CHAPTER VI DISEASES OF THE DIGESTIVE TRACT
(Continued)
Diseases of the Esophagus
The esophagus is rarely involved in inflammatory processes. The only condition of importance to a nurse is corrosive esophagitis and stricture.
Corrosion of the Esophagus. — This is almost always due to the swallowing of strong acids or alkalies. It causes intense pain and burning in the esophagus and swallowing is very painful.
Stricture is a secondary result of corrosion. The healing ulcer causes a narrowing of the alimentary canal at its location, and this interferes with swallowing.
Symptoms. — A slowly increasing difficulty in deglutition, with regurgitation of food. The esophagus is often much dilated above the stricture, and the food may collect in the pouch thus formed, so that regurgitation may be delayed for several hours. There is much loss of flesh. In bad cases of stricture it is necessary to place the child upon a liquid diet.
Diseases of the Stomach In infancy we rarely find the stomach involved alone,
being associated with the intestines in nearly all diseases.
In older children the stomach conditions may be distinct. Capacity. — At birth the capacity of the stomach is
about 1 4 ounce.
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For all practical purposes it is safe to say that the capacity of the stomach increases about 1 ounce for each month, up to eight months; then its development is slower. At one year the capacity is 9 ounces; at eighteen months 12 ounces.
As the quantity of food taken at feeding increases, the time it takes the stomach to empty itself lengthens. From two to eight months of age it takes about two hours for mother's milk and two and a half hours for cows' milk.
Fig. 37. — Stomach of infant at birth, natural size (J. P. C Griffith).
The position at birth is peculiar in that it is almost vertical instead of being horizontal. This explains the ease with which newly born babes regurgitate. There is no attending discomfort, being like the running over of a filled bottle.
Digestion of Milk. — Mother's milk is coagulated into light, flocculcnt curds, and with this diet the stomach becomes empty about an hour after ingestion. Cows' milk is coagulated into tough, compact masses, and it
ii4
DISEASES OF CHILDREN FOR NURSES
takes about a half hour longer for the stomach to empty itself of this diet than it does of mother's milk.
Vomiting is a condition arising from a large number of sources. It may be watery or mucous; bilious or green, which occurs in any case where vomiting and straining are continued; bloody (hematemesis); or purulent, resulting from the rupture of an abscess into the stomach or esophagus.
Fig. 38. — The abdominal regions. The heavy line at the upper border shows the extreme limit of the diaphragm. Imaginary lines divide the abdomen into different regions which, for the sake of clearness and precision, are known as the right and left hypochondriac, the epigastric, the right and left lumbar, the umbilical, the right and left inguinal or iliac, the hypogastric (Kerr).
Fecal vomit (stercoraceous) is indicative of intestinal obstruction and is recognized by its odor and appearance.
Profuse vomiting, where large quantities of frothy, fermented material are ejected, is significant of gastric dilatation.
Vomiting without nausea, distress, or other gastric
DISEASES OF THE DIGESTIVE TRACT 1 1 5
symptoms occurs in certain neuroses of the stomach, in hysteria, uremia, and in brain diseases, such as tumor or meningitis. This form of vomiting is seen at the onset of many fevers in childhood.
Habit vomiting is the name given to that form of emesis in which children vomit from habit alone, no disease of the stomach being present.
Cyclic vomiting is characterized by severe attacks of vomiting occurring at more or less regular intervals. It is uncommon and is of nervous origin.
Hematemesis is the term applied to vomiting of blood. If the hemorrhage is rapid and the blood immediately vomited, it may be bright red in color. However, it is usually retained for some time in the stomach before ejection, and is then dark brown in color, the so-called coffee-ground appearance. The blood is mixed with food and the subsequent stools are dark and tarry.
Hiccough or singultus results from a clonic spasm of the diaphragm. It is often noted as a temporary condition after eating and drinking. Persistent hiccough is fre- quently present in cases of extreme exhaustion following acute or chronic diseases.
Malformations and Malpositions of the Stomach. — The cardiac and pyloric ends may be congenitally stenosed (no opening). At times the stomach is found in the thorax, gaining access through a rupture of the diaphragm.
ACUTE GASTRIC INDIGESTION
Acute gastric indigestion is the name applied to a series of symptoms caused by the inability of the stomach to properly digest the food ingested.
The symptoms are vomiting, dulness, or excitement,
I 1 6 DISEASES OE CHILDREN FOR NURSES
and at times convulsions. The temperature ranges from ioo° F. to io2° F., sometimes higher. The tongue is coated, the appetite lost, and the abdomen distended. In infants there is an associated diarrhea, the stools con- taining undigested food. From six to twelve hours after the onset the vomiting ceases and the symptoms disappear.
GASTRITIS
Acute Gastritis is an acute inflammation of the stomach. The mucous membrane is red, sticky, and lusterless; it is swollen and covered with thick mucus.
Symptoms. — They vary much in degree. In severe cases there is moderate fever (102 ° F. to 103 ° F.) and its associated phenomena. There is loss of appetite, a coated tongue, and intense pain in the epigastric region, which is tender to the touch. In addition there is per- sistent vomiting, ' thirst, and considerable prostration. Jaundice may follow from the extension of the catarrh to the bile-ducts (gastroduodenitis), and diarrhea from extension to the intestines.
The treatment is absolute rest. If the stomach is not entirely empty an emetic should be employed. To re- lieve the pain in the stomach local applications such as turpentine stupes or a mustard plaster will be found effective. In severe cases no food should be given by the mouth. To allay the thirst cracked ice may be given, and later milk and lime-water.
Chronic Gastritis (Chronic Gastric Indigestion, Dyspepsia). — This is a chronic indigestion and signifies a group of symptoms which accompany every disease of the stomach. When, however, the symptoms depend upon nothing more than simple atony, hypersensitiveness,
DISEASES OE THE DIGESTIVE TRACT WJ
or chronic catarrh, the condition is spoken of as a distinct affection. Corresponding to this view there are three forms recognized: (i) Atonic, (2) nervous, (3) catarrhal.
In infancy chronic gastritis is due to the abundant, tough, adherent mucus lining the stomach. This inter- feres with digestion, even though the stomach secretions are normal.
The symptoms are: long retention of food, vomiting six to eight hours after eating, signs of general malnutrition, and undigested food in stools. There is also dilatation of the stomach. In infants under three months the prognosis is bad.
In older children chronic gastritis is usually caused by gastric irritants such as tea and coffee in excess, by dietetic errors such as insufficient mastication from bad teeth, hurried eating, too much food, insufficient food, coarse or improperly cooked food, excessive dilution of food with liquids, excessive condiments, and irregular eating.
Symptoms of chronic gastritis are: coated tongue, per- verted appetite, distress after eating, eructations, flatulence, heart-burn, palpitation, headache, vertigo, disturbed sleep, and lassitude.
In atonic dyspepsia the above symptoms are present and the pain usually appears some time after eating.
In nervous dyspepsia the above symptoms appear in nervous children. The symptoms vary greatly. At one time there will be anorexia, at another an inordinate appetite, and at still another a perverted taste. Pain and vomiting occur just as frequently when the stomach is empty as when it is full.
In catarrhal dyspepsia a condition of chronic inflamma- tion of the stomach exists. Just as in a chronic inflamma-
I I S DISEASES OF CHILDREN FOR NURSES
tion of the mucous membrane in any other part of the body, so here there is a thickening of the membrane and the process of digestion is interfered with. The food remains for a long time in the stomach and undergoes fermentation; thus eructations of gas and sour liquids are frequent. There is more or less nausea, with vomiting, at all times, but especially so in the morning when the frothy mucus, which has collected over the mucous mem- brane during the night, is vomited together with much retained, fermented food.
In catarrhal dyspepsia the nurse is often instructed to wash the patient's stomach every morning by lavage (see page 380).
GASTRALGIA
Gastralgia is a painful, paroxysmal (intermittent) affec- tion of the stomach not associated with any organic lesion.
Symptoms. — There are paroxysms of severe pain in the epigastrium, usually radiating to the back and occurring when the stomach is empty. It is relieved by pressure and the ingestion of foods or warm, stimulating drinks.
Treatment. — The child should be put to bed and hot water or turpentine stupes applied to the epigastrium. If the feet are cold apply hot-water bags there. Hot water containing five or ten drops of brandy and five drops of turpentine should be sipped.
GASTRIC ULCER This is a rare condition in childhood. Ulcers may result from follicular gastritis, tuberculosis, or without obvious exciting cause. The latter is probably due to the digestion of a portion of the stomach by its own juices. This occurs when some local disturbance of the circulation
DISEASES OF THE DIGESTIVE TRACT I ip>
shuts off the blood-supply to a portion of the stomach walls, the lowered vitality of that portion permitting the gastric juice to digest it. This produces the ulcer.
A gastric ulcer is round or oval and is usually situated at the pylorus on the posterior wall, near the lesser curvature. It is a punched-out ulcer, the apex toward the peritoneum, while the floor is usually formed by one of the coats of the stomach. A series of ulcers is not uncommon.
Symptoms. — The general symptoms of dyspepsia are present, and in addition the following characteristic symptoms : Pain, which may be severe, appears soon after eating and almost always radiates toward the back. Hem- orrhage is present in one-half of all cases. The bleeding may be profuse and the blood bright red. Localized tenderness, nearly always two or three inches above the umbilicus. Vomiting, occurring an hour or two after eat- ing and at the height of the pain. Hyperacidity, which is an increase in the hydrochloric acid after a test-meal.
This is a dangerous affection, demanding absolute rest in bed and rectal feeding.
DILATATION OF THE STOMACH
Moderate dilatation is often seen, a very marked dilatation is rare.
Causes. — Rickets, chronic gastritis, and pyloric stenosis.
The only symptoms present in most cases are those of chronic gastric indigestion.
In stenosis of the pylorus there is added vomiting of large quantities of fermented food, which occurs after the lapse of several hours.
In some cases of gastric dilatation the stomach is washed daily (see Lavage, page 380).
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Gastroptosis and enteroptosis is a prolapse or down- ward displacement of the stomach and intestines.
TEST-MEALS
The ordinary test-meal consists of a dry roll and two- thirds of a pint of water or weak tea, without milk or sugar.
In testing for lactic acid the test-meal should consist of a tablespoonful of oatmeal to a liter of water, flavored with a small quantity of salt.
Method of Administration. — The child should be given a very light breakfast. Four hours later the stomach- tube should be introduced and the stomach washed (see Lavage, page 380). The meal should then be eaten, and in an hour recovered by means of the stomach-tube. About 40 c. c. should be obtained.
NURSING
In diseases of the upper gastro-intestinal tract the room should be light and sunshiny, well ventilated, and kept at an even temperature.
The clothing should never bind the abdomen.
Bathing may be continued, except in the more severe forms of illness and in sore throat.
The food should be carefully prepared and given absolutely according to instructions. At times in severe vomiting it is necessary to prohibit food by the mouth. Nothing should then be allowed to enter the stomach.
The character of the vomit must be noted; the length of time after eating it occurs is important; and the presence of blood should be immediately reported.
Unless there is fever the temperature, pulse, and respira- tions need be taken but once or twice a day.