Gastro- Intestinal Disorders

• Enteric fever
• Hernia
• Pyloric Stenosis
• Tracheo-esophageal Atresia
• Hirschprung Disease
• Intestinal Obstruction
• Anorectal Malformation
• Tongue Tie
• Harelip and Cleft Palate
• Worm Infestation

HERNIA

INTRODUCTION
• Hernia is the protrusion or projection of an organ or a part of an organ
through the abnormal opening in the wall of the cavity that normally
contains it.
• The danger from herniation arises when the organ protruding through the
opening is constricted to the extent that circulation is impaired or when the
protruding organs impair the function of other structures.

Hernia has 3 parts

• The orifice –through which it is herniated
• The hernial sac
• Its contents

Incidence
• 10-20 per 1000 live births
• 30% occuring in Preterm infant
• 5 times more common in male children than female

Types
• Inguinal Hernia
• Femoral hernia
• Diaphragmatic Hernia or Hiatal hernia
• Umbilical Hernia
• Ventral Hernia
• Pelvic Hernia
• Intracranial Hernia

Common Hernias in Children

a. Inguinal hernia
• Common in infant and children
• Approx. 80% of total childhood hernia is occupied by inguinal hernia
• Common in male and preterm infants
• Right sided more common(60%) than the left sided (30%) and 10% in
bilateral form.
A hernia that occurs in the groin (inguinal) area is
called an inguinal hernia. An inguinal hernia is a
protrusion of abdominal cavity contents through
the inguinal canal.

CLASSIFICATION
• Reducible hernia: is one which can be pushed back into the abdomen by
putting manual pressure to it.

• Irreducible hernia: is one which cannot be pushed back into the abdomen
by applying manual pressure.
Irreducible hernias are further classified into:
• Obstructed hernia: is one in which the lumen of the herniated part of
intestine is obstructed but the blood supply to the hernial sac is intact.
• Incarcerated hernia: is one in which adhesions develop between the wall of
hernial sac and the wall of intestine.

• Strangulated hernia: is one in which the blood supply of the sac is cut off,
thus, leading to ischemia. The lumen of the intestine may be patent or not.
 Types
• Indirect Inguinal Hernia: protrudes through the inguinal ring and is
ultimately the result of the failure of embryonic closure of the processus
vaginalis after the testicle passes through it

• Direct Inguinal Hernia: enters through a weak point in the fascia of the
abdominal wall, may be due to weakened or injured abdominal muscles

Risk Factors
• Prematurity and low birth weight
• Associated conditions like cryptoorchidism, hypospadias, epispadias,
• Increased abdominal pressure (obesity, chronic cough, ascities)
• Abdominal wall defect like omphalocele

Causes
• Congenital: due to incomplete development of wall during embryologic
developmental period
• Acquired: weakness of the part due to debilitating illness and injury,
increased intra abdominal pressure

PATHOPHYSIOLOGY
• Persistent patency of the processus vaginalis

• Descent of an intestinal portion

• The descended portion tightly caught into the sac

• Compromise of the blood supply to the herniated portion

• Incarceration or Strangulation of the portion

SIGNS AND SYMPTOMS

• It may be present at birth or may not appear until weeks, months or years
later.
• The hallmark signs of an inguinal hernia on physical examination are a
smooth, firm mass that emerges through the external inguinal ring lateral to
the pubic tubercle and enlarges with increased intra abdominal pressure.
• Most often it appears as a painless inguinal swelling that varies in size.
• As the hernia progresses, contents of the abdominal cavity, such as the
intestines, can descend into the hernia and run the risk of being pinched
within the hernia, causing an intestinal obstruction.
• If the blood supply of the portion of the intestine caught in the hernia is
compromised, the hernia is deemed "strangulated" and
gut ischemia and gangrene can result, with potentially fatal consequences.

DIAGNOSTIC INVESTIGATION
• History taking regarding onset of symptoms and clinical features.
• Physical examination: a smooth, firm mass with increased intra abdominal
pressure can be seen.
• Ultra sonogram reveals the herniated portion and its orifice.
• Preoperative tests: blood and urine tests

Management
• IV fluids, medications
• Avoid heavy lifting for 6 to 8 weeks after surgery
Nursing Management
Preoperative and postoperative care

Prevention
• Maintain body weight suitable for age and height
• Strengthening abdominal muscles through regular exercise
• Avoid constipation
• Avoid heavy lifting

FEMORAL HERNIA
• Femoral hernias are rare in children. Less than 1% incidence rate. They are
more common in girls than boys, with a ratio of 2:1.
• Femoral hernias represent a protrusion through the femoral canal.
• The bulge of a femoral hernia is located below the inguinal ligament and
typically projects toward the medial aspect of the thigh.
• The repair of a femoral hernia involves closure of the defect at the femoral
canal.
 UMBILICAL HERNIA
• An umbilical hernia occurs when part of the intestine protrudes through an
opening in the abdominal muscles. Umbilical hernia is a common and
typically harmless condition. Umbilical hernias are most common in infants,
but they can affect adults as well.

• An umbilical hernia is an abnormal bulge that can be seen or felt at the

umbilicus.
• This hernia develops when a portion of the lining of the abdomen, part of the
intestine, and / or fluid from the abdomen, comes through the muscle of the
abdominal wall.
• Umbilical hernias are common, occurring in 10 percent to 20 percent of all
children.
• Low birth weight and premature infants are also more likely to have an
umbilical hernia.
• Boys and girls are equally affected.
• Resolves spontaneously as the abdominal muscle grows and child reach 3-5
years, if doesn’t resolve go for surgical treatment.
CONGENITAL DIAPHRAGMATIC HERNIA

CONGENITAL DIAPHRAGMATIC HERNIA

• Congenital diaphragmatic hernia (CDH) is a congenital malformation of
the diaphragm. Malformation of the diaphragm allows
the abdominal organs to push into the thoracic cavity.
• CDH is a rare condition that occurs 1-5 in10000 births.
• When the abdominal organs are in the chest, there is limited room for the
lungs to grow. This prevents the lungs from developing normally, resulting in
pulmonary hypoplasia.
• This can cause reduced blood flow to the lungs and pulmonary hypertension
(high blood pressure in the pulmonary circulation), as well as asthma,
gastrointestinal reflux, feeding disorders and developmental delays.
• CDH can occur on the left side, right side or, very rarely, on both sides. It can
be life-threatening unless treated.
• CDH is a life-threatening pathology in infants, and a major cause of death due
to two complications, pulmonary hypoplasia and pulmonary hypertension.
 • This condition can often be diagnosed before birth and fetal intervention can
sometimes help, depending on the severity of the condition.
• Infants born with diaphragmatic hernia experience respiratory failure due to
both pulmonary hypertension and pulmonary hypoplasia.
• Survival rates for infants with this condition vary, but have generally been
increasing through advances in medicine.

ANORECTAL MALFORMATION
Introduction

• Ano-rectal malformation are developmental deformities of the lower end of

the alimentary tract.
• The term anorectal malformation is used to describe all congenital anomalies
of anorectal canal or anal area.

Incidence
• Anorectal Malformations affect 1 in 5,000 babies
• Slightly more common in males
• The most common defect in both boys and girls is an imperforated anus
• Approximately 40% of neonates with ARM have associated congenital
anomalies like
– Down’s syndrome
– Congenital heart disease
– Renal abnormalities
– Undescended Testis
 – Spina bifida
– VACTERL syndrome :
– Vertebral defects, anal atresia, cardiac anomaly, TEF with EA, renal
defects, limb defects.

Classification
• Anal stenosis
• Anal agenesis
• Imperforated anal membrane
• Rectal agenesis/ atresia
• Anorectal malformation with fistula: rectovaginal fistula, recto urethral
fistula, cloaca
Depending on the relation with levator muscles (puborectalis):

• Low Anomalies
• Intermediate Anomalies
• High Anomalies

Cause

• The exact cause of the malformation is not known

• It occurs due to arrest in embryonic development of the anus, lower
rectum & urogenital tract at 8th week of embryonic life

Pathophysiology
• At the 6th week gestation rectum and anus starts to develop from
expanded portion of caudal hindgut
 • Caudal hindgut to cloaca to the urorectal septum
• urorectal septum further divides into rectum and urogenital sinus
• From rectum recto anal membrane will develop around 8th week and later
that breaks down to form continuous patent communication between
outside and the remainder part of the gut
• Similarly from urogenital sinus lower part of urogenital tract will develop
into externalopening
• If any arrest ocurs in above development process then ARM occurs

Clinical Manifestations
• Absence of anal opening or abnormally formed anal opening at birth
• Meconium stool is absent or delayed
• Stool passed by way of the vagina or urethra may appear as green-tinged
urine
• Progressive abdominal distention
• Fistula formation and passage of stool through fistula
• (Male : fistula formed between rectum and urinary tract or perineum
• Female: fistula between rectum and vagina or perineum)
• Ribbon like stool

Specific features
• Imperforated anus: infants fail to pass meconium and greenish bulging
membrane is seen on examination
• Anal stenosis: the baby pass ribbon like stools with difficulty as the anal
opening is very small
• Anal agenesis: there is only anal dimple. Usually fistulas are found to the
perineum or urethra in male and perineum or vulva in female. Intestinal
obstruction develops, if there is absence of any fistula.
• Rectal agenesis: It presents with fistula. In male baby, fistula may
communicate with posterior urethra & in female with upper vagina
• Rectoperineal fistula: It is manifested as small orifice in the perineum,
usually anterior to the centre of the external sphincter.In male baby it is
found close to the scrotum & in female at the vulva.
• Rectovaginal fistula: It is the communication between rectum & vagina

Diagnostic Evaluation
• History and Physical Examination of the new born for patency of anus and
rectum
• Abdominal ultrasound to detect urinary obstruction and locate rectal pouch
• X-Ray of the abdomen to find out the level of defect
• Urine examination for presence of meconium and epithelial debris indicates
presence of fistula
• An intravenous pyelogram (IVP) & cystourethrography are done to rule out
urinary abnormalities

Therapeutic Management
• The reconstructive surgery is done to correct or repair the congenital
malformations.It depends the upon the type of anomalies and sex of the
infant.

• In case of low ARM, rectal cutback anoplasty is done for male infants and
dilatation of fistula with definitive repair or perineal anoplasty is performed
for female infants.
• In case of high ARM initial colostomy is done in the neonatal period followed
by definitive reconstructive surgery as posterior sagittal ano-rectoplasty
 (PSARP) at the age of 10 to 12 mths or when the infant is having 7 to 9kg
body weight. Colostomy closure is done after 10 to 12 weeks of successful
definitive surgery

Nursing Assessment
 Perform physical assessment of neonate for abnormalities.
– Presence of perineal fistula
– Meconium from vagina or presence of meconium-stained urine
– No anal opening on digital examination
 Perform thorough examination for other congenital anomalies.
 Assess parents' level of understanding of condition and ability to cope
with infant's surgery.

Nursing Diagnoses

 Preoperative
• Abdominal distension related imporforated anus
• Difficulty in breathing related to abdominal distension
• Fluid and electrolyte imbalance related to vomiting

 Post operative
• Pain related to surgical procedure
• Ineffective breathing pattern related to anesthesia
• Risk for Infection related to surgical incision of anoplasty
• Risk for Impaired Skin Integrity related to colostomy and anoplasty
• Risk for Decreased Fluid Volume related to restricted intake
 Complications
• Urinary infection
• Intestinal obstruction
• Fecal Impaction
• Colostomy infection
• Fistula

Tongue Tie
• Tongue-tie (ankyloglossia) is a condition present at birth that restricts the
tongue's range of motion.
• With tongue-tie, an unusually short, thick or tight band of tissue (lingual
frenulum) tethers the bottom of the tongue's tip to the floor of the mouth,
so it may interfere with breast-feeding.
 Symptoms
• Difficulty lifting the tongue to the upper teeth or moving the tongue from
side to side
• Trouble sticking out the tongue past the lower front teeth
• A tongue that appears notched or heart shaped when stuck out

• Complications
• Breast-feeding problems. Breast-feeding requires a baby to keep his or her
tongue over the lower gum while sucking. If unable to move the tongue or
keep it in the right position, the baby might chew instead of suck on the
nipple. This can cause significant nipple pain and interfere with a baby's
ability to get breast milk. Ultimately, poor breast-feeding can lead to
inadequate nutrition and failure to thrive.
• Speech difficulties. Tongue-tie can interfere with the ability to make certain
sounds — such as "t," "d," "z," "s," "th," "r" and "l."

• Poor oral hygiene. For an older child or adult, tongue-tie can make it
difficult to sweep food debris from the teeth. This can contribute to tooth
decay and inflammation of the gums (gingivitis). Tongue-tie can also lead to
the formation of a gap or space between the two bottom front teeth.

• Challenges with other oral activities. Tongue-tie can interfere with

activities such as licking an ice cream cone, licking the lips or playing a wind
instrument.

Diagnosis

• Physical examination
 Treatment
• Surgical treatment of tongue-tie may be needed for infants, children or
adults if tongue-tie causes problems. Surgical procedures include a
frenotomy or frenuloplasty.