Esophageal Disorders

Question 1

what is GERD?

Answer 1

• Common condition characterized by gastric content and enzyme backflow into the esophagus
• Some backflow of stomach contents is normal, but when the reflux is excessive, the corrosive fluids irritate the esophageal tissue–>causes a delay in their clearance–>exposes esophageal tissue to the acidic fluids–>irritation

Question 2

what causes there to be excessive reflux?

Answer 2

• Incompetent LES
• Pyloric stenosis
• Hiatal hernia
• Excessive intra-abdominal or intragastric pressure
• Motility problems

Question 3

primary tx for GERD

Answer 3

• Diet and lifestyle changes
• Medication: antacids, H2 receptor antagonists, PPIs
• Surgery

Question 4

GERD: health promotion and dz prevention

Answer 4

• Maintain a BMI <30
• Stop smoking
• Limit or avoid alcohol and tobacco
• Eat a low fat diet
• Avoid foods that lower the LES pressure
• Avoid eating/drinking 2 hr before bed
• Avoid tight fitting clothes
• Elevate the HOB 6-8 in

Question 5

GERD: risk factors

Answer 5

• Obesity
• Older age: delayed gastric emptying and weakened LES tone
• Sleep apnea
• NG tube

Question 6

GERD: contributing factors

Answer 6

• Excessive ingestion of foods that relax the LES include fatty & fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, alcohol
• Prolonged or frequent abdominal distention from overeating or delayed emptying
• Inc abdominal pressure from obesity, pregnancy, bending at the waist, ascites, tight clothing at the waist
• Meds that relax the LES: theophylline, nitrates, CCBs, anticholinergics, diazepam
• Inc gastric acids from meds (NSAIDs) or stress
• Debilitation resulting in weakened LES tone
• Hiatal hernia (LES displacement into the thorax w/ delayed esophageal clearance)
• Lying flat

Question 7

GERD: expected findings

Answer 7

• Classic report of dyspepsia after eating an offending food/fluid and regurgitation
• Radiating pain (neck, jaw, back)
• Report of a feeling of having a heart attack
• Pyrosis
• Dyspepsia (indigestion)
• Dysphagia or odynophagia (pain on swallowing)
• Pain that worsens w/ position (bending, straining, laying down)
• Pain that occurs after eating and lasts 20 min to 2 hours
• Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste in mouth (from regurg)
  
  • Chronic GERD can lead to dysphagia
• Inc flatus and eructation (burping)
• Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids
• Manifestations occurring 4-5 times/week on consistent basis
• Tooth erosion

Question 8

what are the diagnostic procedures for GERD?

Answer 8

• EGD
• esophageal pH monitoring
• esophageal manometry
• barium swallow

Question 9

GERD: EGD

Answer 9

• Done under moderate sedation
• Looks for tissue damage and to dilate strictures in the esophagus
  
  • Esophageal lining should be pink, but usually red w/ persistent GERD
• Biopsies will be done to determine if high grade dysplasia (HGD) is present
  
  • HGD is evidenced by squamous mucosa of the esophagus replaced by columnar epithelium (which are the cells seen in stomach/intestines)
    
    • When HGD is found, 30% inc in developing cancer
• Allows for visualization of esophagus revealing esophagitis or Barrett’s epithelium (premalignant cells)
• Nursing Actions:
  
  • Verify gag response has returned prior to providing fluids or food

Question 10

GERD: esophageal pH monitoring

Answer 10

• Small catheter is placed thru the nose and into the distal esophagus, or a small capsule is attached to the esophageal wall during endoscopy
  
  • pH readings are taken in relation to food, position, activity for 24-48 hours
• Most accurate way to diagnose GERD
• Helpful for clients with atypical manifestations
• Nursing Actions:
  
  • Instruct the client to keep a journal of foods, beverages consumed, symptoms, and activity during the test period

Question 11

GERD: esophageal manometry

Answer 11

• Records LES pressure and peristaltic activity of the esophagus
• Client swallows 3 small tubes, and pressure readings and pH levels are tested

Question 12

GERD: barium swallow

Answer 12

• Identifies a hiatal hernia, strictures, or structural abnormalities which would contribute to or cause GERD
• Nursing Actions:
  
  • Instruct the client to use cathartics to evacuate the barium from the GI tract following the procedure
    
    • Failure to eliminate the barium places client at risk for fecal impaction

Question 13

list classes of meds for GERD

Answer 13

• PPIs
• Antacids
• H2 Receptor Antagonists
• Prokinetics

Question 14

GERD: PPIs

Answer 14

• PPIs: pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
• Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
• Nursing Considerations:
  
  • Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
  • Long term use has been related to the development of community acquired pneumonia and c. diff infections
• Client education:
  
  • Long term use of PPIs places the client at risk for frxs, especially in older adults

Question 15

GERD: Antacids

Answer 15

• aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
• Neutralize excess acid and increase LES pressure
• Nursing Considerations:
  
  • Ensure there are no contraindications w/ other meds (levothyroxine)
  • Evaluate kidney function in clients taking magnesium hydroxide
• Client Edu:
  
  • Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour

Question 16

GERD: H2 Receptor Antagonistis

Answer 16

• ranitidine, famotidine, nizatidine
• Reduce the secretion of acid
• Onset is longer than antacids, but effect has a longer duration
• Nursing Considerations:
  
  • Use cautiously in clients w/ kidney dz
• Client Edu:
  
  • Take w/ meals & at bedtime
  • Separate dosages from antacids (1 hour before or after taking antacid)

Question 17

GERD: Prokinetics

Answer 17

• metoclopramide
• Inc motility of esophagus and stomach
• Nursing Considerations:
  
  • Monitor the client taking metoclopramide for extrapyramidal SEs
• Client Edu:
  
  • Instruct client to report abnormal, involuntary movemen

Question 18

GERD: Stretta

Answer 18

• type of therapeutic procedure
• procedure uses radiofrequency energy, applied by an endoscope, to decrease vagus nerve activity
• Causes LES muscle tissue to contract & tighten

Question 19

GERD: fundoplication

Answer 19

• therapeutic procedure for GERD
• can be indicated for clients who fail to respond to other treatments
• Fundus of the stomach is wrapped around and behind the esophagus thru a laparoscope to create a physical barrier
• Nursing Considerations:
  
  • Complications:
    
    • temporary dysphagia: monitor for aspiration
    • Gas bloat syndrome: difficulty belching to relieve distention
    • atelectasis/pneumonia: monitor respiratory function
• Client Edu:
  
  • Diet:
    
    • Avoid offending foods
    • Avoid large meals
    • Remain upright after eating
    • Avoid eating before bedtime
    • Consume 4-6 small meals throughout the day
  • Lifestyle:
    
    • Avoid clothing that is tight fitting around the abdomen
    • Lose weight
    • Elevate HOB 6-8 in
    • Sleep on right side

Question 20

list complications of GERD

Answer 20

• aspiration of gastric secretion
• Barrett’s epithelium or esophageal carcinoma

Question 21

GERD: aspiration of gastric secretion

Answer 21

• Causes: reflux of gastric fluids into esophagus can be aspirated into trachea
• Risks assoc with aspiration:
  
  • Asthma exacerbation from inhaled aerosolization of acid
  • Frequent URI, sinus/ear infections
  • Aspiration pneumonia

Question 22

GERD: Barrett’s epithelium (premalignant) or esophageal adenocarcinoma

Answer 22

• Cause: reflux of gastric fluids leads to esophagitis
  
  • In chronic esophagitis, the body continuously heals inflamed tissue, eventually replacing normal esophageal epithelium w/ premalignant tissue or malignant adenocarcinoma
• Nursing actions:
  
  • Determine cause of GERD w/ client
  • Review lifestyle changes that can decrease gastric reflux
  • Monitor nutritional status

Question 23

Hiatal Hernia

Answer 23

• AKA diaphragmatic hernia
• Protrusion of the stomach (in part or total) above the diaphragm into the thoracic cavity thru the hiatus/opening of the diaphragm

Question 24

2 types of hiatal hernia

Answer 24

• Sliding: more common
  
  • Portion of the stomach and gastroesophageal junction move above the diaphragm
  • Generally occurs w/ increases in intra-abdominal pressure or while the client is in supine
• Paraesophageal (rolling):
  
  • part of the fundus of the stomach moves above the diaphragm although the gastroesophageal junction remains below the diaphragm

Question 25

Hiatal Hernia: health promotion and dz prevention

Answer 25

• Avoid eating immediately prior to going to bed
• Avoid foods/drinks that dec LES pressure
• Exercise regularly
• Maintain healthy weight
• Elevate HOB at least 6 in
• Avoid straining or excessive vigorous exercise
• Avoid wearing clothing that is tight around abdomen

Question 26

hiatal hernia: expected findings

Answer 26

• Presenting manifestations depend on type and are typically worse after a meal
• Sliding: heartburn, reflux, chest pain, dysphagia, belching
• Paraesophageal: fullness after eating, sense of breathlessness/suffocation, chest pain, worsening of symptoms when reclining
• Physical assessment:
  
  • Pharyngitis
  • inspiratory/expiratory wheezes

Question 27

hiatal hernia: list diagnostic procedures

Answer 27

• barium swallow w/ fluoroscopy
• EGD
• CT scan of chest w/ contrast

Question 28

hiatal hernia: barium swallow w/ fluoroscopy

Answer 28

• Allows visualization of esophagus
• Nursing Actions:
  
  • Instruct client to use cathartics to evacuate the barium from the GI tract after procedure
  • Failure to eliminate barium places client at risk for fecal impaction

Question 29

hiatal hernia: EGD

Answer 29

• Allows visualization of esophagus and gastric lining
• Nursing Actions
  
  • Verify gag response has returned prior to giving fluids/food following procedure

Question 30

hiatal hernia: CT scan w/ contrast

Answer 30

• Allows visualization of the esophagus and stomach
• Nursing Actions:
  
  • Assess for iodine allergies
  • Encourage fluids following procedures to promote dye excretion and minimize risk of renal injury
  • Monitor BUN/creatinine

Question 31

hiatal hernia: 2 classes of meds

Answer 31

• PPIs
• antacids

Question 32

hiatal hernia: PPIs

Answer 32

• pantoprazole, omeprazole, esomeprazole, rabeprazole, lansoprazole
• Reduce gastric acid by inhibiting the cellular pump of the gastric parietal cells necessary for gastric acid secretion
• Nursing Considerations:
  
  • Monitor for electrolyte imbalances and hypoglycemia in clients who have DM
  • Long term use has been related to the development of community acquired pneumonia and c. diff infections
• Client education:
  
  • Long term use of PPIs places the client at risk for frxs, especially in older adults

Question 33

hiatal hernia: antacids

Answer 33

• aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarb
• Neutralize excess acid and increase LES pressure
• Nursing Considerations:
  
  • Ensure there are no contraindications w/ other meds (levothyroxine)
  • Evaluate kidney function in clients taking magnesium hydroxide
• Client Edu:
  
  • Instruct client to take when acid secretion is the highest (1-3 hours after eating and at bedtime), and to separate other meds by at least 1 hour

Question 34

what are the therapeutic procedures for hiatal hernia?

Answer 34

• Fundoplication: reinforcement of LES by wrapping portion of fundus of stomach around distal esophagus
• Laparoscopic Nissen fundoplication: minimally invasive w/ fewer complications

Question 35

nursing considerations/client edu for hiatal hernia w/ the therapeutic procedures

Answer 35

• Nursing Considerations:
  
  • Elevate HOB to promote lung expansion
  • Instruct client to support incision during movement and coughing to minimize strain on suture lines
• Client Edu:
  
  • Consume a soft diet for first week postop
  • Avoid carbonated beverages
  • Ambulate, but avoid heavy lifting

Question 36

complications of the therapeutic procedures for hiatal hernia

Answer 36

• Temporary dysphagia
• Gas bloat syndrome (difficulty burping and distention)
• atelectasis/pneumonia

Question 37

hiatal hernia: complications

Answer 37

• Volvulus: twisting of esophagus and stomach
• Obstruction (paraesophageal hernia): blockage of food in herniated portion of stomach
• Strangulation (paraesophageal hernia): compression of blood vessels to the herniated portion of the stomach
• Iron Deficiency Anemia (paraesophageal hernia): resulting from bleeding into gastric mucosa due to obstruction

Question 38

esophageal varices

Answer 38

• Swollen, fragile blood vessels that are generally found in the submucosa of the lower esophagus, but varices can develop higher in the esophagus or extend ot the stomach
• Occurs as a result of portal HTN, usually due to cirrhosis of the liver
• When they hemorrhage, it is a medical emergency w/ high mortality
  
  • Recurrence of esophageal bleeding is common

Question 39

esophageal varices: health promotion and dz prevention

Answer 39

• Avoid alcohol
• Avoid heavy lifting
• Avoid straining w/ bowel movements
• Chew food completely, as poorly chewed foods can irritate the area
• Avoid salicylates and other meds that irritate the esophagus

Question 40

esophageal varices: risk factors

Answer 40

• Portal HTN: elevated blood pressure in veins that carry blood from the intestines to the liver
• Alcoholic cirrhosis
• Viral hepatitis
• Older adults: frequently have depressed immune function, dec liver function, and cardiac disorders that make them vulnerable to bleeding

Question 41

portal HTN

Answer 41

• Caused by impaired circulation of blood thru the liver–>collateral circulation develops, creating varices in the upper stomach and esophagus
  
  • Varices are fragile and can bleed easily
• Primary risk factor for development of esophageal varices

Question 42

esophageal varices: expected findings

Answer 42

• May experience no manifestations until the varices bleed
  
  • Hematemesis, melena, and general deterioration of physical and mental status
• Activities that precipitate bleeding→Valsalva maneuver, lifting heavy objects, coughing, sneezing, alcohol consumption
• Physical Assessment Findings w/ bleeding varices:
  
  • Shock
  • hypoTN
  • Tachycardia
  • Cool, clammy skin

Question 43

esophageal varices: lab tests

Answer 43

• Liver fcn tests: indicate liver disorder
• H&H: can indicate anemia secondary to occult bleeding or overt bleeding
• Elevated serum ammonia level: indicates an inc nitrogen load from bleeding varices

Question 44

esophageal varices: diagnostic procedures

Answer 44

• Endoscopy: therapeutic interventions can be performed during the endoscopy
• Nursing Actions:
  
  • Administer preprocedure sedation
  • After the procedure, monitor V/S and take measures to prevent aspiration

Question 45

esophageal varices: nursing care

Answer 45

• If bleeding is suspected, establish IV access w/ a large bore needle, monitor V/S and HCT, type and cross match for possible transfusions, and monitor for overt and occult bleeding

Question 46

esophageal varices: meds

Answer 46

• nonselective beta blockers
• vasoconstrictors

Question 47

esophageal varices: nonselective beta blockers

Answer 47

• Propranolol: prescribed to decreased HR and consequently reduce hepatic venous pressure
• Used prophylactically (not for emergency hemorrhage)

Question 48

esophageal varices: vasoconstrictors

Answer 48

• Octreotide: synthetic form of hormone somatostatin decreases the bleeding from the varices but does not affect BP
• Vasopressin causes constriction of esophageal and proximal gastric veins and reduces portal pressure
• Nursing Considerations:
  
  • Vasopressin should not be given to clients who have coronary artery dz due to resultant coronary constriction
    
    • Potent vasoconstriction can cause problems with peripheral and cerebral circulation
    • If vasopressin is used with nitroglycerin IV in this client population, it can decrease or prevent the vasoconstriction of the coronary arteries
  • Monitor for fluid retention and hyponatremia, as vasopressin has an antidiuretic effect

Question 49

esophageal varices: list the therapeutic procedures used

Answer 49

• endoscopic variceal ligation (EVL)
• endoscopic sclerotherapy
• transjugular intrahepatic portal systemic shunt (TIPS)
• esophagogastric balloon tamponade
• surgical intervention

Question 50

esophageal varices: endoscopic variceal ligation (EVL)

Answer 50

• Can be used w/ acute bleeding
• During endoscopy, the varices are rubber banded to cut off the circulation to the varices
  
  • Necrosis of the tissue occurs w/ eventual sloughing off of the varix
• There is a significant decrease in rebleeding as well as decreased mortality postprocedure
• Complications:
  
  • Superficial ulceration
  • Dysphagia
  • Temporary chest discomfort
  • Esophageal strictures (rare)
• Nursing Actions:
  
  • Administer preprocedure sedation
  • After procedure, monitor V/S and prevent aspiration

Question 51

esophageal varices: endoscopic sclerotherapy

Answer 51

• During endoscopy, a sclerosing agent is injected into the varices resulting in thrombosis of the varicosity
• Complications:
  
  • Bleeding
  • Perforation of the esophagus
  • Aspiration pneumonia
  • Esophageal stricture
• Nursing actions:
  
  • Administer preprocedure sedation
  • After procedure: monitor V/S and prevent aspiration
  • Antacids, H2 receptor blockers, or PPIs may be administered after the procedure to protect the esophagus and prevent acid reflux which is often caused by sclerotherapy

Question 52

esophageal varices: Transjugular intrahepatic portal-systemic shunt (TIPS)

Answer 52

• Used to tx an acute episode of bleeding when EVL and medications are not controlling the bleeding
  
  • It rapidly lowers portal pressure
  • Procedure is costly and is only used when other measures do not work
• While the client is under sedation or general anesthesia, a catheter is passed into the liver via the jugular vein in the neck
  
  • A stent is then placed b/w the portal and hepatic veins bypassing the liver
  • Portal HTN is subsequently relieved
• Complications:
  
  • Bleeding
  • Sepsis
  • Heart failure
  • Organ perforation
  • Liver failure
• Nursing Actions:
  
  • Monitor V/S
  • Keep HOB elevated

Question 53

esophageal varices: esophagogatric balloon tamponade

Answer 53

• Rarely used but can be used to temporarily control bleeding until another measure can be implemented
• Risks:
  
  • Tube migration: which can lead to airway obstruction
  • Aspiration of gastric contents into lungs
• Clients are often intubated to protect the airway
• Can cause necrosis of tissue if left in place for extended period of time
  
  • Balloon should be in place no longer than 12 hours
• Nursing Actions:
  
  • Check balloons for leak prior to insertion
  • Monitor placement of the tube and observe for possible airway obstruction
  • Monitor for aspiration into lungs and secretions or blood from esophagus
  • Provide oral suction
  • Maintain balloon pressure at prescribed pressure for prescribed time to dec risk of esophageal or gastric necrosis from ischemia
  • Monitor the client who has dec mentation or confusion and who might pull on tube

Question 54

esophageal varices: surgical intervention

Answer 54

• Last resort
  
  • TIPS has replaced many surgical options
  • High morbidity and mortality with surgery
• Bypass procedures establish a venous shunt that pypasses the liver and dec portal HTN
  
  • Common shunts include:
    
    • Splenorenal: splenic, left renal veins
    • Mesocaval: mesenteric vein, vena cava
    • Portacaval: portal vein, IVC
  • Clients commonly have NG tube inserted to monitor for hemorrhage
• Nursing actions:
  
  • Monitor for inc in liver dysfunction or encephalopathy
  • Monitor NG tube secretions for bleeding
  • Monitor PT, PTT, platelets, INR

Question 55

esophageal varices: hypovolemic shock

Answer 55

• complication of esophageal varices
• due to hemorrhage from varices
• Nursing actions:
  
  • Observe for manifestations of hemorrhage and shock (tachycardia, hypoTN)
  • Monitor V/S, Hgb, Hct, and coagulation studies
  • Replace losses and support therapeutic procedures to stop and control bleeding