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Course: Pediatric Nursing

Topic: Nursing care of Child with Gastrointestinal Disorder Part III

The Nurses International Community

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Module Goals

Learners will be able to:

Identify common gastrointestinal illnesses of childhood including signs and symptoms (Hirschsprung Disease, Short Bowel Syndrome, Irritable Bowel Syndrome (IBS)
Identify risk factors associated with these above disorders
Describe common diagnostic procedures for these gastrointestinal disorders and nursing implications
Explain common medical treatments for children with above gastrointestinal disorders and nursing implications
Discuss the nursing management of a child with these above disorders

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Hirschsprung Disease

Hirschsprung disease is a birth defect in which some nerve cells are missing in the large intestine, preventing stool from moving normally and causing a blockage

Cause:

Still a grey area: Studies are still being carried out, genes may play a role

Risk factors:

May occur in children of any race or ethnicity
More common in boys
Genetic carrier

(NIDDK, 2021)

Contact info: info@nursesinternational.org

Cause:

Hirschsprung disease occurs when nerve cells in the intestines don’t develop normally before an infant is born. Experts are still studying factors that may cause problems with how these nerve cells grow. Certain genes increase the chance that a child will have Hirschsprung disease. Experts think that several different genes may play a role.

Risk Factors

Hirschsprung disease is more likely to affect

boys. Hirschsprung disease is about 3 to 4 times more common in boys than in girls.
children who have a sibling or parent with Hirschsprung disease.
infants and young children. Hirschsprung disease is present at birth. Some children develop signs and symptoms and are diagnosed shortly after birth. However, others may develop symptoms and be diagnosed later in infancy or early childhood. About half of all children with Hirschsprung disease are diagnosed in the first year of life.About 80% are diagnosed by age 7.

Hirschsprung disease may occur in children of any race or ethnicity

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Hirschsprung Disease: Diagnosis

Diagnosis:

Medical history and family history
Physical examination
Imaging: Lower GI series
Anorectal Manometry: Inflates a small balloon to check the muscles in the rectum
Rectal biopsy: Tests a piece of tissue from rectum to confirm or rule out disease

(NIDDK, 2021)

Contact info: info@nursesinternational.org

Medical and family history

To diagnose Hirschsprung disease, a doctor will start by asking about the child’s medical and family history. The doctor will also ask about the child’s symptoms and when the symptoms began.

Physical exam

During a physical exam, a doctor typically

Reviews the child’s height and weight
Examines the child’s abdomen—or belly—for swelling
Performs a digital rectal exam—having no stool in the rectum or having explosive stool after a rectal exam may be signs of Hirschsprung disease

Doctors use a combination of imaging tests, anorectal manometry, and rectal biopsies to diagnose Hirschsprung disease.

Imaging tests

To check for signs of Hirschsprung disease, doctors may use imaging tests such as lower GI series, or contrast enema, which uses x-rays and barium or water-soluble contrast medium to view the large intestine.

Anorectal manometry

Anorectal manometry is a test that checks how well the child’s rectum is working. During the procedure, the doctor inflates a small balloon inside the child’s rectum. Normally, the muscles in the rectum will relax. If the muscles don’t relax, the doctor may suspect the child has Hirschsprung disease.

Rectal biopsy

Doctors typically use rectal biopsies to confirm or rule out a diagnosis of Hirschsprung disease. During a rectal biopsy procedure, a doctor will take small pieces of tissue from the rectum. A pathologist will examine the tissue under a microscope to look for signs of Hirschsprung disease.

Two types of rectal biopsy are

Rectal suction biopsy, in which a doctor inserts a small instrument into a child’s anus to take small pieces of tissue from the lining of the rectum
Full thickness rectal biopsy, in which a doctor performs surgery to remove a thicker piece of tissue from the rectum

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Hirschsprung Disease: Signs and Symptoms

Signs and Symptoms may vary with the age of the child

In newborns:

No bowel movement within 48 hours after birth
Green or brown emesis
Swollen abdomen
Feeding problems
Explosive stools or diarrhea after a finger is inserted into the newborn’s rectum

(NIDDK, 2021)

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Hirschsprung Disease: Signs and Symptoms

In older infants and children

Chronic constipation that doesn’t improve after treatment with oral laxatives
Swollen abdomen
Malnutrition or failure to thrive
Symptoms of Hirschsprung-associated enterocolitis, such as diarrhea

(NIDDK, 2021)

Contact info: info@nursesinternational.org

Symptoms in older infants, children, and adults

Children with Hirschsprung disease who don’t have signs and symptoms of intestinal obstruction at birth may not be diagnosed and treated until they are older. Common symptoms in older infants and children include

Chronic constipation that doesn’t get better after treatment with oral laxatives—laxatives that are taken by mouth
Swollen abdomen
Malnutrition or failure to thrive, meaning that an infant or child weighs less or is gaining less weight than expected for his or her age
Symptoms of Hirschsprung-associated enterocolitis, such as diarrhea

In older infants and children, symptoms of Hirschsprung disease, such as constipation, may be similar to symptoms of other conditions. Therefore, doctors may not suspect and diagnose Hirschsprung disease right away.

In rare cases, Hirschsprung isn’t diagnosed and treated until adulthood. Adults with Hirschsprung disease typically have a history of abdominal swelling and chronic constipation that doesn’t get better after taking oral laxatives.

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Hirschsprung Disease: Treatment and Management

Typically treated with surgery

Pull-through procedure to remove the part of intestine where nerve is missing
Ostomy Surgery

(NIDDK, 2021)

Contact info: info@nursesinternational.org

Typically treated with a type of surgery called a pull-through procedure. In some cases, ostomy surgery of the bowel followed by a pull-through procedure.

Pull-through procedure

During a pull-through procedure, a surgeon removes the part of the large intestine that is missing nerve cells. The surgeon then connects the healthy part of the large intestine to the anus.

Surgeons may perform the pull-through procedure as either laparoscopic or open surgery. During laparoscopic surgery, surgeons make small cuts in the abdomen and insert a laparoscope and tools to perform the operation. For open surgery, surgeons make a larger cut to open the abdomen. In some cases, surgeons may perform the pull-through procedure by inserting tools through the anus instead of making cuts in the abdomen.

Ostomy surgery

Doctors may recommend that children have ostomy surgery before having a pull-through procedure, in some cases. For example, children may need ostomy surgery if they have complications, such as severe Hirschsprung-associated enterocolitis, megacolon, or perforation. Ostomy surgery allows a child’s health to improve and intestine to heal before pull-through surgery. A child may also need ostomy surgery if the entire large intestine is affected by Hirschsprung disease.

During ostomy surgery, surgeons create a stoma on a child’s abdomen and connect the stoma to the large or small intestine. After ostomy surgery, waste will leave the child’s body through the stoma.

The stoma is usually temporary. In most cases, surgeons can later close the stoma and connect the healthy part of the intestine to the anus. Waste will move through the intestines, and stool will pass through the anus again.

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Hirschsprung Disease: Nurses’ Role

Promote skin integrity
Promote optimal comfort
Assess and manage pain
Maintain fluid balance
Ensure adequate nutrition: insert NG if indicated
Provide general hygiene
Support child, parents or caregivers
Relieve anxiety
Provide family teaching regarding disease, postoperative care

Contact info: info@nursesinternational.org

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Critical Thinking Question

A nurse discovers that a newborn has not passed stool within 48 hours of the birth.

What additional findings would indicate the infant may have Hirschsprung Disease?

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Short Bowel Syndrome

A group of problems related to poor absorption of nutrients, typically occurs in people who have:

Had at least half or whole of their small intestine removed
Significant damage to the small intestine
Poor intestinal motility, or movement

May be mild, moderate, or severe
Children with short bowel syndrome cannot absorb enough water, vitamins, minerals, protein, fat, calories, and other nutrients

(NIDDK, 2015; Guillen & Atherton, 2021)

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Short Bowel Syndrome: Causes

Born with an abnormally short small intestine or with part of their bowel missing
In infants, occurs following surgery to treat necrotizing enterocolitis
May also occur following surgery to treat conditions such as: cancer, crohn's disease, gastroschisis, internal hernia, intestinal atresia, intestinal injury

(NIDDK, 2015; Guillen & Atherton, 2021)

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Causes Short Bowel Syndrome

The main cause of short bowel syndrome is surgery to remove a portion of the small intestine. This surgery can treat intestinal diseases, injuries, or birth defects.

Some children are born with an abnormally short small intestine or with part of their bowel missing, which can cause short bowel syndrome. In infants, short bowel syndrome most commonly occurs following surgery to treat necrotizing enterocolitis, a condition in which part of the tissue in the intestines is destroyed.

Short bowel syndrome may also occur following surgery to treat conditions such as

Cancer and damage to the intestines caused by cancer treatment
Crohn's disease, a disorder that causes inflammation, or swelling, and irritation of any part of the digestive tract
Gastroschisis, which occurs when the intestines stick out of the body through one side of the umbilical cord
Internal hernia, which occurs when the small intestine is displaced into pockets in the abdominal lining
Intestinal atresia, which occurs when a part of the intestines doesn't form completely
Intestinal injury from loss of blood flow due to a blocked blood vessel
Intestinal injury from trauma
Intussusception, in which one section of either the large or small intestine folds into itself, much like a collapsible telescope
Meconium ileus, which occurs when the meconium, a newborn's first stool, is thicker and stickier than normal and blocks the ileum
Midgut volvulus, which occurs when blood supply to the middle of the small intestine is completely cut off
Omphalocele, which occurs when the intestines, liver, or other organs stick out through the navel, or belly button

Even if an individual does not have surgery, disease or injury can damage the small intestine.

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Short Bowel Syndrome: Diagnosis

Short bowel syndrome diagnosis based on:

Medical and family history
Physical exam
Blood tests
Fecal fat tests
An x-ray of the small and large intestines
Upper gastrointestinal (GI) series
Computerized tomography (CT) scan

(NIDDK, 2015; Guillen & Atherton, 2021)

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How is Short Bowel Syndrome diagnosed?

Short bowel syndrome diagnosis based on

A medical and family history
A physical exam
Blood tests
Fecal fat tests
An x-ray of the small and large intestines
Upper gastrointestinal (GI) series
Computerized tomography (CT) scan

Medical and Family History

Taking a medical and family history may help a health care provider diagnose short bowel syndrome. He or she will ask the patient about symptoms and may request a history of past operations.

Physical Exam

A physical exam may help diagnose short bowel syndrome. During a physical exam, a health care provider usually

examines a patient's body, looking for muscle wasting or weight loss and signs of vitamin and mineral deficiencies
uses a stethoscope to listen to sounds in the abdomen
taps on specific areas of the patient's body

Blood Tests

A blood test involves drawing a patient's blood at a health care provider's office or a commercial facility and sending the sample to a lab for analysis. Blood tests can show mineral and vitamin levels and measure complete blood count.

Fecal Fat Tests

A fecal fat test measures the body's ability to break down and absorb fat. For this test, a patient provides a stool sample at a health care provider's office. The patient may also use a take-home test kit. The patient collects stool in plastic wrap that he or she lays over the toilet seat and places a sample into a container. A patient can also use a special tissue provided by the health care provider's office to collect the sample and place the tissue into the container. For children wearing diapers, the parent or caretaker can line the diaper with plastic to collect the stool. The health care provider will send the sample to a lab for analysis. A fecal fat test can show how well the small intestine is working.

X-ray

An x-ray is a picture created by using radiation and recorded on film or on a computer. The amount of radiation used is small. An x-ray technician performs the x-ray at a hospital or an outpatient center, and a radiologist—a doctor who specializes in medical imaging—interprets the images. An x-ray of the small intestine can show that the last segment of the large intestine is narrower than normal. Blocked stool causes the part of the intestine just before this narrow segment to stretch and bulge.

Upper Gastrointestinal Series

Upper GI series, also called a barium swallow, uses x rays and fluoroscopy to help diagnose problems of the upper GI tract. Fluoroscopy is a form of x ray that makes it possible to see the internal organs and their motion on a video monitor. An x-ray technician performs this test at a hospital or an outpatient center, and a radiologist interprets the images.

During the procedure, the patient will stand or sit in front of an x-ray machine and drink barium, a chalky liquid. Barium coats the esophagus, stomach, and small intestine so the radiologist and a health care provider can see the shape of these organs more clearly on x-rays.

A patient may experience bloating and nausea for a short time after the test. For several days afterward, barium liquid in the GI tract causes white or light-colored stools. A health care provider will give the patient specific instructions about eating and drinking after the test. Upper GI series can show narrowing and widening of the small and large intestines.

Computerized Tomography Scan

Computerized tomography scans use a combination of x-rays and computer technology to create images. For a CT scan, a health care provider may give the patient a solution to drink and an injection of a special dye, called a contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device that takes x-rays.

An x-ray technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia. CT scans can show bowel obstruction and changes in the intestines.

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Short Bowel Syndrome: Signs and Symptoms

The main symptom of short bowel syndrome is diarrhea

Other signs and symptoms may include:

Bloating
Cramping
Fatigue, or feeling tired
Foul-smelling stool
Heartburn
Too much gas
Vomiting
Weakness

(NIDDK, 2015; Guillen & Atherton, 2021)

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What are the signs and symptoms of Short Bowel Syndrome?

The main symptom of short bowel syndrome is diarrhea—loose, watery stools. Diarrhea can lead to dehydration, malnutrition, and weight loss. Dehydration means the body lacks enough fluid and electrolytes—chemicals in salts, including sodium, potassium, and chloride—to work properly. Malnutrition is a condition that develops when the body does not get the right amount of vitamins, minerals, and nutrients it needs to maintain healthy tissues and organ function. Loose stools contain more fluid and electrolytes than solid stools. These problems can be severe and can be life threatening without proper treatment.

Other signs and symptoms may include

Bloating
Cramping
Fatigue, or feeling tired
Foul-smelling stool
Heartburn
Too much gas
Vomiting
Weakness

People with short bowel syndrome are also more likely to develop food allergies and sensitivities, such as lactose intolerance. Lactose intolerance is a condition in which people have digestive symptoms—such as bloating, diarrhea, and gas—after eating or drinking milk or milk products.

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Short Bowel Syndrome: Treatment and Management

Treatment based on a patient's nutritional needs.

May include:

Nutritional support: Oral hydration, parenteral or enteral nutrition
Medications: Antibiotics, H2 blockers, proton pump inhibitors
Surgery:
Intestinal transplant: Diseases intestine is replaced by healthy small intestine

(NIDDK, 2015; Guillen & Atherton, 2021)

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How is Short Bowel Syndrome treated?

A health care provider will recommend treatment for short bowel syndrome based on a patient's nutritional needs. Treatment may include

Nutritional support
Medications
Surgery
Intestinal transplant

Nutritional Support

The main treatment for short bowel syndrome is nutritional support, which may include the following:

Oral rehydration. Adults should drink water, sports drinks, sodas without caffeine, and salty broths. Children should drink oral rehydration solutions—special drinks that contain salts and minerals to prevent dehydration—such as Pedialyte, Naturalyte, Infalyte, and CeraLyte, which are sold in most grocery stores and drugstores.
Parenteral nutrition. This treatment delivers fluids, electrolytes, and liquid vitamins and minerals into the bloodstream through an intravenous (IV) tube—a tube placed into a vein. Health care providers give parenteral nutrition to people who cannot or should not get their nutrition or enough fluids through eating.
Enteral nutrition. This treatment delivers liquid food to the stomach or small intestine through a feeding tube—a small, soft, plastic tube placed through the nose or mouth into the stomach. Gallstones—small, pebble like substances that develop in the gallbladder—are a complication of enteral nutrition.
Vitamin and mineral supplements. Ann individual may need to take vitamin and mineral supplements during or after parenteral or enteral nutrition.
Special diet. A health care provider can recommend a specific diet plan for the patient that may include

small, frequent feedings
avoiding foods that can cause diarrhea, such as foods high in sugar, protein, and fiber
avoiding high-fat foods

Medications

A health care provider may prescribe medications to treat short bowel syndrome, including

Antibiotics to prevent bacterial overgrowth
H2 blockers to treat too much gastric acid secretion
Proton pump inhibitors to treat too much gastric acid secretion
Choleretic agents to improve bile flow and prevent liver disease
Bile-salt binders to decrease diarrhea
Anti-secretin agents to reduce gastric acid in the intestine
Hypomotility agents to increase the time it takes food to travel through the intestines, leading to increased nutrient absorption
Growth hormones to improve intestinal absorption
Teduglutide to improve intestinal absorption

Surgery

The goal of surgery is to increase the small intestine's ability to absorb nutrients. Approximately half of the patients with short bowel syndrome need surgery. Surgery used to treat short bowel syndrome includes procedures that:

Prevent blockage and preserve the length of the small intestine
Narrow any dilated segment of the small intestine
Slow the time it takes for food to travel through the small intestine
Lengthen the small intestine

Long-term treatment and recovery, which for some may take years, depend in part on

What sections of the small intestine were removed
How much of the intestine is damaged
How well the muscles of the intestine work
How well the remaining small intestine adapts over time

Intestinal Transplant

An intestinal transplant is surgery to remove a diseased or an injured small intestine and replace it with a healthy small intestine from an individual who has just died, called a donor. Sometimes a living donor can provide a segment of his or her small intestine.

A health care provider will tailor treatment to the severity of the patient's disease:

Treatment for mild short bowel syndrome involves eating small, frequent meals; drinking fluid; taking nutritional supplements; and using medications to treat diarrhea.
Treatment for moderate short bowel syndrome is similar to that for mild short bowel syndrome, with the addition of parenteral nutrition as needed.
Treatment for severe short bowel syndrome involves use of parenteral nutrition and oral rehydration solutions. Patients may receive enteral nutrition or continue normal eating, even though most of the nutrients are not absorbed. Both enteral nutrition and normal eating stimulate the remaining intestine to work better and may allow patients to discontinue parenteral nutrition. Some patients with severe short bowel syndrome require parenteral nutrition indefinitely or surgery.

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Short Bowel Syndrome: Nurses’ Role

Encourage small, frequent meals
Medications to treat diarrhea
Promote skin integrity
Promote optimal comfort, assess and manage pain
Maintain fluid balance
Ensure adequate nutrition: Insert NG if indicated
Provide general hygiene
Support child, parents or caregiver, relieve anxiety
Provide family teaching regarding disease, postoperative care

Contact info: info@nursesinternational.org

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Case Study

A child is recently diagnosed with short bowel syndrome (congenital).

He is having diarrhea and his parents say that the child has lost weight.

They are anxious and ask about their child’s prognosis.

How would the nurse respond to these parents?

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Irritable Bowel Syndrome (IBS)

Regarded as a functional GI disorder
The child has these symptoms without any visible signs of damage or disease in the digestive tract
In the past, IBS has been called colitis, mucous colitis, spastic colon, nervous colon, and spastic bowel

(NIDDK, 2019)

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Irritable Bowel Syndrome: Types

IBS with constipation (IBS-C)
IBS with diarrhea (IBS-D)
IBS with mixed bowel habits (IBS-M)
IBS unsubtyped (IBS-U)

(NIDDK, 2019)

Contact info: info@nursesinternational.org

Are there different types of IBS in children?

Experts have defined four types of IBS in children. Each type has a different pattern of changes in bowel movements or abnormal bowel movements. Knowing which type of IBS a child has may help the doctor treat IBS symptoms.

IBS with constipation (IBS-C)

In IBS-C, more than a quarter of stools are hard or lumpy, and less than a quarter of stools are loose or watery.

IBS with diarrhea (IBS-D)

In IBS-D, more than a quarter of stools are loose or watery, and less than a quarter of stools are hard or lumpy.

IBS with mixed bowel habits (IBS-M)

In IBS-M, more than a quarter of stools are hard or lumpy, and more than a quarter of stools are loose or watery.

IBS unsubtyped (IBS-U)

In IBS-U, less than a quarter of stools are hard or lumpy, and less than a quarter of stools are loose or watery.

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Irritable Bowel Syndrome: Causes

Exact cause is unknown
May be due to:

A more sensitive colon
Problems with how food moves through the digestive system
Stress or inflammation
Child abuse
Change in microbiome in the digestive tract

(NIDDK, 2019)

Contact info: info@nursesinternational.org

Doctors aren’t sure what causes IBS in children. Experts think that a combination of problems may lead to IBS. Different factors may cause IBS in different children.

Functional gastrointestinal (GI) disorders such as IBS are problems with brain-gut interaction—how the brain and gut work together. Experts think that problems with brain-gut interaction may affect how the body works and cause IBS symptoms. For example, some children with IBS may feel pain when a normal amount of gas or stool is in their gut. In some children with IBS, food may move too slowly through the digestive tract.

Certain problems —such as bacterial infections in the digestive tract, emotional and mental health problems, early life events that cause stress or inflammation and child abuse—are more common in children with IBS. Experts think these problems may play a role in causing IBS. Changes in the microbiome—the bacteria in the digestive tract that help with digestion—may also play a role.

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Irritable Bowel Syndrome: Risk Factors

History of:

Bacterial infections in the digestive tract
Certain emotional or mental health problems (stress, depression, and anxiety)
Events during infancy or early childhood that cause pain or inflammation such as allergies, infections, or surgery
Child abuse
Family members with IBS

(NIDDK, 2019)

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Irritable Bowel Syndrome: Diagnosis

Blood tests
Urinalysis and culture
Stool sample
Stool samples for occult blood
Lactose breath hydrogen test
Abdominal X-ray
Abdominal ultrasound
Endoscopy

(NIDDK, 2019; Cedars-Sinai, n.d.)

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Irritable Bowel Syndrome: Signs and Symptoms

The symptoms may come and go:

Pain in the abdomen, often related to bowel movements
Changes in bowel movements (diarrhea, constipation, or both, depending on which type of IBS a child has)

Other symptoms:

The feeling that they haven’t finished a bowel movement
Mucus in stool
Bloating

(NIDDK, 2019)

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Irritable Bowel Syndrome: Treatment and Management

Changes in diet
Mental health therapies: Cognitive behaviour therapy, hypnosis
Probiotics: Live microorganisms, most often bacteria, that may be similar to microorganisms in the digestive tract
Medications: Antidepressants, Antispasmodics, fiber supplements

(NIDDK, 2019)

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Irritable Bowel Syndrome: Nurses’ Role

Encourage small, frequent meals
Administer medications
Promote skin integrity
Promote optimal comfort, assess and manage pain
Maintain fluid balance
Ensure adequate nutrition and hydration (6-8 glasses of water daily)
Support child, parents or caregiver, address anxiety
Provide family teaching regarding disease, balance diet, foods to avoid
Encourage activity and exercise

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which of the following group of people are at the risk of developing irritable bowel syndrome? (Select all that apply)

Those with change in microbiome in digestive tract
Those with allergies, infections that cause pain in infancy or early childhood
Child abuse
Emotional and mental health issues

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Celiac Disease

A chronic digestive and immune disorder that damages the small intestine
Also called celiac sprue, nontropical sprue, and gluten-sensitive enteropathy
May be serious and cause long-lasting digestive problems preventing absorption of essential nutrients
May also affect areas outside small intestine
Triggered by eating foods containing gluten

(NIDDK, 2020; NHS, 2019)

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Celiac Disease: Causes

Genes: Developed in people with no normal gene variants (DQ2 and DQ8)

Gluten: Consuming gluten, early exposure to gluten

Other Factors: Certain digestive tract infections, exposure to higher number of infections early in life, change in microbiome in digestive tract

(NIDDK, 2020; NHS, 2019)

Contact info: info@nursesinternational.org

Research suggests that celiac disease only occurs in people who have certain genes and eat food that contains gluten. Experts are studying other factors that may play a role in causing the disease.

Genes

Celiac disease almost always occurs in people who have one of two groups of normal gene variants, called DQ2 and DQ8. People who do not have these gene variants are very unlikely to develop celiac disease. About 30 percent of people have DQ2 or DQ8. However, only about 3 percent of people with DQ2 or DQ8 develop celiac disease.

Researchers are studying other genes that may increase the chance of developing celiac disease in people who have DQ2 or DQ8.

Gluten

Consuming gluten triggers the abnormal immune system response that causes celiac disease. However, not all people who have the gene variants DQ2 or DQ8 and eat gluten develop the disease. Research suggests that among children with a genetic predisposition for celiac disease, those who eat more gluten in early childhood may have a greater risk for celiac disease.

Other factors

Researchers are studying other factors that may increase an individual’s chances of developing celiac disease. For example, research suggest that a higher number of infections in early life and certain digestive tract infections may increase the risk. Experts also think changes in the microbiome—the bacteria in the digestive tract that help with digestion—could play a role in the development of celiac disease.

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Celiac Disease: Risk Factors

Genetic predisposition
More common with white Americans
More common in females
More common in people with chromosomal disorders like Down Syndrome, Turner Syndrome, thyroid condition, ulcerative colitis

(NIDDK, 2020; NHS, 2019)

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Celiac Disease: Diagnosis

Physical exam: Weight and growth problems, rashes on skin, abdominal sound
Blood tests: Anemia
Biopsies of the small intestine.
Skin biopsies: Dermatitis herpetiformis
Genetic testing: Gene variants called DQ2 and DQ8

(NIDDK, 2020; NHS, 2019)

Contact info: info@nursesinternational.org

The doctor will review the medical history, including history of conditions that are more common in people who have celiac disease. The doctor will also ask about about family’s medical history and whether anyone in the family has been diagnosed with celiac disease.

Physical exam

During a physical exam, a doctor may

Check for signs of weight loss or growth problems
Examine the skin for rashes, such as dermatitis herpetiformis
Listen to sounds in the abdomen using a stethoscope
Tap on the abdomen to check for pain or swelling

In some cases, a dentist may notice signs of celiac disease during an exam. Celiac disease may cause problems with the teeth and mouth, such as defects in tooth enamel or canker sores.

Blood tests

A health care professional will take a blood sample from the child and send the sample to a lab. Blood tests can show levels of certain antibodies that are often higher than normal in people who have untreated celiac disease. Blood tests may also show signs of health problems that could be related to celiac disease, such as anemia.

Biopsies of the small intestine

A doctor obtains biopsies of the small intestine during an upper GI endoscopy. For an upper GI endoscopy, a doctor uses an endoscope—a flexible tube with a camera—to see the lining of the upper GI tract, including the first part of the small intestine. The doctor passes an instrument through the endoscope to take small pieces of tissue from the small intestine. A pathologist will examine the tissue under a microscope to look for signs of celiac disease.

Skin biopsies

A doctor may order skin biopsies if a child has a rash that could be dermatitis herpetiformis. For skin biopsies, a doctor removes small pieces of skin tissue on and next to the rash. A pathologist will examine the tissue under a microscope to look for signs of dermatitis herpetiformis.

Genetic testing

In some cases, a healthcare professional may take a blood sample or use a swab to collect cells from the inside of the cheek. The sample will be tested for groups of gene variants called DQ2 and DQ8. If they do not have these gene variants, they are very unlikely to have celiac disease.

Having DQ2 or DQ8 alone does not mean a child has celiac disease. Most people with these gene variants do not develop celiac disease. If a child does have DQ2 or DQ8, the doctor may recommend additional tests to check for or rule out celiac disease.

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Celiac Disease: Signs and Symptoms

Vary widely, may come and go
Digestive problems are more common in children

Digestive Symptoms:

Pain in the stomach
Bloating, gas
Chronic diarrhea or Constipation; Loose, greasy, bulky, and foul-smelling stool
Lactose intolerance
Nausea or vomiting

(NIDDK, 2020; NHS, 2019)

Contact info: info@nursesinternational.org

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Celiac Disease: Signs and Symptoms (Continued)

Due to lack of nutritional absorption:

Damage to the permanent teeth enamel
Delayed puberty
Failure to thrive
Mood swings
Slowed growth and short height
Weight loss

(NIDDK, 2020; NHS, 2019)

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Celiac Disease: Signs and Symptoms (Continued)

Symptoms may affect other parts of the body:

Dermatitis herpetiformis
Fatigue, or feeling tired
Joint or bone pain
Mental health, nervous system and reproductive problems
Symptoms involving the mouth

(NIDDK, 2020; NHS, 2019)

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Some people with celiac disease have symptoms that affect other parts of the body. These symptoms may include

Dermatitis herpetiformis
Fatigue, or feeling tired
Joint or bone pain
Mental health problems, such as depression or anxiety
Nervous system symptoms, such as headaches, balance problems, seizures, or peripheral neuropathy
Reproductive problems in women and girls—which may include infertility, delayed start of menstrual periods , missed menstrual periods, or repeated miscarriages—and male infertility
Symptoms involving the mouth, such as canker sores; a dry mouth; or a red, smooth, shiny tongue

Most people with celiac disease have one or more symptoms before they are diagnosed and begin treatment. Symptoms typically improve and may go away after an individual begins eating a gluten-free diet. Symptoms may return if an individual consumes small amounts of gluten.

Depending on how old a child is when a doctor diagnoses their celiac disease, some symptoms, such as short height and tooth defects, may not improve. People with celiac disease who have no symptoms can still develop complications over time if they do not get treatment.

Dermatitis herpetiformis

Dermatitis herpetiformis is an itchy, blistering skin rash that usually appears on the elbows, knees, buttocks, back, or scalp. Among people with untreated celiac disease, about 2 to 3 percent of children and 10 to 20 percent of adults have dermatitis herpetiformis. Some people with celiac disease may have the rash and no other symptoms. After an individual starts a gluten-free diet, the rash may take some time to heal and may return if an individual consumes small amounts of gluten.

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Celiac Disease: Treatment and Management

Celiac disease is usually treated by excluding foods that contain gluten from the diet
Dietician to address gluten free diet

(dairy products, fruits and vegetables, meat, fish, potatoes)

Receive preventive vaccinations (flu, pneumococcal)
Supplement with vitamins and minerals

(NHS, 2019)

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A gluten-free diet

Contains all the nutrients an individual needs. When a child is first diagnosed with celiac disease, they'll be referred to a dietician to help them adjust to their new diet without gluten. Dietician can also ensure the children’s diet is balanced.

If children have celiac disease, they'll no longer be able to eat foods that contain any barley, rye or wheat, including farina, semolina, durum, couscous and spelt.

Even if they only eat a small amount of gluten, such as a spoonful of pasta, they may have very unpleasant intestinal symptoms. If they keep eating gluten regularly, they'll also be at greater risk of developing complications, such as osteoporosis and some types of cancer in later life.

Gluten is not essential in a child’s diet and it can be replaced by other foods. There are many gluten-free versions of common foods such as pasta, pizza bases and bread available in supermarkets and health food shops. Some GPs may provide bread and bread mixes on prescription.

Many foods, such as meat, vegetables, cheese, potatoes and rice, are naturally free from gluten so those foods can still be included in the diet. A dietitian can help identify which foods are safe to eat and which are not. If unsure, following lists can be used as a general guide.

Foods containing gluten (not safe to eat)

If celiac disease, do not eat the following foods, unless they're labelled as gluten-free versions:

Bread
Pasta
Cereals
Biscuits or crackers
Cakes and pastries
Pies
Gravies and sauces

It's important to always check the labels on the foods before buying. Many foods (particularly processed foods) include additives which contain gluten, such as malt flavouring and modified food starch.

Gluten may also be found in some non-food products, including lipstick, postage stamps and some medicines.

Cross-contamination can happen if gluten-free foods and foods that contain gluten are prepared together or served with the same utensils.

Gluten-free foods (safe to eat)

Most dairy products, such as cheese, butter and milk
Fruits and vegetables
Meat and fish (although not breaded or battered)
Potatoes
Rice and rice noodles
Gluten-free flours, including rice, corn, soy and potato flour

By law, food labelled as gluten-free can contain no more than 20 parts per million (ppm) of gluten.

For most people with celiac disease, these trace amounts of gluten will not cause a problem. However, a small number of people are unable to tolerate even trace amounts of gluten and need to have a diet completely free from cereals.

Oats

Oats do not contain gluten, but many people with celiac disease avoid eating them because they can become contaminated with other cereals that contain gluten.

There's also some evidence to suggest that a very small number of people may still be sensitive to products that are gluten-free and do not contain contaminated oats. This is because oats contain a protein called avenin, which is suitable for most people with coeliac disease but may trigger symptoms in a few people.

If, after discussing this with the healthcare professional, oats can be included in the diet, check the oats are pure and that there's no possibility of contamination with gluten.

One should avoid eating oats until their gluten-free diet has taken full effect and their symptoms have been resolved. Once they're free of symptoms, gradually reintroduce oats into their diet. If they develop symptoms again, stop eating oats.

Vaccinations

In some people, celiac disease can cause the spleen to work less effectively, making them more vulnerable to infection.

They may therefore need to have extra vaccinations, including:

Flu jab
Hib/MenC vaccine, which protects against sepsis (blood poisoning), pneumonia and meningitis (an infection of the lining of the brain)
pneumococcal vaccine, which protects against infections caused by the Streptococcus pneumoniae bacterium

However, if the spleen is unaffected by celiac disease, these vaccinations are not usually necessary.

Supplements

As well as cutting gluten out of the diet, a GP or dietitian may also recommend taking vitamin and mineral supplements, at least for the first 6 months after diagnosis.

This will ensure children get all the nutrients they need while their digestive system repairs itself. Taking supplements can also help correct any deficiencies, such as iron deficiency anaemia.

Dermatitis herpetiformis

If a child has dermatitis herpetiformis (an itchy rash that can be caused by gluten intolerance), cutting gluten out of their diet should help.

However, it can sometimes take longer for a gluten-free diet to clear the rash than it does to control their other symptoms, such as diarrhea and stomach pain.

If this is the case, they may be prescribed medicine to speed up the healing of the rash. It's likely that this will be a medicine called dapsone, which usually comes as a tablet and can be taken twice a day.

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Celiac Disease: Nurses’ Role

Refer client to the dietician
Monitor adequate nutrition and hydration status
Education: Select the gluten free foods, recipes
Administer the medications as needed
Administer the supplements (vitamins and minerals)
Monitor intake, output, and bowel movement

(NIDDK, 2020; NHS, 2019)

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Case Study

Celiac disease is a chronic digestive and immune disorder that damages the small intestine.

What kind of foods would trigger the disease and aggravate the symptoms?

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Red Flags

Green or brown vomit
Dermatitis herpetiformis
Delayed puberty
Failure to thrive

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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Cultural Considerations: Examples

Children with Hispanic and African-American backgrounds have a higher risk of developing Peptic Ulcer Disease
IBS, bloating, constipation, chronic functional abdominal pain, and pelvic floor dysfunction, are more prevalent in women than men

(Chuah & Mahadeva, 2018)

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References:

Cedars-Sinai. (n.d.). Irritable Bowel Syndrome (IBS) in Children. https://www.cedars-sinai.org/health-library/diseases-and-conditions---pediatrics/i/irritable-bowel-syndrome-ibs-in-children.html

Chuah, K. H., & Mahadeva, S. (2018). Cultural Factors Influencing Functional Gastrointestinal Disorders in the East. Journal of neurogastroenterology and motility, 24(4), 536–543. https://doi.org/10.5056/jnm18064

Guillen, B., Atherton, N. S. (2021 July 21). Short Bowel Syndrome. StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK536935/

NHS. (2019, Dec 3). Overview: Coeliac Disease. https://www.nhs.uk/conditions/coeliac-disease/

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References:

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2020, Oct). Digestive Disorders: Celiac Disease. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/all-content

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2015, Jul). Digestive Disorders: Short Bowel Syndrome. https://www.niddk.nih.gov/health-information/digestive-diseases/short-bowel-syndrome

Contact info: info@nursesinternational.org

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References:

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2019, November). Digestive Disorders: Irritable Bowel Syndrome in Children. https://www.niddk.nih.gov/health-information/digestive-diseases/irritable-bowel-syndrome-children/diagnosis

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2021, September). Digestive Disorders: Hirschsprung Disease. https://www.niddk.nih.gov/health-information/digestive-diseases/hirschsprung-disease

Contact info: info@nursesinternational.org

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