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 do 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