Imbalance (FEI), IVF for dehydration. KCl for Hypokalemia & Alkalosis.
• Correct Nutritional Balance: TPN as needed / thickened formula.

POST-OP

• Feeding is begun 4 – 6 hrs. post-op, small frequent & slow feedings. Full feeding at 48 hrs. post-op.
• Burp the infant.
• High Fowler’s position during feeding & place at right – lateral after burping.
  

TRACHEOESOPHAGEAL FISTULA (TEF) / ATRESIA OF THE ESOPHAGUS

• Esophagus in front of trachea
• Connect esophagus w/ trachea
  1. Esophagus didn’t connect to stomach
  2. Esophagus twist, food can’t do down
• 5 TYPES OF TEF
  A. B. C. D. E.

MOST COMMON: Type C

• Upper end esophagus blind pouch
• Lower end esophagus connect to trachea

BOTH CONNECTED TRACHEA:

• Upper end esophagus
• Lower end esophagus

MANIFESTATIONS OF ASPIRATION (3 C’s)

• Cough, Choking, Cyanosis
• Problem: Aspiration & Nutrition

NURSING DIAGNOSIS

• Potential for injury related to ABN connection between esophagus & Trachea
  Alteration in Nutrition Less than body requirements

PRE-OP (ASAP)

• Strict NPO (Allow non-nutritive sucking)
• Parenteral fluid / TPN as necessary (based on weight)
• Nursing responsibilities: Higher amount of glucose, vitamins, minerals. Risk of developing hyperglycemia so CBG

POST-OP

• Breastmilk / Formula via Gastrostomy tube
• Prevent aspiration: Suction as necessary
• Humidified O2 – liquefy thick secretion

SURGICAL MANAGEMENT:

• Staging followed by end to end Anastomosis
  1. Cervical Esophagostomy & Gastrostomy insertion
  2. Surgical Correstion by ligating the TEF = Reanastomosing the Esophageal ends; repair done in stages
  

INTUSSUSCEPTION (SMALLER INTESTINE)

• Idiopathic hypertrophy lymphoid tissue 2º to viral infxn pathological lead pt. – POLYP, LYMPHOMA or Meckel Diverticulum Ileocecal valve (ILEOCECAL) ileum invaginates @ cecum & colon
• Hyperactive Portion of SI invaginates into the lumen of another

SYMPTOMS:

• Blood mixes with stool: currant jelly like feces
• Spasmodic abdominal pain
• Blood with mucous in the stool
• Vomiting of bile-stained vomitus (greenish)
• Palpable Sausage Shaped mass

DIAGNOSTIC TEST IS ALSO THE TX:

• BARIUM HYDROSTATIC REDUCTION TECHNIQUE: B. Enema both diagnostic & therapeutic. Introduction of Barium under pressure through rectal catheter. It will not work if there is presence of adhesions. Coiled Spring appearance
• SURGICAL EMERGENCY because POTENTIAL FOR PERFORATION  PERITONITIS like suspected APPENDICITIS
  
  

HIRSHSPRUNG’S DISEASE / CONGENITAL AGANGLIONIC MEGACOLON / AGANGLIONOSIS

CLASSIC PROFILE

• SPIDER TELANGIECTASIS: Upper Abdomen (smaller veins)
• STRIA: Lower abdomen (stretch marks)

SYMPTOMS

• Delayed Meconium (earliest sign in nursery)

DIAGNOSIS

• RECTAL BIOPSY = To know extent → Barium enema is also given
• Early diagnosis: Good health → corrective surgery
  Poor health → palliative management → minor surgery

TREATMENT

• Temporary COLOSTOMY to promote elimination w/ regular COLONIC IRRIGATION using NSS
• Give stool softener
• Modified Diet: Low residue diet (fruits, fresh vegetables), mashed foods because it will facilitate easy passage to colostomy tube. Do not give fiber → will increase bulk of stool (absorbs more fluid).

SURGICAL TREATMENT

• Child weighs 9 kg (20 lbs)
• SUAVE ENDORECTAL PULL THROUGH: pull-down of the normal bowel through muscular sleeve.
• Other procedures: SWENSON, BOLEY, DUHAMEL
  

PSYCHOGENIC MEGACOLON

• Psychological / no treatment: rooted in the anal phase / toilet training years / control of urine. Adults can have it.

IMPERFORATE ANUS

• Failure of membrane separating rectum from anus

SIGNS & SYMPTOMS:

• No meconium at all
• Inability to insert catheter
• Abdominal distention

For Females: RECTOVAGINAL FISTULA: urine is greenish and foul smelling due to Meconium.
For Males: RECTOVESICAL FISTULA: urine is greenish and foul smelling due to Meconium.

SURGICAL TREATMENT

Consideration on Growth & development

• 1’st Stage:
  at nursery do palliative care, Temporary colostomy is done to evacuate feces.
• 2’nd Stage
  Infant at 10 months old
  Readmitted again 1st phase Anoplasty VS. 2nd phase Pullthrough
• 3’rd Stage:
  After 6 months closure of colostomy & child could already feel the “urge”. There should also be bowel training.