The Child with Gastrointestinal Dysfunction

Signs and Symptoms

A history of choking followed by an acute episode of coughing is the most common presentation of foreign body ingestion (Lea, Nawaf, Yoav, et al, 2005). Initial signs and symptoms also may include dyspnea and wheezing. Aspirated foreign bodies that lodge in the larynx or trachea cause stridor. When these are in the large bronchi, crepitations and wheezes can be found. Wheezes and crepitations can be heard in both lungs, but unilateral findings have a higher specificity for foreign body aspiration (Kadmon, Stern, Bron-Harlev, et al, 2008).

Other symptoms may be those that are common with GI complaints in general (e.g., dysphagia, excessive drooling, poor feeding, vomiting, gagging, anorexia, neck or throat pain, sensation of a foreign object, and refusal to eat or drink).

Complications

Less than 1% of esophageal bodies cause a significant problem. However, serious problems that can occur include mediastinitis, pleural effusion, pneumothorax, and lung abscess. Foreign bodies are generally classified as sharp or dull, pointed or blunt, and toxic or nontoxic.

Food bolus foreign bodies should be immediately removed if the child is in severe distress and unable to swallow secretions. Disc batteries are a medical emergency if they are lodged in the esophagus because, if both poles of the battery come in contact with the flat wall of the esophagus, it may result in liquefaction, necrosis, and perforation. However, if the battery passes into the stomach, it will generally pass without incident. Sharp objects (straight pins, needles, straightened paper clips) need to be removed if lodged in the esophagus. If they pass into the stomach, they generally will pass out of the body, but there is a 35% risk of complications.

Diagnostic Evaluation

As mentioned, there may be no signs or symptoms, but some children come to the physician for evaluation because of problems. The nurse should perform a complete history and physical examination. Assess the airway and breathing first. Findings on the chest evaluation might include inspiratory stridor or expiratory wheezing. Findings on an abdominal examination could be small bowel obstruction or perforation. The physical examination might demonstrate swelling, erythema, or crepitus suggestive of esophageal perforation.

Assessment often involves radiologic evaluation. A plain x-ray film of the neck, chest, and abdomen may be ordered. Biplane radiographic studies identify radiopaque esophageal foreign bodies. Flat objects such as coins may be visible in the coronal plane. Objects in the trachea generally orient into the sagittal plane and are easiest to see in the lateral projection. Hand-held metal detectors have been used to detect coins. Endoscopy should be done in patients with symptoms suggestive of obstruction even if the radiographic evidence is negative.

Therapeutic Management

Intervention is urgent when a child has sharp objects, magnets, or disc batteries lodged in the esophagus because of the risk of perforation or acid burns (Kiger, Brenkert, and Losek, 2008). Urgent intervention is also important any time the airway is compromised. If the child is asymptomatic and the foreign body does not carry an emergent risk, it is reasonable to wait 24 hours to see if it will pass. Foreign objects should not be allowed to remain in the esophagus for more than 24 hours because of the potential for complications such as erosion, perforation, or formation of fistulas.

Flexible endoscopy allows direct visualization of the esophagus, stomach, and duodenum. It is the best approach for removing a foreign object. It involves passing a narrow tube with a camera on the end through the mouth into the esophagus, stomach, and duodenum with the patient under sedation. The foreign object can be detected and removed. Rigid endoscopy is used to remove impacted sharp objects at the level of the hypopharynx and cricopharyngeal muscle.

Another technique that has been used is bougienage (Uyemura, 2005). This involves passing a dilator to push objects into the stomach. The drawback is this method does not allow inspection of the esophagus to assess for injury or damage, and it increases the risk of perforation of the esophagus.

Another method involves passing a Foley catheter into the esophagus, inflating it distal to the obstruction, and then withdrawing it (Uyemura, 2005). Again there is a risk of airway obstruction and an inability to directly visualize the esophagus.

Coins have been removed using the penny pincher technique, which involves passing grasping forceps through a nasogastric (NG) tube using fluoroscopic guidance. This is an improvement over the Foley technique because it allows for direct control of the object, but again it does not permit inspection of the esophagus.

Important variables in the application of treatment guidelines include the type of foreign object, its location in the GI tract, and whether the patient is symptomatic. Of all foreign bodies that reach the stomach, 80% to 90% pass spontaneously, 10% to 20% require endoscopic removal, and 1% requires surgery (Byrne, 1999). The progress of a foreign body may be followed radiographically. Examine all stools to detect the passage of the object. The child should be fed the usual diet. Sharp objects such as long pins or chicken or fish bones should be removed endoscopically rather than risk perforation by allowing them to pass spontaneously (Byrne, 1999). Endoscopic or surgical intervention should be implemented if the object fails to progress through the GI tract (Uyemura, 2005).

Nursing Care Management

The primary nursing intervention is prevention of foreign body ingestion through family teaching. All children who are old enough to understand are taught not to put anything in their mouth except food. Infants and young children who cannot follow such advice must have their environment protected.

Prevention includes supervision and ongoing education as the child matures. Any small items, diaper pins, or sharp objects are placed out of the area where an infant is usually cared for, plays, or sleeps. As the infant becomes more mobile, the environment is inspected carefully for hazardous objects. Any potentially dangerous items are placed out of reach of a young child or discarded where they cannot be retrieved easily. Toys are carefully examined for small or removable parts that could be accidentally ingested. If infants and small children wear earrings, the earrings should have screw backs to prevent them from falling off. Infants and small children who wear other jewelry should be carefully supervised. Infants or young children should not be allowed to play with marbles, coins, or objects with small batteries.

Once an object is swallowed, parents need guidelines on seeking treatment (see Emergency Treatment box). When no treatment is advised and the object is left to pass spontaneously, parents should examine all stools for verification that the object has passed safely through the GI tract, usually within 3 or 4 days. For children in diapers, this is easily accomplished by squeezing the stool between the diaper to locate the object. For toilet-trained children a piece of plastic wrap placed across the toilet bowl to collect the stool makes it easier to examine the feces. A tongue blade or similar disposable object may be needed to break up the stool for inspection.

Infancy

The onset of constipation frequently occurs during infancy and may result from organic causes such as HD, hypothyroidism, and strictures. It is important to differentiate these conditions from functional constipation. Constipation in infancy is often related to dietary practices. It is less common in breast-fed infants, who have softer stools than bottle-fed infants. Breast-fed infants may also have decreased stools because of more complete use of breast milk with little residue. When constipation occurs with a change from human milk or modified cow’s milk to whole cow’s milk, simple measures such as adding or increasing the amount of cereal, vegetables, and fruit in the infant’s diet usually correct the problem. When a bottle-fed infant passes a hard stool that results in an anal fissure, stool-withholding behaviors may develop in response to pain on defecation (see Critical Thinking Exercise).

Childhood

Most constipation in early childhood is due to environmental changes or normal development when a child begins to attain control over bodily functions. A child who has experienced discomfort during bowel movements may deliberately try to withhold stool. Over time, the rectum accommodates to the accumulation of stool, and the urge to defecate passes. When the bowel contents are ultimately evacuated, the accumulated feces are passed with pain, thus reinforcing the desire to withhold stool.

Constipation in school-age children may represent an ongoing problem or a first-time event. The onset of constipation at this age is often the result of environmental changes, stresses, and changes in toileting patterns. A common cause of new-onset constipation at school entry is fear of using the school bathrooms, which are noted for their lack of privacy. Early and hurried departure for school immediately after breakfast may also impede bathroom use.

Therapeutic Management

Treatment of constipation depends on the cause and duration of symptoms. A complete history and physical examination are essential to determine appropriate management (Tobias, Mason, Lutkenhoff, et al, 2008). Meconium plugs are often evacuated after digital examination. It may be necessary to facilitate passage of the obstruction by irrigation with a hypertonic solution or water-soluble enema such as diatrizoate meglumine (Gastrografin) or diatrizoate sodium (Hypaque). If the constipation is due to HD, surgical treatment may include resection of the intestine and saline irrigations.

Management of the infant should include education of the parents concerning normal bowel habits. Short, transient periods of constipation usually require no intervention. Mild constipation usually resolves as solid food is introduced in the diet. Stool softeners such as malt extract or lactulose may be used for hard stools or anal fissures. The persistent use of rectal stimulation with thermometers or cotton-tipped applicators is discouraged because these methods often result in anal fissures and increased pain that may trigger stool withholding.

The management of simple constipation consists of a plan to promote regular bowel movements. Often this is as simple as changing the diet to provide more fiber and fluids, eliminating foods known to be constipating, and establishing a bowel routine that allows for regular passage of stool. Stool-softening agents such as docusate or lactulose may also be helpful. Polyethylene glycol (PEG) 3350 without electrolytes (MiraLax) is a chemically inert polymer that has been introduced as a new laxative in recent years. Children tolerate it well because it can be mixed in a beverage of choice (Loening-Baucke and Pashankar, 2006). If other symptoms such as vomiting, abdominal distention, or pain and evidence of growth failure are associated with the constipation, investigate the condition further.

Management of chronic constipation requires an organized approach. It is important for families to realize that it usually requires at least 6 to 12 months of treatment to be effective (Tobias, Mason, Lutkenhoff, et al, 2008). The goals for management include restoring regular evacuation of stool, shrinking the distended rectum to its normal size, and promoting a regular toileting routine. This requires a combination of therapies and should include bowel cleansing, maintenance therapy to prevent stool retention, modification of diet, bowel habit training, and behavioral modification (Box 33-3).

After the impaction is removed, maintenance therapy often lasting for 6 to 12 months is necessary to promote easy passage of stool and to prevent stool retention. Maintenance therapy includes mineral oil, stool softeners, and laxatives. Stool softeners are often ineffective for severe constipation; laxative therapy may be necessary to return the rectum to its normal size. Polyethylene glycol is a more favorable constipation intervention than lactulose (Dupont, Leluyer, Maamri, et al, 2005). Polyethylene glycol increases fluid in the colon. The additional volume of fluid stimulates the urge to defecate.

Changes in the diet may be helpful but are usually not effective alone. A recent study comparing a liquid yogurt fiber mixture to lactulose in 147 children revealed comparable results in the treatment of constipation (Kokke, Scholtens, Alles, et al, 2008). Encouraging the intake of fiber ultimately helps maintain regular elimination once the rectum returns to normal size and the laxatives are tapered. Effective counseling is an essential element of the treatment plan for children with chronic constipation. Explain normal bowel function, the purpose of interventions, and the need for persistence to the child and family.

Retraining therapy involves habit training, reinforcement for sitting on the toilet and defecating, and emotional support. Parents should establish a regular toilet time once or twice a day, preferably after a meal. A reasonable amount of time (5 to 10 minutes) should be spent attempting to defecate completely. Biofeedback may be indicated as a form of behavior modification and as a means to teach children to relax the anal sphincter during defecation.

Nursing Care Management

Unfortunately, constipation tends to be self-perpetuating. A child who has difficulty or discomfort when attempting to evacuate the bowels has a tendency to retain the bowel contents, and thus constipation becomes a chronic problem. Nursing assessment begins with a history of bowel habits; diet; events that may be associated with the onset of constipation; drugs or other substances that the child may be taking; and the consistency, color, frequency, and other characteristics of the stool. If there is no evidence of a pathologic condition that requires further investigation, the nurse’s major task is to educate the parents regarding normal stool patterns and to participate in the education and treatment of the child.

Dietary modifications are helpful in preventing constipation. Fiber is an important part of the diet. Parents benefit from guidance about foods high in fiber (Box 33-4) and ways to promote healthy food choices in children. If bran is added to the diet, creative ways to disguise the consistency, such as adding it to cereal, peanut butter, mashed potatoes, fruit shakes, and baked goods, are helpful. Beans are often found in Mexican dishes children enjoy and can be added to soups, salads, and stews. Beyond the age when foreign body aspiration is a hazard, a good source of fiber is corn and popcorn.

Parents need reassurance concerning the prognosis for establishing normal bowel habits. Many parents are concerned about constipation and view the condition as dangerous. Families need thorough instructions about the treatment plan. If the child needs enemas or medication, give the family the appropriate instructions. It is important to discuss attitudes and expectations regarding toilet habits and the treatment plan.

Pathophysiology

The pathology of HD relates to the absence of ganglion cells in the affected areas of the intestine, resulting in a loss of the rectosphincteric reflex and an abnormal microenvironment of the cells of the affected intestine (Theocharatos and Kenny, 2008). The term congenital aganglionic megacolon describes the primary defect, which is the absence of ganglion cells in the myenteric plexus of Auerbach and the submucosal plexus of Meissner (Fig. 33-2).

The absence of ganglion cells in the affected bowel results in a lack of enteric nervous system stimulation, which decreases the internal sphincter’s ability to relax. Unopposed sympathetic stimulation of the intestine results in increased intestinal tone. In addition to the contraction of the abnormal bowel and the resulting lack of peristalsis, there is a loss of the rectosphincteric reflex. Normally when a stool bolus enters the rectum, the internal sphincter relaxes and the stool is evacuated. In HD, the internal sphincter does not relax. In most cases the aganglionic segment includes the rectum and some portion of the distal colon. However, the entire colon or part of the small intestine may be involved. Occasionally, skip segments or total intestinal aganglionosis may occur.

Clinical Manifestations

Most children with HD are diagnosed in the first few months of life. Clinical manifestations vary according to the age when symptoms are recognized and the presence of complications, such as enterocolitis (Box 33-5). A neonate usually is seen with distended abdomen, feeding intolerance with bilious vomiting, and delay in the passage of meconium. Typically, 95% of normal term infants pass meconium in the first 24 hours of life, whereas less than 10% of infants with HD do so. In older children, a careful history is helpful.

Diagnostic Evaluation

In the neonate the diagnosis is suspected on the basis of clinical signs of intestinal obstruction or failure to pass meconium. In infants and children the history is an important part of diagnosis and typically includes a chronic pattern of constipation. On examination the rectum is empty of feces, the internal sphincter is tight, and leakage of liquid stool and accumulated gas may occur if the aganglionic segment is short. A barium enema often demonstrates the transition zone between the dilated proximal colon (megacolon) and the aganglionic distal segment. However, this typical megacolon and narrow distal segment may not develop until the age of 2 months or later.

To confirm the diagnosis, rectal biopsy is performed either surgically to obtain a full-thickness biopsy specimen or by suction biopsy for histologic evidence of the absence of ganglion cells. A noninvasive procedure that may be used is anorectal manometry, in which a catheter with a balloon attached is inserted into the rectum. The test records the reflex pressure response of the internal anal sphincter to distention of the balloon. A normal response is relaxation of the internal sphincter followed by a contraction of the external sphincter. In HD the external sphincter contracts normally but the internal sphincter fails to relax.

Therapeutic Management

The majority of children with HD require surgery rather than medical therapy with frequent enemas (Levitt, Martin, Olesevich, et al, 2009). Once the child is stabilized with fluid and electrolyte replacement, if needed, surgery is performed, with a high rate of success. Surgical management consists primarily of the removal of the aganglionic portion of the bowel to relieve obstruction, restore normal motility, and preserve the function of the external anal sphincter. The transanal Soave endorectal pull-through procedure is often performed and consists of pulling the end of the normal bowel through the muscular sleeve of the rectum, from which the aganglionic mucosa has been removed (Huang, Zheng, and Xiao, 2008). With earlier diagnosis the proximal bowel may not be extremely distended, thus allowing for a primary pull-through or one-stage procedure and eliminating the need for a temporary colostomy. Simpler operations, such as an anorectal myomectomy, may be indicated in very short–segment disease.

After the pull-through procedure, anal stricture and incontinence may occur and require further therapy, including dilations or bowel retraining therapy. Constipation and fecal incontinence are chronic problems in a significant proportion of patients after surgical correction for HD (Levitt, Martin, Olesevich, et al, 2009). As these children grow older, this can significantly affect their quality of life (Mills, Konkin, Milner, et al, 2008).

Nursing Care Management

The nursing concerns depend on the child’s age and the type of treatment. If the disorder is diagnosed during the neonatal period, the main objectives are (1) to help the parents adjust to a congenital defect in their child, (2) to foster infant-parent bonding, (3) to prepare them for the medical-surgical intervention, and (4) to assist them in colostomy care after discharge.

Clinical Manifestations

During infancy the most common clinical manifestation of GER is passive regurgitation or emesis. Recurrent vomiting occurs in 50% of infants in the first 3 months of life, 67% of 4-month-olds, and 5% of 10- to 12-month-old infants (Rudolph, Mazur, Liptak, et al, 2001). Vomiting generally resolves spontaneously in most of these infants. Clinical manifestations of gastroesophageal reflux are listed in Box 33-6. GER is one of the causes of apparent life-threatening events and has also been associated with chronic respiratory disorders, including reactive airways disease, recurrent stridor, chronic cough, and recurrent pneumonia in infants. Esophagitis can also cause discomfort in the chest area, which may be manifested as unusual irritability or poor intake of nutrients. Poor weight gain and poor growth may occur in a child with an insufficient intake of nutrients or with a large amount of regurgitation.

For preschool children GER may occur with intermittent vomiting. Older children tend to initially come to the physician with a more adultlike pattern of heartburn, regurgitation, and reswallowing. GERD may cause severe inflammation, chronic blood loss with anemia and hematemesis, hypoproteinemia, or melena. If the inflammation goes untreated, scarring and strictures may form. Barrett mucosa, another potential finding in the presence of chronic inflammation, is characterized by changes in the distal esophageal mucosa with metaplastic potentially malignant epithelium.

GER is common in children with asthma, but recurrent pneumonia caused by GER is uncommon except in children with neurologic impairments. Hoarseness has also been associated with GER in children.

Diagnostic Evaluation

The history and physical examination are usually sufficiently reliable to establish the diagnosis of GER. However, the upper GI series is helpful in evaluating the presence of anatomic abnormalities (e.g., pyloric stenosis, malrotation, annular pancreas, hiatal hernia, esophageal stricture). The 24-hour intraesophageal pH monitoring study is the gold standard in the diagnosis of GER (Suwandhi, Ton, and Schwarz, 2006). Endoscopy with biopsy may be helpful to assess the presence and severity of esophagitis, strictures, and Barrett esophagus and to exclude other disorders such as Crohn disease (CD). Scintigraphy detects radioactive substances in the esophagus after a feeding of the compound and assesses gastric emptying. It can differentiate between aspiration of gastric contents from reflux and aspiration from poor oropharyngeal muscle coordination.

Therapeutic Management

Therapeutic management of GER depends on its severity. No therapy is needed for the infant who is thriving and has no respiratory complications. Avoidance of certain foods that exacerbate acid reflux (e.g., caffeine, citrus, tomatoes, alcohol, peppermint, spicy or fried foods) can improve mild GER symptoms. Lifestyle modifications in children (e.g., weight control if indicated; small, more frequent meals) and feeding maneuvers in infants (e.g., thickened feedings, upright positioning) can help as well. Twenty research trials involving 771 children found thickened feeds reduced the regurgitation severity (Craig, Hanlon-Dearman, Sinclair, et al, 2004). Thickened feeding has a significant effect on the reduction of regurgitation frequency and amount in otherwise healthy infants. However, the occurrence of acid GER was not reduced (Wenzi, Schneider, Scheele, et al, 2003).

Feedings thickened with 1 tsp to 1 tbsp of rice cereal per ounce of formula may be recommended. This may benefit infants who are underweight as a result of GERD. Constant NG feedings may be necessary for the infant with severe reflux and failure to thrive until surgery can be performed. Elevating the head of the bed did not have any effect on GER symptoms in the Cochrane systematic review of 20 research trials (Craig, Hanlon-Dearman, Sinclair, et al, 2004). Prone positioning of infants also decreases episodes of GER but is recommended only with extreme caution when the risk of GERD complications exceeds the risk of sudden infant death syndrome (Cavataio and Guandalini, 2005). The American Academy of Pediatrics continues to recommend supine positioning for sleep. (See Chapter 11.)

Pharmacologic therapy may be used to treat infants and children with GERD. Both H₂-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac], or famotidine [Pepcid]) and proton pump inhibitors (PPIs; esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole [Protonix], and rabeprazole [Aciphex]) reduce gastric hydrochloric acid secretion and may stimulate some increase in LES tone. Use of available prokinetic drugs (e.g., bethanechol [Urecholine] and metoclopramide) remains controversial. Careful analyses of published data have failed to demonstrate clinical efficacy in modifying the natural history or therapeutic outcomes of GER in childhood (Suwandhi, Ton, and Schwarz, 2006).

Surgical management of GER is reserved for children with severe complications such as recurrent aspiration pneumonia, apnea, severe esophagitis, or failure to thrive, and for children who have failed to respond to medical therapy. The Nissen fundoplication (Fig. 33-3) is the most common surgical procedure (Christian and Buyske, 2005). This surgery involves passage of the gastric fundus behind the esophagus to encircle the distal esophagus. Complications following fundoplication include breakdown of the wrap, small bowel obstruction, gas-bloat syndrome, infection, retching, and dumping syndrome (Rudolph, Mazur, Liptak, et al, 2001).

Nursing Care Management

Nursing care is directed at (1) identifying children with symptoms suggestive of GER; (2) educating parents regarding home care, including feeding, positioning, and medications when indicated; and (3) caring for the child undergoing surgical intervention. For the majority of infants, parental reassurance of the benign nature of the condition and its relationship to physiologic maturity is the most important intervention. To help parents cope with the inconvenience of dealing with a child who spits up or regurgitates frequently, simple tips such as using bibs and protective clothes during feeding and prone positioning when holding the infant after feeding are beneficial.

It is important to educate and reassure parents about positioning. In the past, recommendations encouraged upright positioning during sleeping for both infants and older children. The supine position for sleeping continues to be recommended by the American Academy of Pediatrics (2005). Parents should not place infants on their sides as an alternative to fully supine sleeping, and avoidance of soft bedding and soft objects in the bed is important. Rescheduling of the family’s routine may be required to accommodate more frequent feeding times. If parents thicken formula with cereal, they should also enlarge the nipple opening for easier sucking. Usually breast-feeding may continue, and the mother may provide more frequent feeding times or express the milk for thickening with rice cereal. Parents should avoid feeding the child spicy foods or any foods that they find aggravate symptoms in general, and avoid caffeine, chocolate, tobacco smoke, and alcohol when breast-feeding. Other practical advice includes advising the parents to avoid vigorous play after feedings and to avoid feeding just before bedtime.

When regurgitation is severe and growth is a problem, continuous NG tube feedings may decrease the amount of emesis and provide constant buffering of gastric acid. Special preparation of caregivers is required when this type of nutritional therapy is indicated.

The nurse can support the family by providing information about all aspects of treatment. Parents often require specific information about the medications given for GER. PPIs are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal. Parents need to be reassured because it takes several days of administration to achieve a steady state of acid suppression. They may not see the results that they expect right away. A number of new formulations available in PPIs allow for more efficient administration. Some preparations are available in dissolvable pills. There are powder and granule preparations as well. Many pharmacies will compound the medication in a liquid form for administration.

Postoperative nursing care after the Nissen fundoplication is similar to that for other types of abdominal surgery. (See Chapter 27.) Gastric decompression by an NG tube or gastrostomy must be maintained to avoid distention in the immediate postoperative period. Usually the NG tube should not be replaced by the nurse if it is accidentally removed because of the risk of injury to the operative site. When postoperative ileus resolves, the NG tube is removed or the gastrostomy tube is elevated in preparation for feeding. If bolus feedings are initiated through the gastrostomy, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube.

Therapeutic Management

The long-range goal of treatment is development of regular bowel habits and relief of symptoms. A Cochrane systematic review found weak evidence of any medication benefits for children with IBS (Huertas-Ceballos, Logan, Bennett, et al, 2009). A 2009 Cochrane systematic review found no high-quality evidence on the effectiveness of any dietary interventions that included fiber supplements, lactose free-diets, or lactobacillus supplementation for children with IBS (Huertas-Ceballos, Logan, Bennett, et al, 2009).

Nursing Care Management

The primary nursing goal is family support and education. The disorder is stressful to children and parents. The nurse can help by providing support and reassurance that, although the symptoms are difficult to deal with, the disorder is not generally a threat to the child’s health (see Community Focus box).

Critical Thinking Exercise—Home Care for the Adolescent

Etiology

The cause of appendicitis is obstruction of the lumen of the appendix, usually by hardened fecal material (fecalith). Swollen lymphoid tissue, frequently occurring after a viral infection, can also obstruct the appendix. Another rare cause of obstruction is a parasite such as Enterobius vermicularis, or pinworms, which can obstruct the appendiceal lumen.

Pathophysiology

With acute obstruction, the outflow of mucus secretions is blocked and pressure builds within the lumen, resulting in compression of blood vessels. The resulting ischemia is followed by ulceration of the epithelial lining and bacterial invasion. Subsequent necrosis causes perforation or rupture with fecal and bacterial contamination of the peritoneal cavity. The resulting inflammation spreads rapidly throughout the abdomen (peritonitis), especially in young children, who are unable to localize infection. Progressive peritoneal inflammation results in functional intestinal obstruction of the small bowel (ileus) because intense GI reflexes severely inhibit bowel motility. Because the peritoneum represents a major portion of total body surface, the loss of extracellular fluid to the peritoneal cavity leads to electrolyte imbalance and hypovolemic shock.

Animation—Appendicitis

Clinical Manifestations

The first symptom of appendicitis is usually colicky, cramping, abdominal pain located around the umbilicus (Box 33-7). Referred pain is the term used for this vague periumbilical localization. The midgut shares the same T10 dermatome, so pain is often perceived to be coming from this area. Generally, this pain progresses and becomes constant. The most important physical finding is focal abdominal tenderness. As the inflammation progresses to involve the serosa of the appendix and the peritoneum of the abdominal wall, the pain may shift to the right lower quadrant. The McBurney point, located two thirds the distance along a line between the umbilicus and the anterosuperior iliac spine, is the most common point of tenderness. Localized peritoneal signs may occur with gentle percussion or maneuvers such as heel strike or shaking the bed. Another helpful finding is Rovsing sign, tenderness in the right lower quadrant that occurs during palpation or percussion of other abdominal quadrants (Colvin, Bachur, and Kharbanda, 2007). Rebound tenderness—pain on deep palpation with sudden release—may be present, but is not a finding specific to appendicitis (Ceydeli, Lavotshkin, Yu, et al, 2006). Nausea, vomiting, and anorexia typically occur after the pain starts. Diarrhea, as well as other common signs of childhood illness such as upper respiratory tract congestion, poor feeding, lethargy, or irritability, may accompany appendicitis.

The child may not be able to walk well and may complain of pain in the right hip caused by inflammation in the psoas or iliopsoas muscles. Low-grade fever (>38° C [100.4° F]) may be present but occurs in only about 55% of all patients. The absence of fever does not exclude appendicitis. Temperature elevations of 38.8° to 39.4° C (102° to 103° F) can occur after perforation; however, very high fevers (>39.4° C [103° F]) are uncommon (Ceydeli, Lavotshkin, Yu, et al, 2006). Because of the great variability in the presentation and location of appendicitis, any child with focal tenderness, regardless of the location, should be considered to potentially have acute appendicitis (see Community Focus box).

Diagnostic Evaluation

Diagnosis is not always straightforward. Fever, vomiting, abdominal pain, and an elevated white blood count are associated with appendicitis but are also seen in IBD, pelvic inflammatory disease, gastroenteritis, urinary tract infection, right lower lobe pneumonia, mesenteric adenitis, Meckel diverticulum, and intussusception. Prolonged symptoms and delayed diagnosis often occur in younger children, in whom the risk of perforation is greatest because of their inability to verbalize their complaints.

Critical Thinking Case Study—Gastroenteritis

Critical Thinking Case Study—Gastrointestinal Problems

The diagnosis is based primarily on the history and physical examination (see Box 33-7). Pain, the cardinal feature, is initially generalized (usually periumbilical). However, it usually descends to the lower right quadrant. The most intense site of pain may be at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Referred pain, elicited by light percussion around the perimeter of the abdomen, indicates peritoneal irritation. Movement, such as riding over bumps in an automobile or gurney, aggravates the pain. In addition to pain, significant clinical manifestations include fever, a change in behavior, anorexia, and vomiting.

Laboratory studies usually include a complete blood count (CBC); urinalysis (to rule out a urinary tract infection); and, in adolescent females, serum human chorionic gonadotropin (to rule out an ectopic pregnancy). A white blood cell count greater than 10,000/mm³ and a C-reactive protein (CRP) are common but are not necessarily specific for appendicitis. An elevated percentage of bands (often referred to as “a shift to the left”) may indicate an inflammatory process. CRP is an acute-phase reactant that rises within 12 hours of the onset of infection.

Computed tomography (CT) scan has become the imaging technique of choice, although ultrasound may also be helpful in diagnosing appendicitis. A CT scan is considered positive in the presence of enlarged appendiceal diameter; appendiceal wall thickening; and periappendiceal inflammatory changes, including fat streaks, phlegmon, fluid collection, and extraluminal gas (Kaiser, Frenchner, and Jorulf, 2002).

Therapeutic Management

The treatment for appendicitis before perforation is surgical removal of the appendix (appendectomy). Usually antibiotics are administered preoperatively. Intravenous (IV) fluids and electrolytes are often required before surgery, especially if the child is dehydrated as a result of the marked anorexia characteristic of appendicitis.

The operation is usually performed through a right lower quadrant incision (open appendectomy). Laparoscopic surgery is increasingly being used to treat nonperforated acute appendicitis in pediatric patients. Three cannulas are inserted in the abdomen: one in the umbilicus, one in the left lower abdominal quadrant, and one in the suprapubic area. A small telescope is inserted through the left lower quadrant cannula, and an endoscopic stapler is inserted through the umbilical cannula. The appendix is ligated with the stapler and removed through the umbilical cannula. Advantages of laparoscopic appendectomy include reduced time in surgery and under anesthesia and also reduced risk of postoperative wound infection (Bensard, Hendrickson, Fyffe, et al, 2009).

Nursing Care Management

Because successful treatment of appendicitis is based on prompt recognition of the disorder, a primary nursing objective is to assist in establishing a diagnosis. Because abdominal pain is a common childhood complaint, the nurse needs to make some preliminary assessment of the severity of the pain. (See Chapter 7.) One of the most reliable estimates is the degree of change in behavior. A child who stays home from school and voluntarily lies down or refuses to play is much more likely to have considerable pain than a child who is absent from school but plays contentedly at home. The younger, nonverbal child may assume a rigid, side-lying position with the knees flexed and have decreased range of motion of the right hip. For nurses involved in primary ambulatory care, the responsibility of recognizing a possible case of appendicitis and prompt medical or surgical referral is particularly important. The importance of a detailed history and thorough abdominal examination cannot be overemphasized. Palpating the abdomen should be delayed until all other assessments have been made. Instruct the child to point with one finger to the site of the abdominal pain. Rebound tenderness may be present but is not always a sufficiently reliable test in children. Light palpation will satisfactorily elicit pain without causing excessive trauma (see Atraumatic Care box). Chapter 6 discusses other techniques for assessment of the abdomen.

Critical Thinking Exercise—Abdominal Pain

Physical preparation of the child with appendicitis is similar to that for any child undergoing surgery. (See Chapter 27.) In situations in which medical treatment is required to correct problems associated with peritonitis, the nurse must anticipate procedures and set up equipment as quickly as possible to avoid any delay in preparing the child for surgery. Psychologic preparation of the child and parents is similar to that used in other emergency situations. (See Chapter 27.)

Pathophysiology

Bleeding, obstruction, or inflammation causes the symptomatic complications of Meckel diverticulum. Gastric mucosa is the most common ectopic tissue found in a Meckel diverticulum. Bleeding, which is the most common problem in children, is caused by peptic ulceration or perforation because of the unbuffered acidic secretion. Several mechanisms may cause obstruction (Olson, Kim, and Donnelly, 2009). Intussusception may be led by Meckel diverticulum. Obstruction may also be caused by entanglement of the small intestine around a fibrous cord, by trapping of a loop of intestine under the band, by incarceration within a hernia sac, or by volvulus of the intestinal segment containing the diverticulum. Diverticulitis occurs when peptic ulceration or obstruction leads to inflammation.

Clinical Manifestations

Signs and symptoms are based on the specific pathologic process, such as inflammation, bleeding, or intestinal obstruction (Box 33-8). The most common clinical presentation is rectal bleeding caused by ulceration at the junction of the ectopic gastric mucosa and normal ileal mucosa. The bleeding is usually painless and may be dramatic and occur as bright red or currant jelly–like stools, or it may occur intermittently and appear as tarry stools. The bleeding may be significant enough to cause hypotension. Obstruction occurs more often in adults, but volvulus and intussusception are common obstructive symptoms in children with Meckel diverticulum.

Diagnostic Evaluation

Diagnosis is usually based on the history, physical examination, and radiographic studies. Meckel diverticulum is often a diagnostic challenge. Radionucleotide scintigraphy (Meckel scan) is most often used, but is less reliable in the presence of bleeding (Menezes, Tareen, Saeed, et al, 2008). CT scan, wireless capsule endoscopy, and mesenteric angiography may be used to investigate complications of Meckel diverticulum (Thurley, Halliday, Somers, et al, 2009). Laboratory studies are usually part of the general workup to rule out any bleeding disorder and to evaluate the severity of the anemia.

Therapeutic Management

The standard treatment for symptomatic Meckel diverticulum is surgical removal. In instances in which severe hemorrhage increases the surgical risk, medical intervention to correct hypovolemic shock (e.g., blood replacement, IV fluids, and oxygen) may be necessary. In diverticulitis, antibiotics may be used preoperatively to control infection. If intestinal obstruction has occurred, appropriate preoperative measures are used to correct fluid and electrolyte imbalances and prevent abdominal distention.

Nursing Care Management

Nursing objectives are the same as for any child undergoing surgery. (See Chapter 27.) When intestinal bleeding is present, specific preoperative considerations include (1) frequent monitoring of vital signs and blood pressure, (2) keeping the child on bed rest, and (3) recording the approximate amount of blood lost in stools.

Postoperatively the child requires IV fluids and an NG tube for decompression and evacuation of gastric secretions. Because the onset of illness is usually rapid, psychologic support is important, as in other acute conditions, such as appendicitis. It is important to remember that massive rectal bleeding is usually traumatic to both the child and the parents and may significantly affect their emotional reaction to hospitalization and surgery.