The gastrointestinal tract develops from the endoderm during the third week of gestation. By the fourth week, the foregut, midgut, and hindgut have formed and will contribute to different parts of the GI system. Notable milestones in GI development include the formation of the stomach, esophagus, liver and pancreas by 5-7 weeks and intestinal lengthening by 8-12 weeks. Tracheo-esophageal fistula and esophageal atresia are birth defects where the esophagus fails to form properly, sometimes connecting abnormally to the trachea. They require surgical correction, often in stages, to allow for feeding and prevent aspiration. Close nursing observation and care is needed

1. GASTROINTESTINAL SYSTEM
NIRMALRAJ.S
MSc(N) II YEAR
PEDIATRIC NURSING – II
COLLEGE OF NURSING,
MADRAS MEDICAL COLLEGE, CHENNAI.

2. Development
of embryonic
gastro
intestinal
system
• The gastrointestinal tract (GIT) arises initially
during the process of gastrulation from
the endoderm of the trilaminar embryo (week 3)
and extends from the buccopharyngeal
membrane to the cloacal membrane. The tract and
associated organs later have contributions from all
the germ cell layers.
•
During the 4th week three distinct regions (fore-,
mid- and hind-gut) extend the length of the embryo
and will contribute different components of the
GIT. The large mid-gut is generated by lateral
embryonic folding which "pinches off" a pocket of
the yolk sac, the 2 compartments continue to
communicate through the vitelline duct.

3. Development of
embryonic gastro
intestinal system
• The oral cavity (mouth) is formed following
breakdown of the buccopharyngeal membrane
(oropharyngeal or oral membrane) and contributed
to mainly by the pharynx lying within the
pharyngeal arches . Loss of buccopharyngeal
membrane opens the tract to amniotic fluid
through the remainder of development, and during
the fetal period is actively swallowed.
• From the oral cavity the next portion of the foregut
is initially the pharynx, a single gastrointestinal
(oesophagus) and respiratory (trachea) common
tube, that lies behind the heart.

4. Milestones in
gastrointestinal
system development
Weeks pregnant Milestone
5 weeks The digestive tube starts to form
7 weeks The stomach, esophagus, liver and
pancreas starts to form
8-10 weeks Cells inside digestive tube hollow it
out
8-12 weeks Intestine grows in length and is
housed in the umbilical cord.
11 weeks The rectum and anus form
12 weeks Intestine leaves the umbilical cord
and returns to the abdomen
13 weeks Baby begins swallowing amniotic
fluid and meconium accumulates in
the intestine.
14 weeks Baby practices sucking and chewing
23 weeks Peristalsis is happening.

5. Parts of the
digestive
sytem
The foregut, which becomes the
esophagus, stomach,liver and
pancreas
The midgut, which contains most
of the small intestine and two-
thirds of the large intestine.
The hindgut, which contains the
rest of the large intestine, the
rectum and the anal canal.

6. ANATOMY OF
GASTROINTESTINAL
SYSTEM
The digestive system breaks food in to basic nutrients
that can be used by the body.
As food moves through the digestive tract, its
digested(broken down into parts and absorbed into the
blood stream).
Certain organs (such as the liver, gall bladder, and
pancreas) help with this digestion.
Parts of food that can’t be digested become stool. This is
waste material that’s passed out of the body

7. MAJOR ORGANS OF GASTROINTESTINAL
SYSTEM
• The mouth takes in food, breaks it into pieces, and begins the process of digestion.
• The esophagus moves food from the mouth to the stomach
• The stomach breaks food down into a liquid mixture.
• The small intestine digests food further and absorbs nutrients. Whats left is passed on to
the colon as a liquid waste.
• The large intestine (colon) absorbs water, salt and other minerals from liquid waste,
forming a solid stool.
• The rectum stores stool until a bowel movement occurs.

8. MAJOR ORGANS OF GASTROINTESTINAL
SYSTEM
• The anus is the opening where stool leaves the body
• The liver makes bile ( a fluid that helps digest fat). It also breaks down nutrients and
stores energy.
• The gallbladder stores bile.
• The pancreas makes enzymes that help with digestion
• The appendix is a small hollow structure that’s attached to the large intestine. It has no
clear function in the body, but it can become blocked and infected.

9. Disorders of
gastrointestinal
system
Congenital gastrointestinal disorder
Disorder of mouth
• Cleft lip and cleft palate
Disorder of oesophagus
• Tracheo- esophageal fistula
Disorder of stomach
• Pyloric stenosis
Disorder of intestine
• Obstructional intestine
• Hernia
• Intussusception
• Hirschsprung's disease
• Anorectal malformations

10. Disorder of Mouth
Cleft lip and Cleft
palate

11. Cleft lip
• A cleft lip result from failure of fusion of maxillary
process with nose elevation on frontal prominence.
• The extent of defect varies from notch in the lip to
a large cleft reaching the floor of the nose
• Cleft lip can be on one side called unilateral cleft
lip or may be on both sides called as bilateral cleft
lip.

12. CLEFT PALATE
Cleft palate results from failure of
the hard palate with each other
and with the soft palate.
Cleft lip also usually occurs with
cleft palate.
Cleft palate can be complete or
incomplete.

13. INCIDENCE
The incidence of cleft lip is 1 in 750 births
Cleft lip is predominantly seen in males and
cleft palate in females.
For cleft palate 1 in 2500 births.
Approximately 15% of affected infants will
have associated defects.

14. ETIOLOGY
Cleft lip and cleft palate are facial
malformations that occurs during early
weeks of fetal growth and development.
The exact cause is not known but it is
believed that it occurs as a result of
genetical and environmental factors.

15. POTENTIAL
CAUSES ARE
Medications taken during pregnancy –
anticonvulsants, acne
Exposure to virus or chemicals during
fetal G & d
Exposure to X-ray
Maternal alcohol intake
Maternal smoking

16. PATHOPHYSIOLOGY
• Failure or incomplete fusion of embryonic
structures
• Fusion of maxillary and premaxillary process
normally occurs during 5th and 8th week of
gestation
• The palatal process fuse about a month later
• Failure of fusion results in cleft lip and cleft
palate

18. DIAGNOSTIC
EVALUATION
• Prenatal diagnosis of cleft is at times possible by
maternal ultrasonography.
• After birth, a physical examination of the mouth,
palate and nose confirms the presence of cleft lip or
palate
• A gloved finger placed in the mouth to feel defect
or visual examination with flash light will confirm
the diagnosis.

19. MANAGEMENT
A team of surgeon are required to treat cleft lip and cleft palate. Team must include
• A plastic surgeon
• An otolaryngologist
• Oral surgeon
• Orthodontist
• Dentist
• Prosthodontist
• Speech pathologist
• Nurse coordinator

20. MANAGEMENT OF
CLEFT LIP
• Cleft lip may require one or two
surgeries depending on severity of
defect.
• The initial surgery is usually
performed at the age of 3months.
• Tennison Randall Triangular Flap
( Z-plasty) is the surgical
correction most usually
performed. Or Millard’s
Rotational Advancement
technique.

21. CLEFT PALATE CORRECTION
• It requires many surgeries over the course of 18 years.
• First surgical repair is done between 6-12 months of age which helps in promoting
functional palate and reduces the chance of fluid entering the middle ears and helps in
proper development of teeth
• When child is 8 years old they may need a bone graft to fill in the upper gum line
• Once the permanent teeth grows they may need braces to straighten teeth.

22. NURSING
MANAGEMENT
1.Care of baby at birth
2.Care of baby before surgery
3.Care of baby after surgery

23. CARE OF BABY AT BIRTH
• It is detected soon after delivery
• Check for associated congenital anomalies
• Explain about possibility of complete correction to parents
• Feeding is a very problem as the defect reduces baby’s ability to suck milk.
• Palatal prosthesis, rubber tube with syringe can be used for feeding.
• Burp the baby between feeds

26. CARE BEFORE SURGERY
Consent
Investigative report checking
NPO for 6 hours before
surgery.

27. CARE
AFTER
SURGERY
Close observation and monitoring
Observe for bleeding
Turn baby’s face to one side for draining secretions
Protect surgical site from injury
Arched devise called a s logan bow is used to prevent
tension on suture site
Administer prescribed medications
Do not allow baby to put any object in mouth

28. TRACHEO
OESOPHAGEAL
FISTULA
Tracheo-esophageal fistula
and esophageal Atresia are
the malformations of
digestive system, in which
esophagus does not
develop properly.
Esophagus is a tube that
normally carries food from
the mouth to the stomach

29. Esophageal atresia
It is the failure of esophagus to form a continuous
passage from the pharynx to the stomach

30. Tracheo-
oesophageal fistula
It is an abnormal connection between the trachea and
the esophagus.

31. Incidence
• Occurs in 1 in 3500 births
• Male predominance
• Esophageal atresia with or without fistula is
common among premature births.
• 50% of these cases will have associated anomalies
like-
• Vertebral column diseases
• Anorectal malformation
• Cardiac arrest
• Renal anomalies
• Limb abnormalities

32. Pathophysiology
The upper part of esophagus develops from
the retropharyngeal segment and lower half
from gastric segment.
At about 4 weeks of gestation, a laryngo-
tracheal groove is formed which divides the
foregut into two longitudinal tubes, which
further develops into trachea and esophagus
Defective separation and ineffective fusion
will leads to the development of TEF

34. Types of
esophageal
tracheo fistula
Type I:
• In this type, there is
esophageal atresia and
proximal and distal
segments of esophagus are
blind. There is no
communication between
trachea and esophagus. This
type is seen in 3-7% of
cases.

35. Types of
esophageal
tracheo fistula
Type II:
• In this type, esophageal
Atresia is present and the
blind proximal segment of
esophagus connects with
trachea by fistula.
• The distal end of
esophagus is blind.
• This types is seen in
0.8% of cases.

36. Types of
esophageal
tracheo fistula
• TYPE III:
• In this type, esophageal
Atresia is present. The
proximal end of esophagus
is a blind pouch and distal
segment of esophagus is
connected by fistula to
trachea
• Observed in 87% of cases.

37. Types of esophageal
tracheo fistula
TYPE IV :
• It is the rarest type that occurs in 0.7%
of cases. In this type, both upper and
lower segments of esophagus
communicate with trachea.

38. Types of
esophageal
tracheo fistula
TYPE V :
• In this type, esophagus
and trachea are normal
and completely formed
but are connected by a
fistula.
• This type is also known
as ‘H’ type and is present
in 4.2% of cases.

39. CLINICAL
FEATURES
• The presence of maternal polyhydromnias
and single umbilical artery should alert
pediatricians about the presence of Atresia
of upper digestive tract.
• Disorder is usually detected soon after
birth when feeding is attempted on the
basis of following manifestations- Violent
response on feeding
• Infant coughs and chokes
• Fluid returns through nose and mouth
• Cyanosis occur
• Infant struggles

40. CLINICAL
FEATURES
• Excessive secretions coming out of
nose and constant drooling of saliva
• Frothy saliva
• Abdominal distension
• Intermittent unexplained cyanosis
and laryngospasm caused due to
aspiration of accumulated saliva in
blind oesophageal pouch
• Pneumonia may occur due to
overflow of milk and saliva

41. DIAGNOSTIC EVALUATION
• Diagnosis can be made antenatally also
• It can be suspected if the ultrasound of the pregnant women shows polyhydramnios.
• Soon after birth vigorous coughing, choking in response to feeding is an important
manifestation
• As soon as the diagnosis is suspected, an attempt is made to pass feeding tube through
nose or mouth into stomach.
• The feeding tube does not pass into the stomach it is an indication of atresia
• X-ray of chest shows air filled esophageal pouch and air in stomach. If the feeding tube
has been inserted, it appears coiled up in the upper esophageal pouch.
• An ultrasound enables identification of the type of tracheo-esophageal pouch
• Ultrasound helps in identification of type of tracheo- esophageal fistula.

42. Diagnostic evaluation

43. Medical management
• Tube placement. Management plans for a delayed repair of the esophageal atresia may include
placing a 10-French Replogle double-lumen tube through the mouth or nose well into the upper
pouch to provide continuous suction of pooled secretions from the proximal portion of the atretic
esophagus; the baby may be positioned in the 45° sitting position; prophylactic broad-
spectrum antibiotics (eg, ampicillin and gentamicin) may be used.
• Gastrostomy. If no distal TEF is present, a gastrostomy may be created. In such cases, the stomach
is small, and laparotomy is required; when a baby is ventilated with high pressures, the
gastrostomy may offer a route of decreased resistance, causing the ventilation gases to flow
through the distal fistula and out the gastrostomy site.
• TEF ligation. In cases such as those above or in cases in which a distal fistula continues to cause
lung soiling, distal TEF ligation should be considered; this ligation is performed by means of a
right-side thoracotomy, ideally via an extrapleural approach.

44. Medical management
• Flourish Pediatric Esophageal Atresia Anastomosis. In May 2017, the US Food and Drug
Administration approved the Flourish Pediatric Esophageal Atresia Anastomosis (Cook Medical)
for management of esophageal atresia in infants up to 1-year-old who do not have teeth and do not
have a TEF (or have had a TEF repaired); the device closes the gap in the esophagus by using
magnets to pull together the upper and lower portions of the esophagus; it is not indicated for use
in patients in whom the distance between the esophageal segments is 4 cm or greater.
• Repair of esophageal atresia. In some pediatric surgical centers, surgeons are gaining experience
in repairing esophageal atresia by means of a minimally invasive thoracoscopic approach; this
approach should be undertaken only by those who have extensive experience in pediatric
thoracoscopic surgery.
• Chest tube care. The chest draining tube is placed in 2 cm of water only to seal it; it is not
connected to a suction device, which could encourage an anastomotic leak.

45. Management
• The management of tracheo esophageal
fistula is mainly surgical.
• Surgical intervention depends upon the
distance between the proximal and distal
pouch of esophagus, type of defect,
condition of neonate and his weight.
• If the distance between proximal and distal
tube is less than 2.5 cms, and the infant
condition is good, primary repair is done by
division and ligation of the fistula along with
end to end anastomosis.

46. Staging surgery
• When the distance is more than 2.5 cms and condition of infant is
poor, a two stage procedure is done.
• Stage I: tracheo esophageal fistula is ligated and gastrostomy is done
to reduce the risk of reflux and to provide feeding
• Stage II: proximal and distal pouches are anastomosed. If the gap is
too large, a segment of colon is used for reconstruction of the
esophagus.
• This is done at 18-24 months of age.

48. Nursing management
• Pre-operative nursing
management
• Post operative nursing
management

49. Nursing management
Risk for aspiration related to structural abnormality:
• Soon after diagnosis attempt to feed should be stopped
• NG tube aspiration should be done frequently to aspirate pooled secretions in upper blind
pouch
• Maintain patency of NG tube by irrigating it with NS
• Observe for respiratory distress like pallor, cyanosis, choking, nasal flaring etc.,
• Administer prescribed medications

50. Nursing management
Risk of deficient fluid volume related to inability to take oral feeds.
• Iv fluid are administered as prescribed by physicians
• Maintain IO chart
• Maintain hydration status of child by monitoring signs of dehydration
Impaired breathing related to laryngospasm and excessive secretion in trachea.
• Monitor vitals of child
• Administer oxygen in case of cyanosis
• Keep child in semi-upright position

51. Complication
Esophagitis
Esophageal
strictures
Recurrent
fistula
Death from
asphyxia
Pneumonitis dehydration

52. Pyloric stenosis
• Pyloric stenosis or
pylorostenosis is
narrowing (stenosis) of
the opening from the
stomach to the first part of
the small intestine known
as the duodenum.
• The pylorus, meaning
"gate".

53. Incidence
• 3/1000 live birth
• Male: Female = 4:1
• Commonly in the first born male child
• Most common cause for laparotomy before 1 year.
• Age 3weeks to 3 months.
• Child of those parents who affected with pyloric stenosis.
• It affect more commonly child than the adult.

55. Clinical
features
• Symptoms appears between 2-4 weeks of age
• Initial presentation is regurgitation and non-
bilious vomiting which may occur both during
and after feeding
• Vomiting becomes progressively forceful, until it
is projectile in nature.
• In projective vomiting, the vomitus is propelled
several feet from the infant
• It is the characteristic feature of pyloric stenosis.
• Vomitus contains gastric contents, mucous and
streaks of blood but does not contain bile.

56. Clinical features
Infant seems to
be hungry Other
symptoms include
Weight loss
Poor weight gain Dehydration
Less bowel
movement
Reduced
frequency and
amount of stool

57. Diagnostic evaluation
Careful physical examination reveals a firm,
olive sized mass in epigastrium
In severely malnourished infants, epigastric
distension may be seen and peristalysis waves
may be seen passing from left to right during
and after feeding
Barium meal X-ray study reveals the narrowed
pylorus

58. Surgical
management
It is treated in 2 stages.
Initially fluids are given intravenously to treat
dehydration and restore body’s normal chemistry
Pyloromyotomy is followed or Fredette- Ramstad
surgery is performed.
This surgery helps in opening tight muscles of
pylorus that caused narrowing.

59. Nursing
management
• Pre operative nursing management
• Observe and record vitals
• Note and record vomitus and stools
• Stop oral feeds and administer IV fluids
• Give small frequent feeds
• Weigh the infant daily to find degree of
dehydration
• Maintain strict intake and output chart

60. Nursing
management
• Observe for signs of complications
• Manage pain
• Provision of adequate fluid and nutrition
• Parental education and follow up after
surgery

61. DISORDERS
OF
INTESTINE

62. Hernia
Hernia is the protrusion of
intestine through a weakness in
the abdominal muscles.
Hernias occurring in newborns
are Omphalocele, Gastroschisis
and Diaphragmatic Hernia.
Commonly diagnosed hernias
during infancy and childhood are
inguinal and umbilical hernia.

63. Etiology and Risk
factors
• For a hernia to occur, two factors must
be present-
• a. A defect in the integrity of muscular
abdominal wall
• b. Increased intra-abdominal pressure

64. Defect in muscular wall or (may be congenital or trauma)
Abdominal protrusion of abdominal organs through the structure that
contain it
Reducible ( when the contents of hernia sac can be
replaced in the abdominal cavity by manipulation )
Irreducible/ incarcerated ( when contents can not
be replaced in abdominal cavity due to
strangulation of hernial segment of intestine)

65. Gastroschisis or
omphalocele
Definition
• Gastroschisis is a
congenital anomaly
characterized by a
defect in the anterior
abdominal wall
through which the
abdominal contents
freely protrude.

66. Gastroschisis or
omphalocele
• There will not be any
overlying sac and the size of
the defect is less than 4cms.
• The abdominal wall defect is
located at the junction of
the umbilicus and normal
skin, and is almost always to
the right of the umbilicus.

67. omphalocele
• Omphalocele is another
congenital anomaly that
involves the umbilical cord
itself, and the organs
remain enclosed in the
visceral peritoneum. With
Omphalocele the defect is
usually much larger than
that of Gastroschisis.

68. Risk
factors
Younger mothers less than 20 years
Folic acid deficiency
Hypoxia
Salicylates, acetaminophen, ibuprofen consumption
during pregnancy
Cocaine and alcohol consumption during pregnancy
High risk pregnancies complicated by low birth
weight babies.

69. Risk factors
OMPHALOCELE
1 in 5,000 new born babies
GASTROSCHISIS 1 in 11,000 babies
Malformation are slightly more frequent in
males than females. The male- female ratio is
5:1.

71. Clinical features
Omphalocele-
• Diameter of abdominal wall defect
is 4-12 cm, it may be centrally
located or in the epigastrium or the
hypogastrium
• Results to injury to baby’s liver
• Sac may rupture in 10-20% of case;
rupture may occur in utero or during
delivery.

72. Clinical features
Gastroschisis:
• The abdominal wall defect is fairly
uniform in size (less than 5cms ) and
location to the right of the umbilical
cord.
• Edema, inflammation and turgor of
intestine depends on the size of the
abdominal cavity and opening of
the abdominal wall.

73. Management for
omphalocele
• Observe for any associated problems such as
chromosomal abnormalities, congenital heart
diseases or any other malformations.
• Maintain IV fluids
• Cover omphalocele with non-adherent dressing
to preserve body heat and moisture
• Prophylactic antibiotic may be given pre
operatively
• Closure of small or medium sized omphalocele
is accomplished without difficulty.
• A baby with ruptured omphalocele should be
treated as the child with Gastroschisis

74. Surgical
repair
• Omphalocele may be treated by
mobilizing skin flaps to cover the
sac.
• A circumferential incision is
made along the skin-
omphalocele junction, keeping
membrane intact.
• Teflon sheets are sutures along
the edge and approximated over
the omphalocele sac.

75. Surgical Repair

76. Medical
management
for
Gastrochisis
• Gastroschisis should be carefully wrapped in
saline so that the intestine does not dry out.
• NG tube is put to remove air from the intestines
• Respiratory distress in neonate with Gastroschisis
may respond to gastric decompression, although
intubation may still be needed.
• Administer iv fluid bolus ( 20ml/kg, RL or NS
followed by 10% dextrose and normal saline 2-3
times the baby’s maintenance fluid requirement).
• Monitor urinary output
• Do rectal examination to dilate anal opening
• Broad-spectrum antibiotics to prevent
contamination of peritoneal cavity.

77. Surgical management for Gastrochasis
• Silastic sheets are sutured to full thickness of extended abdominal
wall defect and closed over the intestines.
• This should be helpful in stretching abdominal musculature, emptying
stomach and bladder, and manually evacuating the colon.
• With new advancement like silo helps in replacing intestines into
abdominal cavity.
• This new procedure allows the bowel to return to its intended shape
and location without further traumatizing viscera.

78. Surgical management for Gastrochasis

79. Prognosis
Current advances in surgical techniques and
intensive care management of neonates
have increased the survival rate to 90%.
Pre-natal diagnosis either through
ultrasonography or any other method
available are helpful.
Morbidity is closely related to the presence
of other malformations and complications of
wound or intestines.

80. INGUINAL
HERNIA

81. Inguinal Hernia
• It is the most common hernia
seen in infants and children. It
occurs in the groin region. It may
be unilateral or bilateral, more
frequently in boys (90%) then girls
(10%). It is more common in
premature than term infants.

82. Pathophysiology
As the male fetus grows and matures during
pregnancy, the testicles develop in the abdomen
and then move down into the scrotum, through
an area called the inguinal canal.
Shortly after the baby is born, the inguinal canal
close, preventing the testicles from moving back
into the abdomen.
If the closure does not occur completely, a loop of
intestine can move into the inguinal canal,
through the weakened area of the lower
abdominal wall, causing hernia.

83. Pathophysiology
Hernia can be reducible or irreducible.
If the hernia is reducible, the contents
of the hernia sac can be placed into the
abdominal cavity by manipulation.
In an irreducible hernia, the contents
of the hernia sac cannot be reduced or
replaced.

84. Clinical
features
Vomiting that
contains bile
Cramping
pain
Abdominal
distension
Fever
Irritable and
restless infant
Strangulation
and gangrene

85. Diagnostic evaluation
• It can be diagnosed by physical examination.
• Determine for reducible or irreducible type of
hernia
• Abdominal X-ray or ultrasonography also helps
in confirming diagnosis.

86. Management
• Specific treatment for hernia depends on the child’s age, overall health and type of
hernia
Two types of surgeries are done. for the repair
• 1. Open inguinal hernia repair ( Herniorrhaphy, Hernioplasty )
• 2. Laparoscopic repair.

87. Laproscopic Procedure Open Inguinal Hernia Repair

88. Complication
• Constipation
• Difficulty urinating
• Urinary incontinence or leakage
• Infection
• Bleeding
• Recurrence
• Injury to surrounding tissue
• Nerve damage
• Rejection of the mesh (The mesh used for hernia repair is
recognized as a foreign object by the body leading to an
inflammatory response)
• Build up of fluid under the surface of the skin (seroma)

89. Umblical hernia
• Umbilical hernia occurs in about
10% of all children, more often in
girls than in boys.
• It frequently occurs in premature
infants.

90. Pathophysiology
When the fetus is growing and developing during pregnancy, there is
small opening in the abdominal muscles so that the umbilical cord
can pass through, connecting the mother to the baby.
After birth, the opening in the abdominal muscle closes as the baby
matures.
Sometimes, these muscle do not meet together completely, and a
small opening remains.
A loop of intestine can move into the opening between abdominal
muscle and cause hernia.

92. Clinical
Features
Appears as bulge or swelling in the belly-
button area.
The swelling may be more noticeable, when
the baby cries and may get smaller or
disappear when baby relaxes.
If the physician gently pushes on the bulge
when the child is calm and quiet laying down,
it will usually get smaller and go back into the
abdomen.

93. Diagnostic evaluation
• Physical examination reveals the
presence of bulge in umbilical
region
• Abdominal X-ray & ultrasound
may be done to examine intestine
closely

94. Management • By 1 year of age many hernias will close with out
any surgeries.
• All hernias are expected to close by 5years of age
• Hernia becomes bigger with age, is not reducible, or
still is present after 3 years of age- it needs surgical
repair.
• During surgery the child is placed under anesthesia.
• A small incision is made in the umbilicus and the
loop of intestine is placed back into the abdominal
cavity.
• Muscles are then sutured together.
• Sometimes a piece of meshed material is used
strengthen the area where the muscle are repaired.

95. Pre Operative
Management
Pre operatively the infant is fed until few
hours before surgery, in order to prevent
dehydration.
All the preoperative routine care is given-
like bath to the child in the morning, putting
operation theatre clothes, placing
identification band on wrist, collecting all
reports of laboratory investigations and
preparing patients file.

96. Post Operative
Management
Later the child comes form operation theatre, receive him
in a comfortable operation bed.
Monitor vitals
IV fluids still bowel movements return
Observe site for bleeding } Discharge once baby starts
oral feeds } No tub baths until 1 week of surgery. Sponge
is advised. } No restriction on movements and play.

97. Intestinal
Obstruction

98. Definition
• Bowel obstruction is a mechanical or functional obstruction of the
intestines, preventing the normal transit of the products of digestion.
• It can occur at any level distal to the duodenum of the small intestine and is
medical emergency.

99. Incidence and
etiology
• 1 in 15oo births
• Intrinsic causes- atresia, stenosis,
meconium ileus
• Extrinsic causes- malrotation, constructing
bands, intra abdominal hernia.

100. Small
bowel
obstruction
Adhesions from previous surgery
Hernias contain bowel
Neoplasm’s
Intussusception
Strictures
Foreign bodies
Intestinal atresia

101. Large bowel
obstruction
Neoplasm’s
Inflammatory bowel disease
Adhesions
Constipation
Fecal impaction
Colon atresia
Pseudo obstruction

102. Pathophysiology
Normal bowel contains gas and Chyme (mixture of food,
saliva, gastric , biliary, pancreatic and intestinal secretions)
Chyme continues to accumulate even without intake of
oral fluids.
Intrinsic or extrinsic obstruction of bowel leads to
accumulation of secretions that dilate the intestine
proximal to the obstruction.
Increased peristaltic contractions and intraluminal pressure
may cause frequent loose stools, flatulus and vomiting
Bowel becomes ischemic when capillary blood flow stops,
allowing bacteria to pass into the peritoneum and then
into the blood stream, leading to septicemia.

103. Clinical
features
Abdominal pain
Abdominal distention
Vomiting
Constipation
Dehydration
Electrolyte imbalance
Respiratory compromise
Bowel ischemia
Colicky pain

104. Investigation
• Blood investigations- serum electrolyte, BUN ,
creatinine , glucose , CBP, ABG
• 2. Urinalysis
• 3. Stool for occult blood
• 4. Imaging studies
• 5. ultrasound

105. Medical management
Stabilize the patient and monitor vital signs
Replace fluids with isotonic sodium chloride or RL
Opioid analgesics
Antiemetics
Broad-spectrum antibiotics

106. Surgical Management
• Adhesions often settles with out surgery
• In infants most of these obstruction are due to
adhesions which needs complete surgical correction.

107. INTUSSUSCEPTION

108. Definition
• Intussusception is the invagination or
telescoping of one segment of intestine into
another adjacent distal segment of the
intestine.
• The term intussusception is derived from Latin
words “Intus” meaning within and “suscipere”
means to receive within

109. Incidence
and
etiology
It is most common cause in children between 3 months
and 6months of age or in older children and adults.
The incidence is 1-4 in 1000 live births.
More common in boys than girls.
Cause is not known.
Since intestinal tract in children is freely movable,
hyperperistalsis due to gastroenteritis or lesion may lead to
this condition.

110. Classification
A. ILEOCOLIC: This is the commonest type
where ileum invaginates into the caecum
and then into the ascending colon.
B. CAECOCOLIC: In this type, the caecum
invaginates into colon.
C. ILEOILEAL: In this type, one portion of
ileum invaginates into the other portion of
ileum.

111. Pathophysiology
A segment of bowel telescopes into a more distal
segment, and drags all the associated blood supply,
nerves, lymph of that part.
This results in compression of veins followed by
swelling of that region, leading to obstruction and
decreased blood floe to that part
Leads to gangrene and bleeding
Rupture may follow leading to abdominal infection
and shock.

112. Clinical features
• Onset of symptom is sudden
• Triad of symptoms- colicky pain, bilious vomiting and jelly like stool
• Colicky pain is identified by infant’s sudden loud crying and drawing of knees up to the chest
while crying
• As the pain increases, infant becomes progressively weaker and lethargic and shock like state
develops.
• Body temperature rises to 41 degrees (106 F)
• Shallow respirations
• Episodes of vomiting
• Abdominal tenderness, distention
• On palpation sausage shaped mass is felt in right upper quadrant.

113. Diagnostic Evaluation
• Barium enema
• Abdominal ultrasound

114. Management The treatment for Intussusception is non
surgical, hydrostatic reduction using
barium and air enema
Air insufflation is believed to be safer than
barium enema.
Successful reduction is reported in about
65- 85% of cases of barium enema an 90%
cases in air insufflation.
If the hydrostatic reduction is unsuccessful
then a surgery is required.

115. Nursing
management
• Pre-operative nursing management:
• Prepare for admission and surgery
• Help parents understand modalities of treatment
• Withhold oral fluid 6-8 hours prior to surgery
• Parenteral fluid is administered incase of shock
• Nasogastric suctioning for decompression of
bowel
• Enema
• I/O chart
• ANTIBIOTICS AS PRESCRIBED

116. Post
operative
management
• Assess general condition
• Assess and observe for barium in stool If surgery is
performed
• Monitor vitals
• Observe the incision site for drainage
• Dressing
• Monitoring abdominal girth daily
• Parenteral fluid until peristalsis is returned
• GI suctioning to keep stomach empty
• Monitor urinary output
• Ambulate child as early as possible last

117. Hirschsprung’s disease
• Hirschsprung’s disease is a
disorder of the gut caused
due to congenital absence of
ganglion cells in the
submucosal and myentric
plexus of intestine. It is also
known as Megacolon or
Congenital Aganglionic
Megacolon.

118. INCIDENCE & ETIOLOGY:
1 in 5000 live births, it is more common in males
than females. Through research it is suggested
that it is caused by interaction between two
proteins encoded by two genes:
RET Proto- oncogene (chromosome 10)
EDNRB gene (chromosome 13)

119. Pathophysiology
Due to absence of ganglionic cells
There is lack of peristalsis in the affected
portion
Functional obstruction of colon
Accumulation of gas & faces proximal to the
defect
Enlargement of the colon occurs and called
Megacolon

120. CLINICAL FEATURES:
In neonates and infants:
• Failure to pass meconium
• Abdominal distension
• Bile- stained vomiting
• Shock
Episodes of diarrhea & constipation In older children:
• Constipation with abdominal distension
• When stool passed foul smelling, and liquid in consistency
• Malnourished and anemic

121. DIAGNOSTIC
EVALUATION:
Hirschsprung’s disease is suspected
in a baby who has not passed
meconium within 48 hours of birth.
• Rectal examination
• Palpation
• Anorectal manometry
• Barium enema & Rectal biopsy

122. • A. Medical management:
• Administration of Isotonic enema
• Administration of stool softeners
• Low residue diet
• B. Surgical management:
• The surgery involves two steps:
• 1) TEMPORARY COLOSTOMY
• 2) DEFINITIVE SURGERY, after about a year of these surgeries, the
colostomy is closed.

124. Nursing management
Pre- operative care:
• i. Assessment, complete history of new born.
• ii. After diagnosis, nurse must help parents.
• iii. Nurse taught about giving isotonic enema, suppositories and stool
softeners.
• iv. Low residue diet must be given to the child.
• v. Monitor vital signs & abdominal girth of child
• vi. Keep the child in semi-fowlers postion.
• vii. Withhold oral feeds & Nasogastric aspiration done on the night before
surgery.

125. Nursing management
• Post-operative care:
• i. Monitor vital signs, observe abdominal bleeding.
• ii. Place the child in comfortable position according to the physician order.
• iii. Child is NPO, so administer IV fluids as ordered.
• iv. Monitor bowel sound.
• v. Colostomy care is to be done which includes following:
• Observe stoma for its colour (reddish- pink colour)
• Observe for bleeding, purulent drainage, edema.
• Provide bland diet.
• apply zinc oxide ointment on skin around stoma.

126. Nursing management
• Frequently empty the collecting bag.
• Keep the colostomy clean and dry.
• Educate parents about colostomy care.
• vi. Encouraging and supporting the family during this
stressful time is the key nursing intervention.

127. Anorectal
malformation
• Anorectal malformations refer to anomalies of the rectum
and distal anus, the urinary tract, and the genital tract.
• They have an incidence of approximately 1 in 5000 live
births worldwide
• These malformations may range from simple imperforate
anal to include other associated complex anomalies of
genitourinary (GU) and pelvic organs,
• Which may require extensive treatment for fecal, urinary,
and sexual function.
• The term imperforate anus (absence of the anal opening)

128. Anorectal
malformation
• Anorectal malformations are frequently associated with
other anomalies. Some babies have VACTERL conditions.
• VACTERL refers to the presence of three or more of the
following anomalies:
• Vertebral anomalies,
• Anal atresia,
• Congenital heart disease,
• Tracheoesophageal fistula,
• Renal anomalies, and
• Limb defects
• Boys with an imperforate anus frequently have a
rectourethral fistula and girls generally have a recto
vestibular fistula.

129. Anorectal
malformation
• Anorectal malformations are
congenital malformation
caused by abnormal
development of the rectum
and anus.

130. Etiology
Generally any congenital
malformation can cause ARM
Family history unusual
Autosomal recessive when
genetically linked
Incidence 1/5000 live births

131. Embryology and
Pathophysiology
The major part of the anus and rectum develops
during 4th to 6th weeks of IUL
The cloaca becomes the common channel for
developing the urinary, genital and rectal system
The division of cloaca occurs at 6th week forms the
an anterior urogenital sinus and posterior intestinal
channel by the anorectal septum. ž
Failure or any interception in the division of cloaca
into the urogenital tract and the rectum results in
the high and intermediate type of anomalies.

132. Classification
• Infant with out normal anus
• With a visible abnormal opening
• Anal stenosis
• Ano perineal fistula
• Anovestibular fistula
with an invisible but manifested opening of the bowel
Rectovagianal fistuala
• Recto urethral fistula
• Rectovesicular fistula
No manifested opening of the bowel
• Persistant anal membrane Rectal atresia

134. Clinical
features
No or abnormally formed anal opening
Failure to pass meconium within the first 24 hours of birth may
be indicative of imperforate anus
Fistula
Presence of meconium in urine
Progressive abdominal distension
Vomiting
Rectal tube cannot be inserted

135. Clinical features
• Imperforate anus
• Anal stenosis
• Anal agenesis
• Rectal agenesis
• Recto perineal fistula
• Rectovaginal fistula
• Cloacal malformations in girls, in which the urinary tract, vagina, and
rectum fuse together, forming a common channel

136. Diagnostic
evaluation
• Physical examination
• Cystoscopy
• An IV pyelogram and a voiding
cystourethrogram are performed to
evaluate associated anomalies
involving the urinary tract.
• Other diagnostic examinations that
may be performed include pelvic MRI,
radiography, ultrasonography, and
fluoroscopic examination of pelvic
anatomic contents and lower spinal
anatomy.

137. Management
Newborn is stabilized and kept NPO for
further evaluation
IV fluids are provided to maintain glucose
and fluid and electrolyte balance.
Current recommendation is that surgery be
delayed at least 24 hours to properly
evaluate for the presence of a fistula and
possibly other anomalies

138. Management
Surgical
• Varies according to the defect
Low ARM
• Rectal cut back anoplasty or Y-V plasty
• Dialation of fistula
High ARM
• Colostomy
• Posterior sagittal anorectoplasty (PSARP) or other pull- through with
colostomy

139. Management
This surgery generally occur between
3 to 6 months of age, although timing
varies among surgeons.
When the operative site has healed,
approximately 2 weeks after surgery,
anal dilations are begun.
When the desired size of the anal
opening has been achieved, the
colostomy is closed

141. Surgical management

142. complications
UTI
Intestinal obstruction
Fecal impaction
Colostomy related problems
Recurrence of fistula
Anal stenosis
Post operative complications

143. Nursing
management
• Assisting in identification of anorectal
malformations
• A newborn that does not pass stool within
24 hours after birth or has meconium that
appears at a location other than the anal
opening requires further assessment.
• Preoperative care includes diagnostic
evaluation,
• GI decompression,
• Bowel preparation, and IV fluids

144. Nursing
diagnosis
• Acute pain
• Impaired skin integrity
• Body image disturbance
• Interrupted family process
• Parental anxiety
• Knowledge deficit
• Risk for infection
• Risk fluid volume deficit
• Risk for electrolyte imbalance
• Risk for complications Pre-post operative
nursing diagnosis

145. General
preoperative
care
• Postoperative nursing care after
anoplasty is primarily directed toward
healing the surgical site without other
complications.
• A program of anal dilations is usually
initiated then the child returns for the 2-
week checkup
• Feedings are started soon after surgical
repair, and breastfeeding is encouraged
because it causes less constipation

146. General
preoperative
care
• In neonates with anomalies such as cloaca (female),
rectourethral prostatic fistula (males), and vestibular fistula
(females), a descending colostomy is performed to allow fecal
elimination and avoid fecal contamination of the distal
imperforate section and subsequent urinary tract infection in
infants with anorectal fistulas.
• Postoperative nursing care is directed toward
• Maintaining appropriate skin care at the stoma sites (both
distal and proximal),
• Managing postoperative pain, and
• Administering iv fluids and antibiotics.
• Postoperative ng decompression may be required with
laparotomy, and
• Maintenance of appropriate drainage

147. Nursing management
• The PSARP is a common surgical procedure for the repair of anorectal
malformations in infants approximately 1 to 2 months after the initial colostomy
• Preoperative PSARP care often involves
• Irrigation of the distal stoma to prevent fecal contamination of the operative site
• Parents must be given accurate yet simple information regarding the infant's
appearance postoperatively and expectations as to their level of involvement in
the child's care
• Parents are instructed in perineal and wound care or care of the colostomy as
needed
• Anal dilations may be necessary for some infants
• Parents should observe stooling patterns and observe for signs of anal stricture
or complications

148. • Information on dietary modifications and administration of
medications is included in counseling
• Quality of life enhanced for the child and family

149. Family
support,
discharge
planning
• Long-term follow-up is essential for children with
complex malformations
• Toilet training is delayed, and complete continence is
seldom achieved at the usual age of 2 to 3 years
• Bowel habit training,
• Bowel management irrigation programs,
• Diet modification, and
• Administration of stool softeners or fiber help children
improve bowel function and social continence
• Daily bowel irrigations (if not acheived)
• Support and reassurance are important during the slow
progression to normal, socially acceptable function.

150. The liver
• The largest single organ in
the human body.
▪ In an adult, it weighs
about 1.5 Kg and is roughly
the size of a football.
▪ Located in the upper
right-hand part of the
abdomen, behind the lower
ribs.

151. Functions of liver
Multi-function, blood-processing “factory”
• Temporary nutrient storage (glucose-glycogen)
• Remove toxins from blood
• Remove old/damaged RBC’s
• Regulate nutrient or metabolite levels in blood—keep constant supply of sugars, fats,
amino acids, nucleotides (including cholesterol)
• Secrete bile via bile ducts and gall bladder into small intestines.

152. Liver transplantation
▪ Liver Transplantation is the replacement of a diseased
liver with a healthy liver allograft.
▪ Used technique is orthotropic transplantation, in which
the native liver is removed and replaced by the donor
organ in the same anatomic location as the original liver.

153. Reasons for
liver
transplantation

154. LIVER FUNCTION TESTS
 LFT (Liver Function Test)
ALT (Alanine Transaminase enzyme)
AST (SGOT) (Aspartate Aminotransferase Test)
ALKALINE PHOSPHATASE
 BILIRUBIN
PROTHROMBIN TIME/INR (measures how long it takes blood to clot)
ALBUMIN

155. Acute Liver
Disease
▪ Infections
▪ Viral Hepatitis A, B, C, D, E, EBV, CMV, HSV,
▪ Others – Leptospirosis, Toxoplasma,
▪ Drugs – MANY – HERBALS/OTC
▪ Alcohol
▪ Toxins
▪ Vascular obstruction (eg. Budd-Chiari) (Blockage of a blood vessel)

156. Chronic Liver
Disease
▪ Alcohol
▪ Viral hepatitis: B & C
▪ Autoimmune – autoimmmune hepatitis, PBC (Primary
Biliary cirrhosis), PSC (Primary Sclerosing Cholangitis)
▪ Non-alcoholic fatty liver disease (NAFLD)
▪ Drugs (MTX, amiodarone)
▪ Haemochromatosis
▪ Cystic fibrosis, a1antitryptin deficiency, Wilsons disease
▪ Vascular problems (Portal hypertension + liver disease)
▪ Cryptogenic (Disease whose cause is unkown)
▪ Others: sarcoidosis, amyloid, schistosomiasis

157. Global
number of
liver
transplant

158. Model for
End-Stage
Liver
Disease
(MELD)
MELD score = 0.957 x Loge (creatinine mg/dl) + 0.378 x
Loge (bilirubin mg/dl) + 1.12 x Loge (INR) + 0.643 Multiply
the score by 10 and round to the nearest whole number
Established in Feb 2002
Numerical scale, from 6 (less ill) to 40 (gravely ill)
This ‘score’ tells us how urgently LT is required within next
3 months Most patients on LT waiting list have MELD score
between 11 and 20

159. living
related
liver
transplant :
Donor requirements
Unsolicited volunteer
Family member (not necessarily blood relative)
No clear medical contra-indications
Size appropriate
ABO matched (Blood group system)
Age <50 ▪ Normal liver, HIV negative (Human immuno
deficiency virus)

160. Donor problems
▪ Biliary
complications
(Liver Blood
vessels) 6%
▪ Re-operation
5%
▪ Death <0.3%
▪ Mean ICU
Stay 0.5 days
▪ Hospital Stay
6.4 days

161. Recipient Issues
Re-transplant rate 2.5%
▪ Acute liver Failure (Complete
dead) 2%
▪ Biliary complications 23%
▪ Arterial complications 8%

162. The Liver Transplant Operation
• A liver transplant involves the removal of and preparation of the donor
liver, removal of the diseased liver, and implantation of the new organ. The
liver has several key connections that must be re-established for the new
organ to receive blood flow and to drain bile from the liver. The structures
that must be reconnected are the inferior vena cava, the portal vein, the
hepatic artery, and the bile duct. The exact method of connecting these
structures varies depending on specific donor and anatomy or recipient
anatomic issues and, in some cases, the recipient disease.

163. The Liver
Transplant
Operation

164. Management • During Surgery: Liver transplant surgery takes
between six and 12 hours. During the operation,
doctors remove the diseased liver and replace it
with the donated liver. Most patients stay in the
hospital for up to three weeks after surgery. The
surgeon will disconnect your diseased liver from
your bile ducts and blood vessels before
removing it. The blood that flows into your liver
will be blocked or sent through a machine to
return to the rest of your body. The surgeon will
put the healthy liver in place and reconnect it to
your bile ducts and blood vessels. Your blood will
then flow into your new liver.

165. Management
• After surgery: - You will stay in the hospital for an
average of 1 to 3 weeks to be sure your new liver is
working. You will take medicines to prevent rejection
of your new liver and to prevent infections. Your
doctor will check for bleeding, infections, and
rejection. During this time you will start to learn how
to take care of yourself and use your medicines to
protect your new liver after you go home. - In the
hospital, you will slowly start eating again. You will
start with clear liquids, then switch to solid food as
your new liver starts to work. - Liver transplants are
performed in many centers across the country. The
healthy liver is obtained from a donor who has not
suffered liver injury. The healthy liver is transported in
a cooled saline solution that preserves the organ for
up to 8 hours. This time allows for testing to
determine if the blood and tissue of the donor match
the recipient. The diseased liver is removed through an
incision in the upper abdomen. The new liver is put in
place and attached to the patient's blood vessels and
bile ducts. The operation can take up to 12 hours and
may require blood transfusions.

166. Management • Patients require hospital care for 1 to 4
weeks after liver transplant, depending on
the degree of illness. After liver
transplantation, patients must take
immunosuppressive medications for the rest
of their lives to prevent immune rejection of
the transplanted organ.
• Eating a healthy diet and taking the
medications are part of taking care of
your new liver.

167. Infection
post
Transplant
Week 1
▪ Hepatic Artery thrombosis
▪ Portal Vein thrombosis
▪ Infections (Bacterial/Viral/Fungal)
▪ Drug toxicity
▪ Renal Impairment
Acute cellular rejection
Month 1
▪ Nosocomial infection (Hospital
acquired infections)
▪ Bacteria and fungi ▪ 19-28% of
patients have bacteremia
Staph, Enterococcus (50-60%)