GASTROINTESTINAL SYSTEM
B. Ostomy Care
1. An ostomy is a stoma that is surgically created from either the small intestine (ileostomy) or large intestine (colostomy) with the purpose of divert- ing waste outside the body. An ostomy appliance is placed to allow for the collection of stool.
2. Stoma Assessment. The bowel is highly vascular- ized and a stoma should be pink and moist. There are no nerves in a stoma. If a stoma becomes pale or dusky that should be reported to the provider as perfusion to that intestinal segment may be impaired. Stoma output varies related to what seg- ment of the bowel is used for stoma creation; the more proximal the bowel the more acidic and liquid the output will appear. The more distal in the colon the stoma is placed, the thicker and more formed the stool, which will be thickest in the descending colon.
3. The ostomy appliance should be changed every 3 days or sooner if it leaks. The wafer should not be in place for longer than 3 days unless the patient is in the immediate postop period and output is minimal.
A warm wet washcloth can be used to remove the old pouch. The skin should be pushed down versus pulling off the wafer as this is generally less painful.
Clean the skin with water and allow the skin to dry.
The new wafer can be cut according to the pattern.
If there is not a pattern, placing a paper towel on top of the stoma will give an approximate measure of the size (dark and wet area on the paper towel can be used as a pattern) and the size to cut on the wafer for the stoma opening. After removing the paper on the wafer, place the wafer on the skin surrounding the stoma. Hold the wafer in place for 5 minutes to allow the plastic to melt and best adhere to the skin.
Apply the bag to the appliance if not a one piece or already attached.
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4. Nursing care includes emptying the bag when it is one-third full to extend the wafer adhering for a longer time to the skin. Pouches that become filled with air should be relieved to prevent wafer dis- lodgement. Measure and document the stoma efflu- ence every 4 hours. Placing two to three cotton balls in the bag if the output is liquid will help absorb the effluence and prolong adherence of the appliance. If available, a WOC nurse should be consulted to opti- mize stoma care and educate the child and parents.
GASTROESOPHAGEAL REFLUX DISEASE A. Definition and Etiology
1. GER is the involuntary movement of gastric contents from the stomach to the esophagus with or without regurgitation or vomiting. In the majority of infants, GER resolves by 1 year of age. GERD occurs with persistent GER that results in complications and impacts the child’s quality of life.
2. Etiology
a. At-risk children include those with prema- turity, congenital esophageal abnormalities, congenital diaphragmatic hernia, neurologic impairment, cystic fibrosis, history of lung trans- plant, respiratory disorders, obesity, and family history of GERD.
B. Pathophysiology
1. Normally, the LES rests when there is a peristal- tic wave and this relaxation is transient.
2. The LES rests (5−30 seconds) are of longer dura- tion when the pressure in the esophagus is the same as the stomach (Barnhart, 2016) and is the physio- logical cause of GER.
C. Clinical Presentation 1. History
a. Evaluate symptoms and what allevi- ates or aggravates them, dietary history, and comorbidities.
b. GERD varies with age. Symptoms can range from persistent vomiting to intermittent spitting to apparent life- altering events with a significant decline at 1 year of age.
2. Physical Examination
a. No specific examination findings are diag- nostic of GER/GERD
i. Review anthropometric measurements and growth charts.
ii. Spitting and nonbloody and nonbilious vomiting are the most common symptom in infants. Other symptoms include feed- ing refusal, poor weight gain, respiratory symptoms, arching, choking, and coughing (Papachrisanthou & Davis, 2015).
iii. In children, the most common symptoms are vomiting, heartburn, abdominal pain, and anorexia (Papachrisanthou & Davis, 2016).
3. Diagnostic Tests
a. There is no single diagnostic test confirma- tory of GER/GERD.
b. According to the joint recommenda- tions from the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (Vandenplas et al., 2009):
i. Esophageal pH monitoring. This is a valid quantitative test of acid exposure;
however, severity does not correlate with symptoms or complications.
ii. Combined multiluminal impedance and pH monitoring. Detects acid and non- acid reflux episodes and is superior to pH monitoring for determining the relation- ship between the symptoms and disease.
iii. Motility studies. Esophageal manom- etry studies may be abnormal but lack sen- sitivity and specificity for GERD diagnosis confirmation.
iv. Endoscopy and biopsy. Endoscopically visible breaks in esophageal mucosa are the most reliable to diagnose reflux esophagitis and, although it is not diagnostic of GERD, it may be helpful for the diagnosis of other disorders.
v. Upper GI. Not recommended for GERD diagnosis, may be helpful in determining alternate diagnoses.
vi. Empiric trial of aid suppression. For the older child, a 4-week trial of a PPI is used for symptom improvement; however, this is not recommended in infants and younger chil- dren. Improvement in the child’s heartburn does not confirm the GERD diagnosis as clin- ical improvement may be related to sponta- neous improvement or placebo effect.
4. Clinical Course
a. Persistent GER symptoms that progress to GERD with complications, including esophagi- tis and respiratory complications are expected.
D. Patient Care Management
1. Preventive Care or “Lifestyle Changes”
a. Infants
i. Elevate head of bed to 30 degrees, mini- mize overfeeding, and consider a 1- to 2-week trial of hypoallergenic formula (Garth, 2016).
b. Children
i. Elevate head of bed, encourage left side-lying positioning, weight reduction if indicated; there is no evidence to support dietary modification (e.g., minimize caffeine, fatty or spicy foods, carbonation, eat small frequent meals; Garth 2016; Vandenplas et al., 2009).
2. Direct Care a. Pharmacology
i. Administer a PPI (up to 8 weeks)—not FDA approved in infants younger than 1 year.
ii. Administer a histamine-2 receptor antagonist— generally first-line treatment.
iii. Prokinetic agent—The adverse side effects outweigh potential benefit for GERD treatment and these agents are not recommended.
b. Surgical intervention
i. Indications for surgery include depen- dence on long-term medication ther- apy, nonadherence to medical therapy, repeated episodes of aspiration or related pneumonia episodes, and an apparent life- threatening event.
ii. Nissen fundoplication may be per- formed open or laparoscopically and is a 360-degree circumferential wrap of the fundus of the stomach around the intra- abdominal esophagus.
3. The child may be unable to “burp” or vomit, which can lead to gastric distension and, in rare cases, gastric rupture. The child may require placement of an NG tube or, if a gastrostomy tube is present, it is placed to gravity drainage. Feeds, if administered through an enteric tube, should be administered continuously and vented (with a Farrell bag or syringe) during the immediate postoperative period.
E. Outcomes
Symptoms that begin after 3 years of age are less likely to resolve without intervention.
ACUTE ABDOMINAL TRAUMA
Acute abdominal trauma is more often blunt versus penetrating, which is considered blunt abdominal trauma. The organs most commonly injured are the spleen and liver.
A. Definition and Etiology
Anatomic differences in children compared with adults include a body size that allows greater distribution of injury, a larger body surface area that allows for greater heat loss, abdominal organs that are more anterior with less SC fat protection, and a smaller blood volume resulting in hypovolemia with relatively smaller vol- ume losses.
B. Pathophysiology
1. Blunt injuries are caused by compression of solid or hollow viscous organs against the spine; rapid acceleration and deceleration with subsequent tear- ing of structures; or increased abdominal pressure resulting in contusion, laceration, or rupture of organs with subsequent hemorrhage. Solid organs are injured more often than hollow organs, and the most commonly injured organ is the spleen. Blunt trauma can result in lethal injury without visible signs of trauma.
2. Penetrating injuries are most often caused by gunshot or stab wounds. The most common injury is to the hollow viscera. The onset of peritonitis may be immediate. Wounds that penetrate the abdomen usually require surgical exploration.
C. Clinical Presentation
1. History. History is given by a parent or emer- gency responder report. If age appropriate, speak with the child and attempt to get a history. As with all trauma, if the history does not explain the injuries, providers should be suspicious of child maltreatment.
2. Physical Examination
a. Significant injuries to the head and extremi- ties may overshadow abdominal injuries.
b. Signs of injury are often subtle and include rebound tenderness, pain, rigidity, pallor, grunting
ACUTE ABDOMINAL TRAUMA ■ 549
respirations, hypotension, failure to respond to fluid resuscitation, and increasing abdominal girth. Acute abdominal distention occurs even with minor trauma, especially in infants and often in children as a result of crying and swallowing air.
Distention may lead to vomiting and aspiration.
c. Signs of retroperitoneal bleeding include Cullen’s sign (ecchymosis around the umbilicus) and Turner’s sign (ecchymosis over the flank).
3. Diagnostic Tests
a. Abdominal x-rays, supine and lateral, are useful for determining intraperitoneal free air, ground-glass appearance (suggests intraperito- neal blood or urine), associated lower rib fractures (indicates severe force), and signs of an ileus.
b. Ultrasound (US), or FAST (focused abdomi- nal sonography for trauma), is a rapid diagnos- tic tool used to identify intraperitoneal fluid in the hemodynamically unstable child with blunt trauma. However, FAST is poor at identifying organ- specific injury and therefore does not replace the abdominal CT as a tool for definitive diagnosis of abdominal injury. The sensitivity of the FAST exam is highly variable; however, use of FAST scans has reduced the number of CT scans in some institutions (Notrica, 2015).
c. Abdominal CT scan is the standard of care for evaluation of the peritoneal cavity and retroperi- toneum in the hemodynamically stable child. The use of IV contrast is recommended to evaluate organ perfusion, bowel integrity, and the pres- ence of intraperitoneal fluid (Ellison et al., 2015).
d. Diagnostic peritoneal lavage (DPL) is a tech- nique that is rarely performed with the advent of newer imaging techniques (e.g., FAST exam) and involves the insertion of a catheter into the peritoneal cavity. Aspiration of blood is a posi- tive tap. If no blood is obtained, then 10 mL/kg of normal saline (NS) or Ringer’s lactate solu- tion (RL) is infused through the catheter and the effluent is drained by gravity. Cell count and chemistries are obtained. White cell counts greater than 500 cells/mL, red cells counts greater than 100,000 cells/mL, amylase greater than 175 mg/dL, and aspirating stool or blood is a positive tap. A tap positive for blood indicates hemoperitoneum but provides no information on the bleeding source.
e. Complete blood count (CBC) and coagula- tion studies may help to evaluate bleeding.
f. The utility of other laboratory tests in the diagnosis of intra-abdominal injury is
controversial. Elevated AST and ALT suggest liver injury (see Table 7.1). Elevated amylase and lipase suggest pancreatic injury.
g. Urinalysis should be obtained to evaluate for the presence of blood, which indicates kid- ney or bladder injury.
D. Patient Care Management
1. Preventive Care. Safety measures include appro- priate child-restraint devices in automobiles and wearing appropriate protective gear when partici- pating in contact sports.
2. Direct Care
a. Early management of airway, breathing, and circulation (ABC) has the most direct impact on survival. The critically ill child may require intubation and mechanical ventilation for stabi- lization of the airway and breathing. Circulatory stabilization requires the placement of large- bore IV lines and fluid resuscitation. Inadequate airway and fluid resuscitation are the leading causes of preventable death. Central venous pressure (CVP) and arterial blood pressure (BP) lines are placed to allow close monitoring of the child’s intravascular volume and BP.
b. Current management of blunt abdominal trauma is based on the child’s hemodynamic status (e.g., hemoglobin [Hgb] >7 mg/dL) as compared to injury severity grading scales.
The mainstay of treatment remains nonop- erative management for blunt solid abdomi- nal organ injury (McVay, Kokoska, Jackson, &
Smith, 2008).
c. Insertion of an NG or OG tube allows for gastric decompression, minimizes aspiration risk, and maximizes respiratory effort.
d. Serial laboratory studies are necessary for evaluation of injury, especially following the hematocrit, which is imperative to assess for ongoing bleeding. For blunt injuries for which serial values are being monitored, phlebotomy may be discontinued after two to three stable values (McVay et al., 2008).
e. Most solid-organ abdominal injuries are man- aged nonoperatively. The blood volume of a child is approximately 80 mL/kg. Fluid resuscitation guidelines include administering up to 40 mL/
kg of saline or RL solution. If the child remains hemodynamically unstable, a blood transfusion should then be given. Indications for surgical exploration include massive fluid resuscitation
(>40 mL/kg of blood transfusions or more than 50% of blood volume), penetrating trauma, signs of peritonitis, radiographic evidence of pneu- moperitoneum, and certain blunt injuries (e.g., diaphragmatic injury or bladder rupture).
3. Organ-Specific Care
a. The spleen is the most commonly injured abdominal organ in blunt abdominal trauma.
i. Signs and symptoms include left upper quadrant (LUQ) tenderness, bruis- ing, or abrasion, positive Kehr’s sign (LUQ pain radiating to the left shoulder), signs of decreased perfusion (pallor, tachycardia, delayed capillary refill, and hypotension), and nausea and vomiting. Other signs may include Cullen’s or Turner’s sign.
ii. Diagnostic studies. Abdominal x-ray examinations are rarely helpful but may demonstrate an elevated left hemidiaphragm or a medially displaced lateral stomach
border suggesting splenic laceration. The hematocrit may be decreased related to bleeding, or leukocytosis may be noted.
Definitive diagnosis is made by abdominal CT scan with contrast.
iii. Classification is based on location and extent of injury (Table 7.5).
iv. Management. The standard of care is nonoperative treatment in hemodynami- cally stable patients. See Table 7.6 for current activity restrictions, hospital length of stay, and imaging recommendations. Patients are NPO until stable. Surgery may include a sple- nectomy or splenorrhaphy. In most instances, suturing the injury or splenorrhaphy results in salvage of the spleen. The ultimate goal is preservation of the immune function of the spleen. Massive splenic injury requires a sple- nectomy. Postoperative care includes mon- itoring for potential complications such as atelectasis, bleeding, ileus, pain, and infection.
TABLE 7.5 Splenic Injury Scale Grade Injury Description I
Hematoma Subcapsular, nonexpanding, <10% of surface area Laceration Capsular tear, nonbleeding, <1 cm of parenchymal depth II
Hematoma Subcapsular, nonexpanding, 10%−50% of surface area, intraparenchymal, nonexpanding, <5 cm in diameter
Laceration Capsular tear, 1−3 cm of parenchymal depth that does not involve a trabecular vessel III
Hematoma Subcapsular, >50% of surface area or expanding, ruptured subcapsular or parenchymal hematoma, intraparenchymal hematoma, >5 cm or expanding
Laceration >3 cm of parenchymal depth or involving trabecular vessels IV
Hematoma Ruptured intraparenchymal hematoma with active bleeding
Laceration Laceration involving segmental or hilar vessel producing major devascularization (>25% of spleen) V
Laceration Completely shattered spleen
Vascular Hilar vascular injury that devascularizes spleen
Source: Adapted from Lynch, J. M., Meza, M. P., Newman, B., Gardner, M. J., & Albanese, C. T. (1997). Computed tomography grade of splenic injury is predictive of the time required for radiographic healing. Journal of Pediatric Surgery, 32, 1093−1096. doi:10.1016/S0022-3468(97)90406-1
ACUTE ABDOMINAL TRAUMA ■ 551
v. Complications include rebleeding or splenic laceration 3 to 5 days after the initial injury. Splenectomized children are at risk for overwhelming postsplenectomy infec- tion (OSI). Streptococcus pneumoniae is the most common causative agent. Vaccination against encapsulated bacteria, including S.
pneumoniae, Haemophilus influenzae type b, and Neisseria meningitides, is recommended after splenectomy. Daily penicillin prophylaxis is recommended in children younger than 5 years and for 2 years following splenectomy and longer if there are other immunosuppres- sion factors or a history of OSI (Buzelé, Barbier, Sauvanet, & Fantin, 2016). Parents should be taught signs and symptoms of infection and when to seek medical attention. Children who sustain an isolated splenic injury are restricted from contact sports and strenuous physical activity for a period consisting of the grade of injury plus 2 weeks.
b. The liver is second only to the spleen as a major source of hemorrhage and is the most common source of lethal hemorrhage. Bleeding stops spontaneously with most injuries.
i. Signs and symptoms include right upper quadrant (RUQ) tenderness, ecchymosis, abrasion, enlarging abdominal girth, signs of
shock, and associated injuries such as lower rib fractures, pelvic fracture, or head injury.
ii. Diagnostic studies. Definitive diagnosis is made with abdominal CT scan with con- trast. Elevated transaminases are highly sug- gestive of liver injury, especially AST greater than 200 IU/L and ALT greater than 100 IU/L (Puranik, Hayes, Long, & Mata, 2002). A rap- idly falling hematocrit suggests severe liver injury. See Table 7.6 for suggested radiologic monitoring to assess healing or continued bleeding based on the grade of injury.
iii. Classification. Injuries are graded according to increasing severity (Table 7.7).
iv. Management is similar to the treatment of splenic injury and involves supportive care with a nonoperative approach (see Table 7.6).
Nonoperative management requires close monitoring of vital signs and physical exam- inations. Fever, leukocytosis, and abdominal tenderness remote from the liver injury may indicate an occult injury. Serial hematocrits, coagulation studies, chemistries, and transami- nase levels should be monitored for significant liver dysfunction and monitored until stable.
Close monitoring for ongoing bleeding is nec- essary, and patients should remain on strict bed rest until they are stable. Surgery is indicated for the hemodynamically unstable child, signs of peritonitis, or transfusion requirements exceeding 50% of the estimated blood volume during the first 24 hours (Garcia & Brown, 2003). Children with isolated hepatic injury are restricted from contact sports and strenuous physical activity for a period consisting of the grade of injury plus 2 weeks.
v. Complications of operative manage- ment include delayed bleeding, abscess for- mation, abdominal compartment syndrome, biliary obstruction, and biloma.
c. The pancreas is located deep in the upper abdomen and is infrequently injured unless a significant sustained force compresses it against the spine. The classic injury is compression by bicycle handlebars in which the child flips over the bike and is impaled in the epigastrium by the handlebars. Other mechanisms include motor vehicle collisions and child maltreatment.
i. Signs and symptoms include dif- fuse abdominal tenderness, deep epigas- tric pain radiating to the back, and bilious vomiting. Pain may diminish within the first 2 hours of injury and worsen with the TABLE 7.6 Proposed Guidelines for Resource Use in
Children With Isolated Spleen or Liver Injury CT Grade
I II III IV
ICU (day) None None None 1
Hospital stay 2 3 4 5
Predischarge
imaging None None None None
Postdischarge
imaging None None None None
Activity restriction
(week)a 3 4 5 6
aReturn to full-contact, competitive sports (i.e., football, wrestling, hockey, lacrosse, mountain climbing) should be at the discretion of the individual pediatric trauma surgeon. The proposed guidelines for return to unrestricted activity include “normal” age-appropriate activities.
Source: From McVay, M. R., Kokoska, E. R., Jackson, R. J., & Smith, S. D.
(2008). Throwing out the “grade” book: Management of isolated spleen and liver injury based on hemodynamic status. Journal of Pediatric Surgery, 43(6), 1072−1076. doi:10.1016/j.jpedsurg.2008.02.031