GIT DISORDERS IN INFANTS

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 2ΒΊ 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.

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