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Pediatric Nursing Lecture :

Digestive/ Endocrine Disorders

Physiology: At birth mechanical function of digestion is immature:

There is no voluntary control over swallowing until 6 weeks Decrease stomach capacity: stomach capacity of the neonate is

30 – 60 ml, and gradually increases to 200 to 300 by age 12 months

Spit - ups are frequent in the neonate because of the immature muscle tone of the lower esophageal sphincter and the low volume capacity of the stomach

Liver is immature throughout infancy resulting in: Inefficient detoxifying of substance and medications Liver’s slow development of glycogen storage capacity makes

the infant prone to hypoglycemia Gastric acidity ; low in infants; rises until 10 years of age Digestive process mature by toddlerhood

Assessment: Digestive Disorders A. Presenting problems:

Vomiting Abnormal bowel habits: diarrhea, constipation, bleeding Weight loss, failure to thrive Pain

B. Physical Examination General appearance:

- Height and weight- Measure mid – arm circumference- Observe for color: jaundice

Mouth: dentition Abdomen:

- Skin integrity Auscultate bowel sound- Palpate for tenderness Palpate for tenderness- Abdominal distention Inspect for hernias- Visible peristaltic waves

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- Liver span ( inferior edge palpated 1-2 cm below right costal margin

- Spleen : felt on respiration 1-2 cm below the left costal margin

Disorders of the teeth

Dental Carries- erosion of the enamel and dentine of the teeth which results from the combination of fermenting sugars and starched and acid- forming organisms Prevention:

Dental hygiene Good nutrition Fluoridation Regular visit to the dentist

Cleft lip and Cleft Palate- Occur when the bone and tissue of the upper jaw and palate fail

to fuse completely at the midline in the first trimester of pregnancy

Cleft lip – is a separation of 2 sides of the lip. It may affect both sides of the lip as well as the bone and soft tissues of the alveolusCleft palate - is a midline opening of the plate that results from the failure of the 2 sides to fuse during the embryonic stage

Cause: Exact cause is unknown It may occur as a part of chromosomal abnormality or

after prenatal exposure to teratogens, such as anticonvulsant medications and alcohol

Clinical manifestations:

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Palpable or visible unilateral or bilateral cleft lip or palate or both

Nasal distortion Feeding difficulties, difficulty in sucking, inability to

form an airtight seal around nipple Difficulty in swallowing Formula milk escapes through the nose in infants with

cleft palate Abdominal distention from swallowed air

Complications Speech difficulties may include hypernasality,

compensatory articulation Failure to thrive (due to inadequate oral intake) Malocclusion may occur with abnormal teeth eruption

pattern Dental decay Chronic otitis media Hearing defects Increased risk for aspiration and upper respiratory

infection Altered self- esteem and body image

Preoperative cleft lip and cleft palate careCleft Lip

Fee the infant slowly and in an upright position to decrease the risk of aspiration

Burp the infant frequently during feeding to eliminate swallowed air and decrease the risk of emesis

Use gavage feedings if oral feedings are unsuccessful Give a small amount of water after feedings to prevent

formula from accumulating and becoming a medium for bacterial growth

Give small frequent feedings to promote adequate nutrition and prevent tiring

Hold the infant while feeding, and promote sucking between meals; sucking is important for speech development

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Cleft palate Be aware that the infant must be weaned from the bottle or

breast before cleft palate surgery: he must be able to drink from cup

Feed the infant with a cleft palate nipple or a Teflon to enhance nutritional intake

Teach the parents that the infant is susceptible to pathogens and otitis media from the altered position of the Eustachian tube

Management: Multidisciplinary team evaluation – to counsel patient on

the condition and to prepare them for the surgical plan: otolaryngologist, speech therapist, pediatrician, dentist, audiologist

Surgical correction:o Cheiloplasty – correction of the cleft lip; cleft lip is

repaired at 8 – 12 weeks of age, if the baby demonstrated good weight gain; baby should weigh 10 lbs at the time of repair

o Palatoplasty - involves reconstruction of the palatal musculature with the goal of normal speech development; usually performed when the child is 12 – 18 months, weighing 18 – 20 lbs.

Postoperative cleft lip care o Maintain a patent airwayo Observe for cyanosis to detect signs of respiratory

compromise as the infant begin to breathe through the nose

o Maintain an intact suture line; keep the infant’s hands away from is mouth by using restraints

o Clean the suture line after feedings and apply antibiotic ointment if ordered

o Anticipate infant’s needs; this will prevent cryingo Give extra care and support as the infant’s emotional

need can’t be met by sucking

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o When feeding resumes, use a syringe with rubber tip or a dropper to administer foods at the side of the mouth to prevent trauma to the suture line, never use a straw for feedings

o Place the infant on his right side after feedings to prevent aspiration( Don’t put the infant in a prone position)

o Monitor for pain and administer pain medication as prescribed

o Feeding should not last for 20- 30 minutes, otherwise the calories taken in is expended by the feeding effort

Postoperative cleft palate care o Position the infant on his abdomen or side to maintain

a patent airwayo Assess fo4 signs of altered oxygenation to promote

good respirationo Use a cup for feeding to prevent injury to the suture

line; don’t use a nipple or a pacifiero Keep hard or pointed objects ( oral thermometer,

utensils, straws frozen dessert sticks) away from the infant’s mouth

o Use elbow restraints to keep the child’s hands out of the mouth

o Provide soft toys to prevent injuryo Distract or hold the infant to try to keep his tongue

away from the roof of the moutho Start the infant on clear liquids and progress to a soft

dieto Rinse the suture line by giving sips of water after each

feeding to prevent infectiono Don’t brush teeth 1 – 2 weeks after surgery

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ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA

Esophageal Atresia – upper segment of the esophagus ends in a blind pouch or the esophagus is closed off at some point and food cannot enter the stomach through the esophagus

Tracheoesophageal fistula - opening or abnormal connection develops between the esophagus and the trachea. It is a defect in which embryonic structures fail to divide into separate esophagus and trachea

What causes it Result of the failure of the embryonic esophagus and trachea

to develop and separate correctly( during 4th and 6th weeks of embryonic development)

Defective growth of the endodermal cells lead to atresia

Manifestations Copious oral and nasal secretions ( first sign of the defect) 3 C’c( coughing, choking, cyanosis) Reflux of air and gastric secretions into the tracheobronchial

tree through the fistula Infant with esophageal atresia but no fistula have scaphoid

( boat- shape) gasless abdomen In fistula without atresia, the usual symptoms are current

aspiration, pneumonia, atelectasis that remains “ silent” for days or even months

Types TypeA - Esophageal atresia without fistula Type B - Esophageal atresia with tracheoesophageal fistula

to the proximal segment Type C – Esophageal atresia with fistula to the distal

segment Type D - Esophageal atresia with fistula to both segments Type E – Traheoesophageal fistula without atresia

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Diagnostic Test Radiopaque catheter is inserted

- into the esophagus, and an X- ray is take to see where the catheter goes or what obstruction it hits

Bronchoscopy – to visualize the fistula between the trachea and esophagus

Chest X- ray shoes pneumonia and a dilated, air- filled upper esophageal pouch

Complications Leaking at the anastomosis site Strictures Gastroesophageal reflux Feeding difficulties, and tracheomalacia ( weakness of the

tracheal wall, allowing the trachea to collapse)Treatment

Surgical correction and usually surgical emergencies:o Ligate fistulas and anastomose the esophagus to

the stomacho Esophageal lengthening may be needed if the

esophagus is too short to join the stomacho Insertion of chest tube to drain intrapleural fluid

and air Postoperative care

o Involve Parents in the care of the child and prepare them for caring for the child at home

o Nasogastric or orogastric tube is attached to a low-suction or gravity drainage

o Document amount and character of drainage at least every 4 hours

o Gastrostomy feeding may be given until the esophagus heals

o Monitor for signs of respiratory distresso Monitor chest tube drainage and care of the chest

tube siteo Begin oral feedings with sterile water and

advance to normal feedings as tolerated

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o Encourage sucking on a pacifier to prevent oral aversion

o Educate the parents on proper oral or gastrostomy feedings

o Monitor for signs of esophageal constriction such as drooling, difficulty swallowing, or regurgitating undigested food

Gatroesophageal Reflux - gastric contents flow backwards into the esophagus and - stomach is relaxed

Factors That Predispose The child to Gastroesophageal Reflux 1. High pressure on the lower esophageal sphincter2. High volume of reflux material in the esophagus3. Rate of gastric secretions4. Inability of the stomach to empty

Manifestations:1. Chronic vomiting (most common)2. Weight loss ( failure to thrive)3. Apnea (in infant) due to aspiration or obstruction4. Hematemesis or melena due to esophageal bleeding5. Recurrent bronchitis or pneumonia6. Irritability, loss of appetite

Surgical Management1. Fundoplication - upper end of the esophagus is

wrapped around the lower portion of the esophagus , and the fundus is sutured in front of the esophagus to create a circular acute angle valve mechanism

2. Placement of gastrostomy tube- to ensure adequate nutrition and simplifies care

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Nursing Interventions:1. Promote adequate nutritional and fluid intake

a. Maintain head of bed elevated in 30 - 60 degree position for 30 minutes after feeding

b. Raise head of bed with 6 inch blockc. Provide small frequent feeding every 2- hoursd. Thicken formula with cereale. Weigh child dailyf. Measure intake and output

2. Observe, monitor and report signs of respiratory distress; assess for changes in respiratory status3. Preoperatively prepare child and family for surgery4.Monitor surgical site for intactness5. Prevent abdominal distention

a. Maintain patency of NGT or gastrostomy tube if placedb. Check position of NGTc. Auscultate for bowel sound

6. Monitor for signs and symptoms of post operative hemorrhage;a. Decreased blood pressureb. Gross blood in the NGTc. Coffee- ground NGT drainage expected for the first 24 hoursd. Assist patient in the verbalization of feelings

HIATAL (DIAPHRAGMATIC) HERNIA - It is a protrusion (herniation) of the upper part of the stomach

through the diaphragm and into the stomach Manifestations:

1. Often asymptomatic2. Later in life- are associated with gastro intestinal disorders:

- Gastro esophageal reflux- Dysphagia

- Heartburn- Epigastric pain- Regurgitation and substernal discomfort after eating

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Diagnostic Tests1. Examination using barium2. Endoscopy3. Chest X- Ray - will show protrusion of the stomach into the

thorax Interventions:

1. Surgical repair - closure of the large opening through the diaphragm and repositioning the organ

2. Frequent small meals3. Avoid recumbent position after eating4. Weight control for obese individuals5. Avoid supports and tight clothing6. NGT suction7. Inspect incision line8. Encourage parents to participate in child’s care

PYLORIC STENOSIS (HYPERTROPHIC PYLORIC STENOSIS )

Pyloric Sphincter - is the opening between the lower portion of the stomach and the beginning portion of the intestine, the duodenum

Pyloric stenosis- is the obstruction of the pyloric sphincter caused by hypertrophy

of the sphincter muscle- The circular muscle increases to as much as twice as the normal

thickness and the pylorus strength which results in severe narrowing of the lumen

- Exact cause is unknown, but factors that increases likelihood of pyloric stenosis in infants are:

Increased gastric secretions by the mother in the last trimester of pregnancy caused by stress

` - Associated with malrotation, esophageal atresia, and anorectal malformation

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ClinicalManifestations:1. Olive -shaped bulge below the right costal margin and a

distended abdomen2. Purposeful or projectile vomiting immediately after

feeding3. Vomitus is free of bile because feeding does not reach

the duodenum to mix with bile4. Hungry feeding- eager to be fed after vomiting5. Constipation because little food reaches the intestine6. Fluid and electrolyte imbalance7. weight loss]8. Irritability and crying9. Signs of dehydration

Diagnostic Tests1. Vomitus is positive for blood2. Bloodchemistry reveals: hypocalcemia, hyponatremia,

hypokalemia, and hypochloremia3. ABG reveals metabolic alkalosis4. Abdominal ultrasound and endoscopy reveal a

hypertrophied sphincter5. Upper GI series reveal delayed emptying

Surgical Intervention Pyloromyotomy - muscles of the pylorus are split and

separated

Nursing Interventions: Pre-operative:

1. NPO before surgery2. IV fluids to correct fluid and electrolyte imbalance3. Insert NGT and kept open for decompression4. Prevent vomiting by:

a. Giving thickened feedingb. High fowler’s

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c. Place on right side after feeding, allowing gravity to help the flow of fluid through the pyloric valve

5. Strict MIO 6.Weigh patient daily

7. Assess abdominal and cardiovascular status to detect early signs of compromise

Post-operative:1. Promote and maintain fluid and electrolyte balance:

a. MIOb. IVF as orderedc. Maintain Patent NGT

2. Feed the child with small amount of oral electrolyte solution; then increase the amount and concentratio0n of food until normal feeding is achieved

3. Burp the child frequently during feeding4. Provide a pacifier to maintain comfort and satisfy the

infant’s sucking reflex 5. Monitor intake and output6. Keep incision area clean to prevent infection 7. Administer analgesics round the clock for pain

management

INTUSSUSCEPTION - Telescoping or invagination of one part of the intestine into another that causes strangulation of the blood supply- Most common site is the ileocecal valve - Usually occur at about 6months, but can occur in children up to 3 years but never in older children

Causes:- Unknown in most cases- It may result from polyps, hyperactive peristalsis or an abnormal bowel lining-May also be linked to viral infection

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Manifestations:1. Intermittent attacks of colicky abdominal pain, characterized

by screaming and drawing knees to the chest2. Vomiting of bile- stained fluid3. Bloody mucus in stool4. Sausage-shaped mass in the right upper quadrant5. Currant -jelly stool ( dark gelatinous stool because of blood and

mucus)6. Abdominal distention and tenderness as intestinal obstruction

becomes more acute

Management:1. Ultrasound2. Abdominal X-ray shows a soft tissue mass and signs of

complete or partial obstruction3. Barium enema confirms colonic intussusception when it

shows the characteristic coiled spring sign 4. Surgical Intervention:

Reduction - is an emergency procedure involving hydrostatic pressure exerted by enema given under a fluoroscopic guidance. (air pressure or a solution of barium or water- soluble contrast medium is introduced into the rectum)Surgical reduction - is done to children who fail or who are not candidate for hydrostatic reduction

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HIRSCHPRUNG’S DISEASE - Is the functional obstruction of the colon caused by inadequate

motility- It is the absence of parasympathetic ganglionic cells in the

segment of the colon , usually at the distal end if the large intestine

- This absence results in abnormal or absent peristalsis and the total absence of bowel evacuation

Cause- Exact cause is unknown but believed to be the result of a

congenital familial defect- The disease may co- exist with other congenital anomalies, particularly Down syndrome and anomalies of the urinary tract

Diagnostic Tests:1. Rectal biopsy -provides definitive diagnosis by showing

the absence of ganglion cells2. Rectal manometry - reveals failure of the internal anal

sphincter to relax and contract 3. Abdominal X- rays -show distention of the colon

Clinical Manifestations1. Failure to pass meconium stool within 24 hours after

birth2. Bilious vomiting3. Abdominal distention4. Reluctance to feed5. Irritability, lethargy6. Weight loss7. Signs of dehydration

SurgicalManagement:

1. Temporary colostomy -initially:- to decompress the bowel and divert the fecal contents

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- to allow the dilated and hypertrophied portion of the bowel to regain normal tone and size ( about 3 - 4months)

2. At age 6 - 12 months or when infants weighs 8 - 10 kg, a rectal pull- through procedure is done, in which all aganglionic bowel is removed and normal bowel is connected to the anus; Colostomy is closed

`Nursing Interventions: 1.Monitor nutritional status:

- High calorie-protein diet- MIO- Weigh daily

2. Monitor clinical status preoperatively:- VS every 2 hours as needed- MIO- Observe for signs of bowel peroration like vomiting, increased tenderness, irritability, dyspnea- Measure abdominal girth every 4 hours to assess abdominal distention

3.Monitor infant’s reaction to preoperative preparation such as:- enema - Pre-op medications- IV insertion - NGT insertion- FBC insertion -NPO 12hours prior to surgery

4.Post Operative Care:a. Monitor child’s post op status:

-Auscultate for return of bowel sound- VS every 2hours- Monitor for abdominal distention

b. Monitor child’s hydration status:- signs of dehydration and fluid overload- Measure NGT, colostomy and FBC drainage- Monitor IV infusion- Observe for electrolyte imbalance

c. Observe and report signs of complications:` - intestinal obstruction caused by adhesion

-Volvulus or intussusception

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-leakage from anastomosis- Sepsis, fistula, constipation, bleeding

d. Promote return of peristalsise. Alleviate pain and minimize discomfortf. Prevent infection - inspect incision siteg. Promote client teaching and discharge planning

IMPERFORATED ANUS (ANORECTAL AGENESIS_ - Is the stricture of the anus and anus appear as a dimple- Membrane that separates the rectum and the anus is absorbed

during the embryonic life- In girls fistula maybe present between the rectum and vagina- In boys fistula maybe present between the rectum and the urinary

tract at the scrotum

Clinical Manifestations:1.Absent anal opening2. Failure to pass meconium stool within 24 hours after birth3. Inability to take infant’s temperature rectally4. Passage of meconium through fistula or misplaced anus5. Gradual distention and signs of bowel obstruction if no fistula is present

Diagnostic Tests:1. Rectal examination- insertion of rectal thermometer2. If fistula is present, urine maybe examined for meconium

epithelial cells3. Ultrasound to locate rectal pouch

Management:1. Surgery - perianal anoplasty( abdominal perianal

pull through procedure) low lesions are corrected by pulling the rectal pouch through the sphincter to the opening in the anal skin. Fistula if present is closed.

Nursing Interventions:1. monitor infant’s response to surgery (VS, I&O, surgical site)2. Monitor for S&S of complications ( UTI, decreased urine output,

constipation, bleeding)3. Maintain fluid and electrolyte balance

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4. Dressing care5. Colostomy care6. If anoplasty heal regular dilatation of anus to prevent stricture7. After surgery, side -lying or prone position with hips elevated.

APPENDICITIS - Inflammation of the vermiform appendix. ( a projerction from the

apex of the cecum) caused by obstruction of appendical lumenand results in edema, inflammation, venous engorgement,

increased intraluminal pressure and ischemia.- It may lead to bacterial invasion, necrosis, perforation and

peritonitis

Clinical Manifestations1.Pain- cramping around the periumbilical area migrating to the right lower quadrant2. Anorexia3.Nausea and vomiting4.Fever5. Rebound tenderness6 Decrease or absent bowel sound7. Constipation8. Diarrhea9.Difficulty 10 Irritability

Complications if not diagnosed:1.perforation 2.Perritonitis

Diagnostic Tests:1.CBC-leukocytosis, neutrophilia, absence of eosinophils2. Elevated acetone in urine

Interventions:1. Appendectomy2. No enemas3. No heating fads

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4. Avoid unnecessary movements and palpation of the abdomen

PARASITISM - Presence of parasites such as roundworms and pinworms

Parasites – are organisms that live and obtain their food supplies from other organisms

Helminthic infections – refers to pathogenic and parasitic ones

Assessment:- Pinworms – anal itching, disturbed sleep- Hookworms – also found in human feces and enter the body

through then skin and migrate to the intestinal tract. They suck blood from the intestinal wall

- Roundworms – colic, abdominal pain, lack of appetite, weight loss, lives in the intestinal tract . Eggs are excreted in the feces; children typically ingest the eggs when they eat food with their hands that are improperly washed

Nursing Intervention- Obtain stool culture- Observe all excreta for presence of worms- Scotch tape swab- Instruct parents to change clothing, bed linens, towels, and

launder in hot water- Instruct proper hand hygiene – scrub hands and fingernails prior

to eating and after using toilet- Avoid nail biting and to wash hand before food preparation or

eating

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CONSTIPATION - Difficulty of passing hardened stool- Decrease in the number of bowel movement with large hard

stools- Maybe caused by high fat and protein and low fluid diet- May cause bowel obstruction

‘Assessment:- Less frequent stool- Difficulty on defecation- Bleeding- Abdominal pain

Management:- Drug therapy- Diet therapy- Enema to loosen hard stool ( initial therapy)- Stool softener

Nursing Interventions:- Assess for the pathologic cause of obstruction- Increase fiber and fluid intake- Prune juice- Digital extraction if possible- Urge to defecate their bowel at the same time everyday to form a

habit

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HYPOPITUITARISM (PITUITARY DWARFISM)- Hyposecretion of growth hormone by the anterior lobe of then

pituitary gland

Cause: Unknown

Assessment:

- Normal size newborn, but by age 5 child falls below the 3rd percentile

- Child is well proportioned; overweight for height- Underdeveloped jaw, abnormal position of teeth- High – pitched voice, delayed puberty- Normal IQ - X- ray reveals delayed closing of epiphyseal plates of long bones

Nursing interventions:- Communicate according to chronological age or developmental

level- Administer growth hormone as prescribed- Observe for signs and symptoms of other neurologic disorder- Record height and weight- Encourage parents to express feelings- Assist child I n learning to interact with peers

HYPERPITUITARISM (GIGANTISM)- Hypersecretion of growth hormone

Assessment:- Overgrowth of long bones- Height beyond maximum percentile- Proportional with muscle growth- Coarse facial features

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Management:- Surgery to remove tumor- Radiation therapy

Nursing Interventions:- Record height and measure head circumference- Care for client receiving radiation therapy- Provide care for child with brain tumor- Interact with peers

CONGENITAL HYPOTHYROIDISM- Absence of non- functioning thyroid hormone- Supply of maternal thyroid hormone to newborn for 3 months

Signs and Symptoms:- Altered body proportion, short stature with .legs shorter than

they should be in proportion to trunk- With enlarged tongue that protrudes which result in breathing

and feeding difficulties- Hypothermia with cold extremities- Short, thick neck, delayed dentition- Hypotonia- Low levels of T3 and T4

Management:- Neonatal screening- Administer oral thyroxine and Vitamin D- Teach importance of continued therapy

HERNIA- Protrusion of the intestine through a weakness in the abdominal

muscles or through the inguinal ring- caused by failure of certain normal openings to close during fetal

development- Increased intra abdominal pressure

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Types:1. Umbilical hernia- connective tissue fails t close completely and a

circular defect remains beneath the umbilicus- Protrusion of a portion of the intestine through the umbilical ring,

muscle and fascia surrounding the umbilical cord- Small defect closes spontaneously- Surgery is done for larger defects that persists more than 5 years

Assessment:- Inspect for protruding umbilicus- Palpate for abdominal content

Management:- Conservative Surgery

Nursing Intervention:- Teach parents safe and effective care and how to assess

strangulation- Do not apply binders- Taping of coin may cause skin damage and prevent

natural closure and may lead to bowel strangulation

2. Inguinal hernia- A protrusion of a section of the bowel into the inguinal ring- Occurs usually in boys ( 9:1 ) ( because as the testes descend from

the abdominal cavity into the In scrotum later in fetal life, a fold of parietal peritoneum also descends, forming a tube from the abdomen to the scrotum. In most infants, this tube closes completely. If it fails to close, intestinal descent (hernia) may occur anytime when there is an increase in intra abdominal pressure.

Treatment:

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- Bowel is returned to the abdominal cavity and retained there by sealing the inguinal ring

3. Femoral hernia- Occur through the femoral ring and common in females than in

males- Begin as a plug of fat in the femoral canal that enlarges and

gradually pulls the peritoneum and almost inevitably the urinary bladder in the sac

- There is a high incidence of incarceration and strangulation in this type of hernia

Assessment:- History of intermittent appearance of a mass in the groin ( bulge

in the groin, scrotum, or labia)- Pain- Continuous crying- Vomiting- Abdominal distention- Scrotal / colon change

Complications

- Recurrence of hernia- Incarcerated hernia- Atrophy of the gonads

Medical Management: Herniorrhapy as soon as diagnosis is made

Nursing Interventions:

- If incarceration occur elevate foot of bed and aplly ice bag- Elevate foot of bed- Post- operative: small dressing, encourage ambulation, resume

activity gradually- Monitor for complications

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OMPHALOCOELE- Herniation of abdominal viscera through the visceral ring, usually

with an intact peritoneal sac- Protrusion of the abdominal contents through the abdominal wall

at the point of the junction of the umbilical cord and abdomen- Herniated organs are usually the intestines but they may include

stomach and liver - At approximately 6-8 weeks of intrauterine life, the fetal

abdominal contents are extruded from the abdomen to the base of the umbilical cord. At 7-10 weeks, the intestine returns to the abdomen. Omphalocoele occurs when the abdominal contents fail to return to the abdomen.

GASTROSCHISIS- Failure of the abdominal wall to close, allowing evisceration of

abdominal contents; no membrane- A condition similar to omphalocoele except the abdominal wall

defect is a distance from the umbilicus and abdominal organs are not contained by peritoneal membrane but rather spill freely from the abdomen

Interventions:- Determine extent of defect- Sac covered directly with sterile gauze, wet with saline; protect

sac from rupture- NPO - Surgery

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