Pediatric emergency medicine trisk 1170

FIGURE 135.11 The button: Replacement gastrostomy device Leaking Leaking can occur directly from the lumen of the tube or from the peristomal area Leaking from the stoma often indicates that the stoma has widened and now exceeds the size of the tube Determining whether the leaking substance is formula, pus, or gastric fluid is important in the management If purulent drainage is coming from the stoma, the physician needs to look further for signs of stomal cellulitis or peristomal abscess (see the next section) If formula is leaking from the lumen of the tube, the physician must assess the tube position and check the balloon In the case of a leaking button, problems with valve patency could occur If fluid is leaking from the stoma, the stoma may have become larger than the tube One approach to this problem is removing the tube for a short period, thus allowing constriction of the stoma The stoma may also have become disrupted and therefore requires surgical evaluation Reflux Gastroesophageal reflux may be a complication of G-tube placement An increase in prior reflux disease can occur when a Nissen fundoplication is not performed simultaneously The patient may present with an increase in episodes of vomiting and symptoms of esophageal irritation after G-tube placement Patients in this category may benefit from continuous enteral feedings If continuous feedings are not effective in reducing symptomatic reflux, fundoplication may be indicated Gastric Ulceration Gastric irritation leading to ulceration may occur as a complication of gastrostomy in several scenarios If the tip of the G-tube is too long, it may abrade the opposite surface of the stomach mucosa, resulting in bleeding or traumatic ulceration Similarly, the balloon may accidentally become overinflated and cause friction, especially when the stomach is empty Balloon overdilation can occur if medications or flushes are erroneously administered via the balloon port A patient with gastric ulcer caused by mechanical trauma presents with symptoms similar to other ulcer patients Common symptoms are abdominal pain, irritability, hematemesis, hematochezia, and coffee ground gastric drainage from the G-tube lumen Saline lavage should be performed If the fluid obtained is nonbloody, medications such as H2 -blockers other than ranitidine, antacids, and sucralfate may be administered and upper endoscopy should be scheduled The G-tube should be changed and the patient’s symptoms should be monitored carefully Gastric Outlet Obstruction Gastric outlet obstruction is a rare but serious complication of G-tubes It is usually the result of the migration of the tube tip into the pyloric channel Occasionally, the G-tube can migrate superiorly and block the esophagus In very rare cases, the entire apparatus can migrate distally, resulting in gastric outlet obstruction The child has retching or sudden onset of emesis and appears uncomfortable The G-tube needs to be pulled back to its proper location until it is snug against the abdominal wall If this procedure is not successful, the tube must be removed completely Stomal Complications Irritant Dermatitis/Allergic Hypersensitivity Skin irritation around the stoma may result from chronic leakage of gastric or jejunal fluid around the tube If the stoma widens, the leakage may become excessive, resulting in more significant dermatitis Adhesives and cleansing solutions may result in an allergic rash around the stoma The peristomal skin should be thoroughly cleansed and dried before assessment Small vesicular lesions with surrounding erythema suggest irritant dermatitis Treatment includes keeping the area as dry as possible and using barrier creams to protect the skin from further breakdown Stomahesive Powder (Convatec, Princeton, NJ) is useful for molding to the skin surface and keeping the area dry and free of debris In addition, identifying and treating the cause of the leakage are important If the leakage is caused by an enlarged stoma, surgical intervention may be required in the near future Hypergranulation Tissue Children with G- and J-tubes may develop hypergranulation tissue in the peristomal area, extending beyond the wound bed Although these granulomatous lesions may be harmless, they can be distressing to caregivers There is often drainage associated with the granulation tissue; however, this does not uniformly indicate the presence of infection Hypergranulation tissue may begin to cause occlusion of the stoma and should be treated Treatment options include the application of silver nitrate swabs (though this may be uncomfortable to the patient), triamcinolone cream (0.5%) twice a day, and polyurethane foam dressings Cellulitis When peristomal skin surrounding the G-tube or J-tube is irritated by recurrent or intermittent exposure to drainage or other irritants, cellulitis may occur The infection may begin as superficial skin irritation or contact dermatitis and then evolve into a deeper infection The surrounding peristomal area may become reddened, warm, tender, and edematous These symptoms and signs may occasionally be accompanied by systemic symptoms and fever The patient with a G- or J-tube may become resistant to tube feedings because of the discomfort associated with manipulation of the apparatus Once cellulitis is present, the patient requires systemic antibiotics for resolution of this infection The common organisms, staphylococci and streptococci, usually respond to a first-generation cephalosporin Occasionally, a peristomal abscess, heralded by a localized area of fluctuance, can complicate the cellulitis This abscess requires incision and drainage (generally by a surgeon) Fungal Infection Recurrent moisture caused by gastric or jejunal leakage in the stomal area can predispose the patient to fungal infection The most common causal organism is Candida albicans , appearing as fiery red plaques at the stoma site Topical clotrimazole is curative in most situations Keeping the area as dry as possible is imperative to promote healing GASTROINTESTINAL AND GENITOURINARY DIVERSION Background Pediatric patients may have a GI or genitourinary (GU) diversion for one of many reasons Congenital causes include Hirschsprung disease, imperforate anus, cloacal exstrophy, bladder exstrophy, meningomyelocele with a neurogenic bladder, and posterior urethral valves Acquired lesions may include ulcerative colitis, Crohn disease, and necrotizing enterocolitis Traumatic injuries leading to GI or GU diversion include penetrating wounds and falls GI diversions consist primarily of colostomy and ileostomy A colostomy brings the colon to the skin; these patients usually have semi-formed stools because the absorptive and storage function of the bowel is preserved An ileostomy brings the ileum to the skin Since these patients not possess large bowel function, they consequently have a watery, frequent stooling pattern The major forms of chronic urinary diversions consist of ureterostomy, vesicostomy, pyelostomy, and ileal conduits In addition, there are temporary percutaneous urinary diversions that are maintained with a drainage catheter Ureterostomy brings the dilated ureter to the level of the skin, whereas pyelostomy brings the dilated renal pelvis to the skin In contrast, an ileal conduit implies that the ureters are attached to a short segment of the ileum, which is then externalized A vesicostomy opens the bladder to the skin Nephrostomy or cystostomy is a temporary percutaneous tube into the renal pelvis or bladder, typically placed by the interventional radiologist These temporary diversions are most often used to allow for minimally invasive management of stone disease Urinary undiversion indicates that the patient has undergone a surgical procedure that internalizes the urine passage via a “neobladder” composed of the original bladder and/or a combination of large and small bowel In general, a stomatherapist is crucial to the physicians and families of all patients with stomal sites and appliances However, patients continue to present to the ED with ostomy-related problems, and the emergency physician should become facile with the various types of GI and GU diversions and their specific complications Pathophysiology The nature of the disease and the location of the lesion(s) guide the surgeon when choosing the type of diversion to use An ileostomy is usually performed in newborns for conditions such as meconium ileus, necrotizing enterocolitis, and intestinal atresia It may be required in older children and adolescents because of ulcerative colitis or polyposis The surgical method used depends on the predicted length of time required for the ostomy, as well as the location of the disease Colostomy in infants is required for complications of colonic atresia, high forms of imperforate anus, and Hirschsprung disease The level of the colostomy is related to the disease type and to anticipated future procedures Some of the ostomy complications that occur in patients with GU and GI diversions are similar In both types of diversions, many complications relate to the actual stoma These conditions are discussed in the previous enteral feeding section Other complications are metabolic or mechanical in nature A vesicostomy is usually performed for patients with myelomeningocele, posterior urethral valves, prune belly syndrome, or spinal cord injury resulting in a neurogenic bladder This procedure consists of bringing the dome of the bladder ... possible is imperative to promote healing GASTROINTESTINAL AND GENITOURINARY DIVERSION Background Pediatric patients may have a GI or genitourinary (GU) diversion for one of many reasons Congenital... appliances However, patients continue to present to the ED with ostomy-related problems, and the emergency physician should become facile with the various types of GI and GU diversions and their