Domis-ag, Precious Alpha Hirschsprungs Disease

BSN3-1

Also known as Congenital Aganglionic Megacolon. It is the congenital absence of or arrested development of parasympathetic ganglion cells in the intestinal wall, usually in the distal colon. Symptoms are related to chronic intestinal obstruction and usually appear shortly after birth but may not be recognized until later in childhood or (rarely) in adulthood. The lack of colorectal innervation inhibits peristalsis, and the affected portion of intestine becomes spastic and contracted. The internal rectal sphincter fails to relax, which prevents evacuation of fecal material and gas and causes severe abdominal distention and constipation. The most common site affected is the rectosigmoid colon (short segment disease), and the less common is the upper descending colon and possibly the transverse colon are affected (long segment disease). Occurs in 1:5000 live births 4x more common in male Increases in siblings and offspring of affected children Common in children with down syndrome Accounts for 15%-205 of neonatal intestinal obstruction

INCIDENCE: 1. 2. 3. 4. 5.

Assessment: 1. In the neonate: No meconium passed w/in 24-48hrs of birth Vomiting bile stained or fecal Abdominal distention Constipation occurs in all patients Overflow-type diarrhea Anorexia, poor feeding/ reluctance to feed Temporary relief of symptoms with enema History of constipation at birth Recurrent diarrhea Distention of the abdomen progressive enlarging Thin abdominal wall with observable peristaltic activity Constipation no fecal soiling, relieved temporarily with enema Stool appears ribbon like, fluid like foul smelling, or in pellet form Failure to thrive loss of subcutaneous fat; appears malnourished; perhaps has stunted growth Anemia

2. Infancy and childhood (symptoms not prominent at birth):

COMPLICATIONS 1. Enterocolitis(acute) 2. Leakage at anastomosis 3. Anal strictures

4. Incontinence (long term) Diagnostic Evaluation: 1. Rectal examination demonstrate absence of fecal material in the long segment disease; in short segment disease, rectal impaction may be present and, when the finger is removed, it may cause a rush of stool as the obstruction is temporary relieved. 2. X-rays shows severe gaseous distention of the bowel, with absence of gas in the rectum. 3. Radiopaque markers, when ingested, measure intestinal transit time. Children with short segment disease retain the markers in the rectum for long periods. 4. Barium enema shows narrowed intestine proximal to anus and dilated intestine proximal to narrow segment. 5. Rectal biopsy may be done to demonstrate absent or reduced number of ganglion nerve cells, and confirm diagnosis. 6. Anorectal manometry may be done to record the reflex response to anal sphincter, requires cooperation of the child. 7. Ultrasonogram may be done to demonstrate dilated colon. Therapeutic Interventions: 1. Enema or colonic irrigation with physiologic saline solution. 2. Older child whose symptoms are chronic but not severe may be treated with isotonic enemas, stool softeners, and a low residue diet. Surgical Interventions: 1. Initially, a colostomy or ileostomy is performed to decompress intestine, divert fecal stream, and rest the normal bowel. 2. Definitive surgery is done to remove the non-functioning bowel segment with various pull-through procedures (abdominoperineal, endorectal, or rectorectal). Nursing Interventions: Preoperative 1. Assist in emptying the bowel by giving repeated enemas and colonic irrigations. 2. If abdominal distention is not relieved by enemas, discomfort is significant, and rectal tube insertion fails to give relief, consult doctor for a nasogastric (NG) tube. 3. Offer pacifier for infant to suck if on parenteral fluids. 4. Encourage parents to hold and rock the infant. 5. Maintain position of comfort with head elevated. Offer soothing stimulation (eg. music, touch, play therapy). 6. Offer small frequent feedings. Low residue diet will aid in keeping the stool soft. 7. Administer parenteral nutrition if feeding causes additional discomfort because of distention and nausea. 8. For older child, provide demonstration and written and verbal instruction to family for saline enema administration and use of stool softeners.

Postoperative 1. Change wound dressing using sterile technique. 2. Prevent wound contamination from diaper. 3. Prevent perianal and anal excoriation by thorough cleaning and use of ointments after the infant soils (postoperative stools can number 7 to 10 per day). 4. Use careful handwashing technique. 5. Report any wound redness, swelling or drainage, evisceration, or dehiscence immediately.( signs of infection) 6. Suction oral secretions frequently to prevent infection of the tracheobronchial tree and lungs. 7. In older child, encourage frequent coughing and deep breathing to maintain respiratory status. 8. Allow the infant to cry for a short period to prevent atelectasis. 9. Change position of infant frequently to increase circulation and allow for aeration of all lung areas. 10.Maintain patency of NG tube immediately postoperatively. 11.Maintain NPO status until bowel sounds return and the bowel is ready for feedings as determined by the physician. 12.Provide frequent oral hygiene while on NPO status. 13.Administer fluids to maintain hydration and replace lost electrolytes. Begin oral feedings as ordered. 14.Support the parents when teaching them to care for their childs colostomy. Reassure parents that colostomy will not cause delay in the childs normal development. 15.Involve the entire family in teaching colostomy care to enhance acceptance of body change of the child. NURSING INTERVENTIONS: PREOPERATIVE CARE 1. 2. 3. 4. Monitor nutritional status before surgery Prepare infant and family emotionally Monitor clinical status preop Monitor infants reaction to presurgical preparations

POSTOPERATIVE CARE 1. 2. 3. 4. 5. 6. 7. 8. 9. Monitor and report childs postoperative status Monitor childs hydration status Observe and report signs of complications Promote return of peristalsis Promote and maintain fluid intake and electrolyte balance Alleviate pain Prevent infection Promote skin integrity Provide emotional support