Hernia= protrusion or projection of an organ or a part of an organ through the muscle wall of the cavity that normally contains it.
Results from imperfect closure of the umbilical muscle ring
Often associated with diastasis recti (lateral separation of the abdominal muscles)
Around week 11 gestation and obliterated umbilical vessels occupy the space in the umbilical ring
Herniated umbilicus protrudes with coughing, crying or straining
Hernia can be reduced by pushing contents back into fibrous ring
Most defects spontaneously resolve by 3-4 years of age as the muscular ring closes
Surgery indicated in cases of strangulation, increased protrusion after 2 years of age or no improvement in large defect after 4 years.
Disorders of Motility
Constipation and encorpresis
GER is the regurgitation of stomach contents into the esophagus d/t an incompetent lower esophageal sphincter.
Three mechanisms allow reflux to occur
Lower esphageal relaxations
Anatomic disruption of esophagogastric junction (aka hiatal hernia)
What's the difference between GER and GERD?
Gastroesophageal reflux (GER)
is the backward flow of stomach contents up into the esophagus or the mouth. It happens to everyone. In babies, a small amount of GER is normal and almost always goes away by the time a child is 18 months old.
Gastroesophageal reflux disease (GERD)
occurs when complications from GER arise, such as failure to gain weight, bleeding, respiratory problems or esophagitis
How is GERD diagnosed?
presence of vomiting, pain associated with regurgitation, arching back (Sandifer syndrome) and feeding refusal.
However, in very young infants, it may be difficult to differentiate GERD from normal GER or colic because some of the symptoms are similar—constant or sudden crying, spitting up or vomiting, hiccups, irritability or pain and refusal to eat. Infants with GERD can also have atypical symptoms, including respiratory problems.
A small degree of reflux is common in all infants
up18% of all infants
up to 70% w/ co-existing medical conditions
Shorter intra-abdominal Esophagus
Swallow less while asleep
How is GERD diagnosed?
Diagnoses: on hx alone (mild) or pH probe or upper GI endoscopy
endoscopic studies or
measuring the amount of reflux with pH-probes
A trial of medications may also be a useful diagnostic tool.
In infants less than 3 months, try changing the formula, if allergy is suspected.
Try smaller, more frequent feedings.
Thickening the formula also helps. Adding rice cereal makes the liquid less likely to slosh up out of the stomach into the esophagus. Studies show that even though the total amount of reflux may not change, the symptoms improve after the formulas are thickened.
Keeping the baby upright before and after feedings will also decrease the amount of reflux.
Burp several X’s during feeding
If bottle feeding, find a nipple that makes a good seal to prevent air into mouth
If child is overweight, consult PCP to set weigh loss goals
Medications for GERD
The two major pharmacotherapies are H2-blockers and proton pump inhibitors (PPIs), both of which are effective in decreasing acid secretion and have been used safely in children.
Another group of drugs, prokinetics, can be prescribed to increase motility.
These are usually given with medications that inhibit the acid. Examples are metaclopramide (Reglan) and cisapride (Propulsid).
Antacids may be tried first in children with mild symptoms.
Medications for GERD
H2 receptor blockers:
help decrease the amount of acid the stomach makes, which, in turn, will cut down on the heartburn associated with reflux.
Medications for GERD
Prevent excess acid secretion in the stomach
Management of severe GERD:
Nissen fundoplication—the fundus of the stomach is wrapped around the distal esophagus to increase LES pressure.
Risk for Aspiration related to reflux
Fluid Volume deficit related to reflux
Imbalanced nutrition, less than body requirements
Constipation is a common complaint and accounts for 25% of GI referrals
Affects 3% of preschool-age children and 1-2% of school-age children
(For Infants) Defined by criteria of
Pebble-like hard stools for a majority of BM’s X 2 weeks
Firm stools more than twice/week x 2 weeks
Constipation…think hardness, not frequency
Constipation may result from defects in filling, or more commonly emptying, or the rectum.
Please refer to Table 30-5 in text.
Constipation can be caused by underlying disease, diet or psychological factors
Abnormal elimination pattern characterized by the recurrent soiling or passage of stool at inappropriate times.
1% of school-age children
Primary vs Secondary encorpresis
Retention of stool of lower bowel/ rectum, leads to constipation, dilation of lower bowel and incompetence of the inner sphincter
made on hx and PE, may perform barium enema to r/o organic causes
Clear out impacted stool
Centered around educating the child and parents about the disorder and its tx
Reassurance/ emotional support
Congenital aganglionic megacolon
Absence of ganglion cells in the colon results in mechanical obstruction due to inadequate motility
Most common area affected is rectosigmoid colon
Etiology? Usually congenital, often a familial defect.
Also associated w/ Down’s Syndrome
And anomalies of urinary tract
As stool enters the affected area, it remains there until additional stool pushes it through. The affected part of the colon dilates; a mechanical obstruction may result
Failure to pass meconium within 24 hours
Constipation during first month of life
Reluctance to eat
Failure to thrive
V/D; stool w/ ribbon-like appearance
Digital examination of rectum reveals absence of stool followed by explosive release of gas
Rectal biopsy makes definitive diagnosis – absence of ganglion cells
Hirschsprung’s Disease Treatment
Surgery to remove aganglionic bowel
Usually 2 stagesSurgery – (if complete obstruction)
First stage – temporary colostomy (until infant weighs 8-10kg or 10mos-1yr)—to decompress the colon
Second stage – Abdominal pull-through with excision of aganlionic segment and reanastomosis
NG tube is generally inserted preop
Dietary modification, stool softeners, and isotonic irrigation to prevent impaction
Monitor F/E balance
Pre- and Post-Op care
Promote bowel program
Constipation related to aganglionic bowel
Post-op: Altered skin integrity
Post-op: Risk for Infection
Post-op: Risk for Fluid volume deficit/altered nutrition < body requirements
inflammation of the stomach and small and large intestines. It is an infection caused by viruses, bacteria or parasites.
Commonly manifested as diarrhea
Children under 5 years, 2 cases/year average
Gastroenteritis caused by viruses may last 1-2 days.
Viral Gastroenteritis accounts for 70-80% of acute diarrhea in North America.
Bacterial cases can last a week or more.
Complications include: Dehydration, electrolyte and acid base disturbance, bacteremia and sepsis and malnutrition
What is it?
Watery stool, increased frequency or both
Acute vs Chronic Diarrhea
Acute: lasting less than 2 weeks, which is usually r/t bacterial or viral infections; most common childhood reason for Diarrhea= Rotavirus
Chronic: lasting longer than 2 weeks, usually r/t functional disorders, such as IBS, or diseases such as UC or Crohn’s disease
What causes Diarrhea?
Bacterial, viral or parasitic infection
Food intolerances or allergies
Reaction to medications
Diseases such as Chron’s Disease or UC
Refer to Table 30-6 for Other causes of Diarrhea in Children
Meds used to tx Diarrhea
Metronidazole (Flagyl)- anerobic bacteria, some parasites and in combination for H pylori
Imodium (an anti-diarrheal)
Chart on page 1132 reviews major parasites
Recurrent Abdominal Pain
Inflammatory Bowel Disease
Definition: peptic ulcer is erosion in the lining of the stomach or duodenum (the first part of the small intestine). The word “peptic” refers to pepsin, a stomach enzyme that breaks down proteins.
Small ulcers may not cause any symptoms. Large ulcers can cause serious bleeding . Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through is called a perforation of the intestinal lining.
What causes Peptic Ulcers?
Something damages the stomach lining.
The most common cause of such damage is a bacterium called Helicobacter pylori (H.pylori) .
Most people with peptic ulcers have this organism living in their gastrointestinal (GI) tract.
Other factors can make it more likely for you to get an ulcer , including:
Using aspirin, ibuprofen, or naproxen
Drinking alcohol excessively
Smoking cigarettes and using tobacco
Abdominal pain is a common symptom but it may not always be present.
Other possible symptoms include:
Nausea , vomiting
Heartburn , indigestion , belching
Bloody or dark tarry stools
Dx: upper GI, or esophagogastroduodenoscopy, and Guiac of stool and CBC w/ diff
Tx: A combination of medications to kill the H pylori , reduce acid levels, and protect the GI tract.
Antibiotics to kill Helicobacter pylori
Acid blockers (like cimetidine, ranitidine, or famotidine)
Proton pump inhibitors (such as omeprazole)
Bismuth (may help protect the lining and kill the bacteria)
Appendicitis= inflammation of the appendix
Occurs most often in adolescent males (10-19yr)
Caused when the opening from the appendix into the cecum becomes blocked.
The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum.
As edema continues, vascular supply is compromised, bacteria followed by an immune response…can lead to rupture.
Appendicitis should be suspected in any child with pain in the RLQ
Two types of presentation: typical and atypical.
The typical history includes pain starting centrally (periumbilical) before localizing to the right iliac fossa (the lower right side of the abdomen)
Pain is usually associated with loss of appetite and fever
Nausea or vomiting
Atypical symptoms may include pain beginning and staying in the right iliac fossa, diarrhea and a more prolonged, smoldering course.
These include localized findings in the right iliac fossa.
digital rectal examination elicits tenderness
Coughing causes point tenderness at McBurney's point
Guarding upon palpation, suspect Peritonitis
I FIGURE 30–14 McBurney’s point is the common location of pain in children and adolescents with appendicitis.
Other signs include:
Deep palpation of the left iliac fossa may cause pain in the right iliac fossa.
Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief.
If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This Maneuver will cause pain in the hypogastrium.
Diagnosis is based on Hx and PE
Abdominal CT or ultrasound
For atypical presentation
Labs: CBC w/ diff
Also an elevation of neutrophilic white blood cells.
Pregnancy test to r/o ectopic pregnancy
Pre and Postoperative care
Correction of fluid and electrolyte deficits
Risk for Infection
Necrotizing Enterocolitis (NEC)
A medical condition primarily seen in premature infants, where portions of the bowel undergo necrosis. Potentially life-threatening inflammatory disease.
Most common GI emergency occurring during the neonatal period
Etiology is multifactorial:
Bacterial or viral infection
Immaturity of the GI mucosa
Clinical manifestations occur b/t 3-14 doa, but can occur as early as the first day of life and as late as 3 months of age.Initial symptoms include:
feeding intolerance (increased gastric residuals, vomitting, irritability, and abdominal distension)
Symptoms may progress rapidly to abdominal discoloration with intestinal perforation and peritonitis and systemic hypotension requiring intensive medical support.
the presence of free peritoneal gas, and abd wall changes on X-ray