Gi Dysfunction

1. NAVEED ULLAH
NAZEER HASSAN
NIAZ MUHAMMAD
OWAIS KHAN
QURAT-UL-AIN
RAHID ULLAH
Unit- X
Gastrointestinal disorders

2. Topics to be covered
 Ingestion problems and structural defects of GI (Cleft palate, cleft lip
tongue tie and Tracheo esophageal fistula
 Pyloric stenosis.
 Biliary Atresia
 Liver Abscess
 Intestinal obstruction
 Hernia
 Hirschprung’s disease
 Intussusceptions
 Volvulus
 Amibiasis
 NEC (Necrotizing Enterocolitis)
 Nursing care, pharmacological, medical and surgical modalities for
dealing with the above disorders
 Commonly used medications in Pakistan for the above disorders

4. Congenital disorders
 “Abnormality of structure and, consequently its functions of
the human body arising during development”.
 Causes :
 May be the result of genetic abnormalities.
 The intrauterine environment,
 Errors of morphogenesis,
 Maternal Infections
 Chromosomal abnormality.
 Mother diets

5. Cleft palate (palatoschisis)
“A common congenital deformity in which the plates of
palate (in the roof of the mouth) fail to close during
fetal development”. The resulting fissure may occur on
 The soft palate only.
 May extend forward through the hard palate,
 May be unilateral or bilateral
 May occur alone or in conjunction with cleft lip

6. Cleft lip (cheiloschisis)
“A congenital anomaly in which there is a fissure in
the top of the lip”
 Partial or incomplete cleft : a small gap in the lip.
 Complete cleft: it continues into the nose
 May be unilateral or bilateral

7. Problems Associated With Cleft Lip And Cleft Palate
A cleft lip and palate can:
 Affect the appearance of the face
 Lead to problems with feeding
 Failure to gain weight
 Flow of milk through nasal passages during feeding
 Poor growth
 Repeated ear infections
 Speech difficulties
 Poorly aligned teeth

8. Treatment
 Surgical repair of cleft lip and cleft palate.
 Cheiloplasty (cleft lip surgery) is performed between
birth and the age of three months.
 Palatoplasty (cleft palate repair) is performed between
12 and 18 months of age.

9. Tongue-tie
“Also known Ankyloglossia is a congenital oral anomaly
that is caused by an unusually short, thick lingual frenulum,
and that may decrease mobility of the tongue tip.”
 Tongue tie is when the bottom of the tongue is attached to
the floor of the mouth.
 Restrict tongue to move freely.

10. Symptoms
 Problems with breast feeding.
 Irritable, even after feeding
 Difficulty creating or keeping suction on the nipple.
 Poor weight gain
 The breastfeeding mother may have problems with breast
pain and may feel frustrated.

11. Management
 Examine the new born
 Tongue tie surgery, called a frenulotomy
 Problems with tooth development, swallowing, or speech
if not properly treated.

12. Tracheoesophageal fistula
”TEF is a congenital or acquired communication between
the trachea and oesophagus that often leads to severe and
fatal pulmonary complications.”
“Incomplete formation of the esophagus is known as
esophageal atresia”

13. Symptoms
 Neonates develop copious, fine white frothy bubbles of mucus in
the mouth and nose.
 Infants may develop rapid respiration and episodes of coughing and
choking in association with cyanosis.
 Symptoms worsen during feeding.
 Cough , aspiration, and fever.
 Abdominal distention secondary to collection of air in the stomach.

14. Tests to diagnose
 Plain chest radiographs may reveal tracheal compression
and deviation
 Contrast studies
 CT scans
 Esophagoscopy
 Bronchoscopy

15. Treatment and care
 Surgical repair
 In healthy infants without pulmonary complications,
primary repair is performed within the first few days of
life.
 Preoperatively, a cuffed endotracheal tube is placed distal
to the fistula site in order to prevent reflux of gastric
contents into the lungs.
 Post operative care

16. Nursing interventions
 Parents experience grief and guilt so they need emotional
support.
 Determine the effective feeding methods , special nipples are
available for such children.
 Assess for aspiration.
 Assess for vital sign, input out put to determine fluid volume
status.
 Prepare the child and also parents for surgical repair.
 Post operative care, positioning, wound care, diet from clear
liquids to soft to normal, and also preventing post operative
complications.

17. Intestinal obstruction
 “Intestinal obstruction is a partial or complete blockage
of the bowel that results in the failure of the intestinal
contents to pass through”

18. Causes
It may due to:
 A mechanical cause
 Ileus is a disruption of the normal propulsive ability of the
gastrointestinal tract.
 Paralytic ileus:Obstruction of the intestine due to paralysis
of the intestinal muscles
Chemical, electrolyte, or mineral disturbances (such as
decreased potassium levels)
Complications of intra-abdominal surgery
Decreased blood supply to the abdominal area (mesenteric
artery ischemia)
Intra-abdominal infection
Use of certain medications, especially narcotics

19. Mechanical causes
It may include:
• Abnormal tissue growth
• Adhesions or scar tissue that form after surgery
• Foreign bodies
• Hernias
• Impacted feces (stool)
• Tumors blocking the intestines
• Volvulus (twisted intestine)
• Worm infestations.

20. Intussusception
 Intussusception is the sliding of one part of the intestine
into another.
 part of the intestine being pulled inward into itself.
causes obstruction.

21. Symptoms
 Pain is colicky
 Bloody, mucus-like stool, sometimes called a "currant
jelly" stool
 Fever
 Shock
 Stool mixed with blood and mucus
 Vomiting
 Mass in the abdomen

22. Tests
Tests may include:
 Abdominal x-ray
 Ultrasound

23. Treatment
 Nasogastric tube insertion
 An intravenous (IV) line will be passed to prevent
dehydration.
 A barium or air enema. This is both a diagnostic and
therapeutic procedure. If an enema works, further
treatment is usually not necessary.
 The child will need surgery.
 Intravenous feeding and fluids will be continued until
the child has a normal bowel movement.

24. Complication
 Intestinal perorations
 Infections
 It is fatal in younger children.

25. Intestinal volvulus
 It is a complete twisting of a loop of intestine
around its mesenteric attachment site.
 It leads to mechanical obstruction of the
proximal intestine
 And twisting of the intestines with subsequent
ischemia (with or without necrosis) of part or all
of the midgut
 It may occur at different areas of the GI tract.

26. Sign and Symptoms
 Abdominal distention
 Abdominal fullness, gas
 Abdominal pain and cramping
 Breath odor
 Constipation
 Diarrhea
 Vomiting (bile)

27. Tests and treatment
Tests that show obstruction include:
 Abdominal CT scan
 Abdominal x-ray
 Barium enema
 Upper GI and small bowel series
Treatment
 Surgical correction is indicated
 A connection of the intestines to the outside, through which
bowel contents can be removed (colostomy or ileostomy).

28. Hernia
“ It is the protrusion of an organ or the fascia of an organ
through the wall of the cavity that normally contains it.”

29. Types of Hernias
The types of hernias are based on where they occur:
 Femoral or inguinal hernia:
appears as a bulge in the upper thigh,
just below the groin.
 Is more common in women than men.
 Hiatal hernia:
Occurs in the upper part of the stomach, a part of the upper
stomach pushes into the chest.

30.  Incisional hernia:
Occurs through a scar if you have had abdominal
surgery in the past.
 Umbilical hernia:
appears as a bulge around the umbilicus. It occurs when
the muscle around the Umbilicus doesn't close
completely.

31. Causes
 Any activity or medical problem that increases pressure on the
abdominal wall tissue and muscles may lead to a hernia, including:
 Chronic constipation,
 Chronic cough
 Extra weight
 Fluid in the abdomen (ascites)
 Heavy lifting/ Overexertion
 Peritoneal dialysis
 Poor nutrition
 Undescendedtesticles

32. Sign and symptoms
 Most often, have no symptoms.
 May be discomfort or pain.
 The discomfort may be worse when you stand, strain, or
lift heavy objects.
 Complain about a growth that feels tender and is
growing.
 Although a hernia may only cause mild discomfort, it
may get bigger.

33. Diagnostic tests and treatment
 Abdominal X-ray
 Ultrasound
 CT abdomen
 Treatment is surgical repair.

34. Nursing care of patient with intestinal obstruction/ hernia
 Provide simple explanation about the disease and
treatment for a child who is old enough to understand.
 Monitor vital sign ; a change in temperature may indicate
the sign of sepsis.
 Monitor input output charting to prevent dehydration.
 NG tube insertion, care ,its out put and replacement,
 Pain relieving medication.
 Monitor the passage of stool and passing of gas to know
the extent of obstruction.
 Monitor bowel sound,
 Prepare for surgery if needed.

35. Post surgical care
 After surgery encourage the parents to stay with their
child and participate in care.
 Administration of antibiotics to prevent infections.
 Administration of pain relieving medications.
 Monitor the suture site for sign of infection, drainage
and suture separation.
 Monitor for return of bowel sound.
 Wound dressing care.
 Stoma care if any.

36. Hirschsprung’s disease (congenital aganglionic
megacolon)
 “A blockage of the large intestine due to improper
muscle movement in the bowel. It is a congenital
condition.”
 “It is the absence of parasympathetic ganglion cells
in a segment of the colon usually at the distal end of
the large intestine. Causing an absence of peristaltic
movement.”

37.  Peristalsis help digested materials move through the
intestine.
 Nerves in between the muscle layers trigger the
contractions.
 In Hirschsprung's disease, the nerves are missing from a
part of the bowel which cannot push material through
(blockage).

38. Sign and Symptoms
Symptoms that may be present in newborns and infants
include:
 Failure to pass meconium shortly after birth
 Infrequent but explosive stools
 Jaundice
 Poor feeding, Poor weight gain
 Vomiting
 Watery diarrhea (in the newborn)
Symptoms in older children:
 Constipation that gradually gets worse
 Fecal impaction
 Malnutrition
 A rectal examination may reveal a loss of muscle tone in the
rectal muscles.

39. Tests to diagnose Hirschsprung's disease
 Abdominal x-ray
 Anal manometry (a balloon is inflated in the
rectum to measure pressure in the area)
 Barium enema
 Rectal biopsy

40. Treatment
 Before surgery, a procedure called serial rectal
irrigation helps relieve pressure in (decompress) the
bowel.
 The abnormal section of colon must be removed
with surgery
 the rectum and abnormal part of the colon are
removed. The healthy part of the colon is then pulled
down and attached to the anus.
 Sometimes this can be done in one operation.
However, it is often done in two parts. A colostomy
is performed first, and another procedure is
performed later in the child's first year of life.

41. Complications
 Inflammation and infection of the intestines (enterocolitis)
 Perforation or rupture of the intestine
 Short bowel syndrome, a condition that can lead to
malnourishment and dehydration.
 Sepsis
 Hypovolemic shock

42. Nursing care
 The parent need great deal of emotional support.
 Prepare them for surgery, explain the whole procedure and
prognosis .
Preoperative care may include
 Administration of IV fluid to prevent dehydration and correct
electrolytes. Pain relieving medication
 Maintain NPO status, Administer antibiotics
 Insert NG tube for gastric decompression.
 Administer isotonic enemas to evacuate the bowel

43. Post operative care
After surgery: Colostomy and ileostomy care.
 Monitor input output as ileostomy some time cause
electrolytes loss
 Keep the area around the stoma clean and dry.
 Monitor for return of bowel sounds
 Keep the wound clean and dry to prevent infection.
 Don’t use rectal thermometer and suppositories.
 Begin oral feeding when bowel sound return
 Educate the parents about suture line care
 Teach the patient about the sign of constipations,
infections loss of electrolytes and dehydration.

44. Pyloric stenosis
 “A narrowing of the pylorus, the opening from the
stomach into the small intestine.”
 In pyloric stenosis, the muscles of the pylorus are
thickened. That prevent the stomach from emptying into
the small intestine.
 The cause is unknown, although genetic
factors may play a role.

45. Sign and Symptoms
 Forceful (projectile ) may occur after every feeding
 The infant is hungry after vomiting and wants to feed again
Other symptoms generally appear several weeks after birth and
may include:
 Abdominal pain, Belching, constant hunger.
 Dehydration
 Failure to gain weight, swollem belly.
 Abnormal pylorus feels like an olive-shaped mass, when
touching the stomach area.

46. Test
 An ultrasound of the abdomen may be the first imaging
test performed.
 Barium x-ray -- reveals a swollen stomach and
narrowed pylorus
 Blood chemistry -- often reveals an electrolyte
imbalance

47. Treatment
 Treatment of pyloric stenosis involves surgery to split
the overdeveloped muscles.pyloroplasty
 Balloon dilation may be considered for infants when the
risk of general anesthesia is high.

48. Nursing intervention
 Provide the child an age appropriate explanation of all the
test, procedure and surgery.
 Answer the parents questions.
 Monitor vital sign and intake and out put to prevent
dehydration.
 Record the amount, frequency and characteristics of vomit.
 Daily weight measurement.
 Prepare for surgery

49. Post operative
 Feed the child small amount of electrolytes solution, then
gradually increase the amount and concentration of feed.
 Keep the incision area neat and clean to prevent
infection.
 Keep the child on his right side to improve the flow of
fluid through the pyloric valve.
 Analgesic administration to relieve pain.
 Teach the parent proper incision site care.

50. Biliary atresia
 Biliary atresia, also known as "extrahepatic ductopenia"
is a disease of the bile ducts that affects only infants.
“In biliary atresia, the bile ducts become inflamed and
blocked soon after birth. This causes bile to remain in the
liver, where it starts to destroy liver cells rapidly and cause
cirrhosis, or scarring of the liver”
 Causes may be congenital or unknown

51. Sign and symptoms
 Symptoms of biliary atresia usually appear between
two and six weeks after birth.
 The baby will appear jaundiced
 The liver may harden and the abdomen may become
swollen.
 Stools appear pale grey and the urine may appear dark.
 Baby may develop intense itching.

52. Investigations
 Tests may include blood count
 liver function tests
 ultrasound examination
 X-rays
 liver biopsy

53. Treatment and care
 Unfortunately, there is no cure for biliary atresia.
 The only treatment is a surgical procedure in which the blocked bile ducts
outside the liver are replaced with a length of the baby’s own intestine, which
acts as a new duct.
 This surgery is called the Kasai procedure
 Successful in babies younger than 3-months-old.
 The aim of treatment after surgery is to encourage normal growth and
development.
 If bile flow is good, the child is given a regular diet.
 If tests show that bile flow is reduced, a low-fat diet and vitamin supplements
will be required.

54. Liver abscess
 It is pus-filled cavity within the liver, usually caused by
a biliary tract source.
 May be caused by pyogenic, amebic, or (rarely, and
usually in severely immunocompromised patients)
fungal

55. Sign and symptoms
 Fever (either continuous or spiking)
 Chills
 Right upper quadrant pain
 Anorexia
 Malaise
 Cough or hiccoughs due to diaphragmatic irritation may be reported.
 Referred pain to the right shoulder may be present
 Tender hepatomegaly

56. Investigations
 CBC count: Anemia of chronic disease
 Neutrophilic leukocytosis
Liver function studies :
 Hypoalbuminemia
 Elevation of alkaline phosphatase
 Elevations of bilirubin levels (variable)
 Blood cultures are positive in roughly 50% of cases.
 Enzyme immunoassay should be performed to detect E histolytica
 CT scan and ultrasound

57. Management
 Percutaneous needle aspiration of cavity material Under CT scan
or ultrasound guidance can be performed.
 It can be performed with the initial diagnostic procedure.
 Percutaneous catheter drainage :
has become the standard of care and should be the first intervention
considered for small cysts.
 Surgical drainage
For cysts greater than 5 cm, ruptured cysts surgical drainage is
generally recommended over percutaneous intervention
 Antimicrobial treatment is a common adjunct to percutaneous or
surgical drainage.

58. Amibiasis
 It is a parasitic infection of the intestines caused by
entamoeba histolytica.
 Entamoeba histolytica is a single-celled protozoan
that enters the human body primarily through
ingestion of cysts in food or water.
 It can produce amebic dysentery.

59. Sign and symptoms
 Abdominal cramps
 Diarrhea: Passage of 3 to 8 semi formed stools per day,
or passage of soft stools with mucus and occasional blood
 Fatigue
 Excessive gas
 Rectal pain while having a bowel movement (tenesmus)
 Unintentional weight loss
 Abdominal tenderness
 Fever
 Vomiting

60. Investigation
 Hepatomegaly on examination
 Blood Counts
 Stool examination

61. Treatment
 Usually, antibiotics are prescribed.
 Antiameobic drugs
 Hydration
Education for prevention of disease:
 Thoroughly wash hands with soap and water after using
the bathroom and before handling food.
 Thoroughly wash fruits and vegetables before eating.
 Boil water, or treat it with iodine.
 Avoid milk, cheese, or other unpasteurized dairy
products.
 Avoid food sold by street vendors.

62. Complications
 Liver abscess
 Peritonitis
 Pericarditis
 Genitourinary disease

63. Necrotizing enterocolitis
 NEC is a medical condition primarily seen in premature
infants where portions of the bowel undergo necrosis
(tissue death).
 Necrotizing enterocolitis occurs when the lining of the
intestinal wall dies and the tissue falls off.
 The exact cause of this disorder is unknown

64. Symptoms
May come on slowly or suddenly, and may include:
 Abdominal bloating
 Blood in the stool
 Diarrhea
 Feeding problems
 Lack of energy
 Unstable body temperature
 Vomiting

65. Investigation
 Abdominal x-ray
 Stool for occult blood test
 Elevated white blood cell count in a CBC
 Lactic acidosis

66. Treatment
Treatment for a baby that may have necrotizing entercolis include:
 Relieving gas in the bowel by inserting a tube in the stomach
 Giving IV fluids and antibiotic medicines
 Monitoring the condition with abdominal x-rays, blood tests,
and measurement of blood gases
 The infant will need surgery if there is a hole in the intestines or
inflammation of the abdominal wall (peritonitis).
In this surgery, the doctor will:
 Remove dead bowel tissue
 Perform a colostomy or ileostomy
 The bowel is reconnected after several weeks or months when
the infection has healed

67. Gastro esophageal reflux diseases (GERD)
 “It is a condition in which the stomach contents (food or
liquid) leak backwards from the stomach into the
esophagus”.
 This action can irritate the esophagus, causing heartburn and
other symptoms.
 After eating, food passes from esophagus to the stomach.
 Once food enter the stomach, the lower esophageal
sphincter prevents food from moving backward into the
esophagus.
 If this sphincter muscle doesn't close well, food, liquid, and
stomach acid can leak back into the esophagus.

68. Causes
 Alcohol (possibly)
 Hiatus hernia
 Obesity
 Pregnancy
 Smoking
 Heartburn and gastroesophageal reflux can be made
worse by pregnancy
 different medications. Such as beta-blockers,
Bronchodilators, Calcium channel blockers,
Progestin, Sedatives and Tricyclic antidepressants

69. Sign and Symptoms
 Feeling that food is stuck behind the breastbone
 Heartburn or a burning pain in the chest
 Increased by bending,lying down, or eating
 More likely or worse at night
 Relieved by antacids
 Nausea after eating
 Less common symptoms are:
 Bringing food back up (regurgitation)
 Cough or wheezing, horseness.
 Difficulty swallowing, hiccups, sore throat.

70. Diagnostic tests
 Esophagogastroduodenoscopy (EGD) is often used to
find the cause and examine the esophagus for damage.
 Barium swallow
 Continuous esophageal pH monitoring
 Esophageal manometry
 Stool occult blood may diagnose bleeding that is
coming from the irritation in the esophagus, stomach,
or intestines.

71. Treatment
 Anti acid
 H2 receptor blocker
 Proton pump inhibitors
 Drugs which increase gastric motility
(metaclopromid) to empty stomach
 Anti-reflux operations (fundoplication and others)
may be an option for patients whose symptoms do not
go away with lifestyle changes and drugs

72. Complications
 Asthma
 Barrett's esophagus (a change in the lining of the esophagus
that can increase the risk of cancer)
 Bronchospasm (irritation and spasm of the airways due to acid)
 Chronic cough or hoarseness
 Dental problems
 Esophageal ulcer
 Stricture (a narrowing of the esophagus due to scarring)

73. Nursing role
 Education of the child to the level of his understanding and
parent about lifestyle change.
 Elimination of food which promote acidity (carbonated drinks,
tea etc ).
 Avoid food that delay gastric emptying time (fatty acid,
alcohol)
 Elevate head of the bed to relieve symptom of acidity.
 Avoiding bending
 Treatment of pain after surgical procedure.

74. Appendicitis
 “Appendicitis is inflammation of the appendix
( small pouch attached to the beginning of large
intestine)”.

75. Causes
It usually occurs when the appendix becomes blocked by
 Feces
 Foreign object
 Rarely , a tumor.
 Infection

76. Sign and symptoms
The classic symptoms of appendicitis include:
 Dull pain at the upper abdomen and as the swelling in the
appendix increases, the pain tends to move into your right lower
abdomen. called McBurney's point. This is usually the first sign.
 Loss of appetite
 Nausea and/or vomiting soon after abdominal pain begins
 Abdominal swelling
 Fever of 99-102 degrees Fahrenheit
 Inability to pass gas
 pain may occure anywhere in the upper or lower abdomen, back,
or rectum
 Severe cramps
 Constipation or diarrhea with gas

77. Different signs
Kosher‘s sign
 From the history given, the appearance of pain in the
epigastria region or around the stomach at the
beginning of disease with a subsequent shift to the
right iliac region.
Obturator sign
 by flexing and internal rotation of the hip causes pain
in the hypogastrium.

78. Complications
 Abnormal connections between abdominal organs or
between these organs and the skin surface (fistula)
 Abscess
 Blockage of the intestine
 Infection inside the abdomen (peritonitis)
 Infection of the surgical wound

79. Treatment
 If no complications then Appendectomy.
 The newer method to treat appendicitis is the
laparoscopic surgery.

80. Diagnostic tests
 The following tests are usually used to make the
diagnosis.
 Abdominal exam to detect inflammation
 Urine test to rule out a urinary tract infection
 Rectal exam
 Blood test to see if your body is fighting infection
 CT scans and/or ultrasound

81. Nursing intervention
 Provide the child an age appropriate explanation of
all the test, procedure and surgery.
 Answer the parents questions.
 Monitor vital sign and intake and out put to
prevent dehydration.
 Record the amount, frequency and characteristics
of vomit.
 Asses daily weight measurement.
 Prepare for surgery

82. Post operative
 Feed the child small amount of electrolytes
solution, then gradually increase the amount
and concentration of feed.
 Keep the incision area neat and clean to
prevent infection.
 Antibiotic administration
 Analgesic administration to relieve pain.
 Teach the parent proper incision site care.

83. References:
 Hockenberry, M.J., Wilson, D. and Wong, D.L.,
2012. Wong's Essentials of Pediatric Nursing9: Wong's
Essentials of Pediatric Nursing. Elsevier Health Sciences.
 Pillitteri, A., 2010. Maternal & child health nursing: Care of
the childbearing & childrearing family. Lippincott Williams
& Wilkins.
 Spitz, L. and Coran, A. eds., 2013. Hernias in children (pp.
277-299). Boca Raton, FL: CRC Press.
 Lip, C., Palate, C., Teeth, M., Tears, G.M., Ulcer, P.,
Intolerance, F. and Anus, I., 2005. The gastrointestinal tract.