from 2. Upper GI Disorders Flashcards
stages of swallowing
- preparatory
- oral
- pharyngeal
- esophageal
risks for dysphagia
NEUROMUSCULAR DISORDERS, SURGERY, TRAUMA Stroke–CVA Multi-infarct dementia or Alzheimer’s Brain aneurysms Amyotrophic lateral sclerosis (ALS) Parkinson’s disease Diabetic neuropathy/gastroparesis Cerebral palsy Achalasia Raynaud’s Scleroderma Closed head injury Caustic ingestion Burns Facial/laryngeal trauma Head and neck cancer tracheostomy
dysphagia: s/s
anorexia and wt loss.
food sticking in throat.
choking on food, liquid or saliva.
Coughing or discomfort in throat or chest when swallowing.
heartburn or acid reflux.
pt finds fluids/solids difficult to swallow.
symptoms indicating aspiration, such as recurrent chest infection.
Need for repeated swallowing.
Drooling or rocking the tongue.
Pockets of food pooling in the mouth or throat.
Difficulty chewing.
Gurgling or wet voice quality.
Hoarse breathing.
dysphagia: Dx
bedside swallow evaluation.
MODIFIED BARIUM SWALLOW/ VIDEO FLUOROSCOPY SWALLOW STUDY.
various food consistencies for swallow test.
dysphagia: Dx recommendations
- NPO with re-eval if status improves
- Modified barium swallow
- Dysphagia diet
- Swallowing therapy
dysphagia: Tx
Swallowing therapy
Devices like special straws
Electrical stimulation
Modified food and beverage consistency
aspiration
Food or beverages enter the respiratory tract.
Can cause immediate respiratory distress, block the airway, or lead to aspiration pneumonia.
May occur only with certain consistency foods or all foods
National Dysphagia Diet (NDD)
level 1: pureed
level 2: mechanically altered
level 3: advanced
level 4: regular diet
achalasia
LES fails to relax (opp of GERD),
absence of esophageal peristalsis.
achalasia: possible cause
defective nerves or maybe a virus
achalasia: s/s
Dysphagia for solids and liquids Weight loss/ malnutrition Substernal chest pain Fullness in the chest Nausea & vomiting Regurgitation and burning
achalasia: Meds
Calcium channel blockers Nifedipine (Adalat) or nitrates (isordil) to relax the LES
achalasia: Management
intrasphincteric injection of botulinum toxin.
Pneumatic dilatation - A balloon is inflated at the level of the gastroesophageal junction.
laparoscopic Heller Myotomy -Surgery to divide some of the LES muscle fiber.
Worst case esophagectomy.
achalasia: MNT
help lessen discomfort.
disphagia diet,
freq small slow feedings,
fat to relax LES
achalasia: avoid
extreme temp, spicy, acid, hard fibrous foods
esophageal (Zenker) diverticulum
weakened esophageal wall causing a pouch in esophagus
esophageal (Zenker) diverticulum: s/s
dysphagia, fetid breath, GERD
esophageal (Zenker) diverticulum: Tx
laproscopic surgical removal
GERD
Gastroesophageal reflux disease. (low LES pressure, stays open, opp of achalasia)
long term GERD
lead to Barett’s esophagus - increase esophageal cancer risk (esp if genetically susceptible)
GERD: avoid
spicy, high fat food, eating too much, factors that lower LES pressure
GERD: s/s
Pyrosis (heart burn)
Dysphagia
Pulmonary symptoms /aspiration
Chest pain
Burning throat
bitter or sour taste of the acid in the back of the throat
GERD: Management
add factors that increase LES pressure, lower gastric acidity, surgery fundoplication
low LES pressure factors:
High fat foods Alcohol Coffee/caffeine Chocolate Smoking Peppermint/spearmint Acid foods like citrus or tomatoes Hot spicy foods mustard Pepper Red wine Carbonated beverages
Meds such as: Estrogen Progesterone Valium L-dopa narcotics
higher LES pressure factors:
high protein intake,
Metoclopramide (reglan) - speed gastric emptying,
obesity, overeating, reclining, large fluid intake, constipation, running, aspirin. (aloe vera, deglycyrrhizinated licorice, apple cider vinegar, gum?)
OTC meds to decrease gastric acid:
Histamine receptor blockers, antacids
PRESC meds to decrease gastric acid:
proton pump inhibitors (work best)
histamine receptor blocker names
nizatidine (Axid)
ranitidine (Zantac)
famotidine (Pepcid)
cimetidine (Tagamet)
antacid names
Mylanta, Maalox, Tums, Rolaids, Gaviscon-foams and decreases acid reflux into esophagus
PPI’s names
-work best to decrease gastric acid- esomeprazole (Nexium) lansoprazole (Prevacid) omeprazole (Prilosec) pantoprazole (Protonix) rabeprozole (Aciphex) dexlansoprazole (Dexilant)
antacids decrease absorption of:
iron, thiamin, phosphorus, vit A
PPI’s & Hist blockers decrease absorption of:
vit B-12
lower stomach acid decrease absorption of:
Ca, Mg, Fe
Magnetic Sphincter Augmentation (MSA)
surgical device to treat GERD. restore sphincter-like fcn, may cause dysphagia
nissen fundolication
transoral endoscopic fundoplication - lessens reflux
hiatal hernias
stomach protrudes through diaphragm up into thorasic cavity.
sliding & rolling (paraesophageal)
hiatal hernias: symptoms
none or similar to GERD (pyrosis, dysphagia, aspiration, chest pain, bitter burning throat)
ulceration of the herniated stomach may result in:
bleeding & anemia, obstruction, torsion, gangrene, perforation
gastric volvulus w/strangulation
stomach becomes twisted and angulated in its midportion. surgical emergeny if stomach cannot be decompressed.
gastric volvulus occurance
occurs post-prandially, seen in 30% of paraesophageal hernias
borchardt’s triad
chest pain,
retching w/out vomit, and inability to pass a nasogastric tube.
often requires emergency surgery
hiatal hernias: management
same as GERD (try to increase LES pressure), maybe surgery
esophagitis
infection like candida albicans, HIV, Epstein Barr virus, CMV, TB, etc.
can be acute or chronic
esophagitis: symptoms
similar to heartburn, cough, dysphagia, hoarseness, sore throat
causes of esophagitis
Trauma Bulimia/frequent vomiting Chemotherapy or radiation exposure as in cancer therapy Drug side effect Ingestion of caustic materials Crohn’s disease Graph vs host disease eosinophilic (may be related to food allergies) Alcohol or smoking
esophagitis: Plummer-Vinson syndrome
dysphagia, upper esophageal webs, difficulty swallowing, iron def anemia, glossitis, koilonychias (spoon nails), pallor
Plummer-Vinson syndrome: Tx
iron sups
Mallory Weiss Syndrome
led to from Barrett’s esophagus. tears in esophagus w/bleeding. a few cases require surgery.
Mallory Weiss syndrome: common in
alcohol abusers,
those w/ hiatal hernias
esophagitis: Management
treat condition causing it.
correct iron def in Plummer-Vinson syndrome.
otherwise, tx is similar to GERD
esophageal cancer
squamous cell carcinoma or adenocarcinoma
esophageal cancer: risks
tobacco/alcohol use, barrett's esophagus, irritant exposure, viruses, high meat & low F&V intake
esophageal cancer: stages
I (localized)
II (metastasized)
esophageal cancer: s/s
Difficult or painful swallowing. Severe weight loss. Pain in the throat or back, behind the breastbone or b/w shoulder blades. Hoarseness or chronic cough. Vomiting. Coughing up blood.
esophageal cancer: Management
esophagectomy,
may need radiation and/or chemo and/or laser therapy
esophagectomy
removes the tumor along w/all or a portion of esophagus, nearby lymph nodes, and other tissues in the area. remaining healthy part is anastamosed to stomach or plastic tube, or part of intestine will be used to replace the esophagus.
esophageal replacement surgery
congenital anomalies, severe trauma/damage from swallowing caustic materials, stricture, cancer.
part of the colon, SI, or a tube may be used to replace the esophagus.
esophageal replacement surgery: TF
jejunostomy tube often placed, pt is weaned from TF to oral food in freq small feedings. liquid sups are helpful, start w/water. may have to give TPN if pt needs aggressive tx.
post esophageal replacement surgery complications
dysphagia lactose intolerance GERD poor taste bad tastes
3 components of vomiting
nausea, retching, emesis
N&V: causes
virus, bacteria, motion/morning sickness, DKA, PUD, brain tumor, Meniere’s disease, bowel obstruction, chemo, meds, etc.
psychogenic - food aversions, self induced - manually or with ipecac, erotic.
severe N&V: consequences
aspiration, Na, K depletion, dehydration, alkalosis go to ER if vomit is black/coffee ground-like, tears in esophagus, esophagitis, tooth deterioration
N&V: Antiemetic meds
antivert (Meclizine) and bonine (Cyclizine) - antihistamines. Compazine (prochlorperazine), Phenergan (promethazine), Dramamine (dimenhydrinate), scopolamine, kytril (Granisetron), reglan (metoclopramide), Marinol® (dronabinol), Emend® (aprepitant), tigan (Trimethobenzamide), Zofran (Ondansentron), anzemet (Dolasetron), emete-con (benzquinamide)
hyperemesis gravidarum (HG)
intractable N&V at 2% pregnancies. makes pg high risk.
40-90% of women experience morning sickness (mild, no wt loss or poor wt gain)
hyperemesis gravidarum (HG): etiology
not clear, maybe: hormonal changes, allergies/immunological factors, stomach or metabolic abnormalities, psychosomatic as in AN/bulimia, genetic incompatibilities, GERD, Helicobacter pylori, vit def such as B6 or Mg?
hyperemesis gravidarum: s/s
Severe N&V, dehydration, electrolyte depletion, ketosis, weight loss or poor weight gain, poor oral intake and appetite, multiple nutritional deficiencies, ptyalism (excessive salivation), esophagitis, esophageal tears, liver damage, kidney damage, encephalopathy, brain or retinal hemorrhage, injury or death of mother or baby
HG: Tx
give anti-emetics that are safe for pg, restore fluid & electrolyte balance & nutr status.
if anti-emetics don’t work, pt will need jejunostomy or TPN until can have normal intake. may take wks to mos. good outcome if treated.
gastritis: cause
inflammation of stomach lining.
caused by bacteria, , viruses, alcohol, allergies, autimmune reactions as in pernicious anemia, medications, chemical damage, bile reflux, Crohn’s, radiation gastritis, GVHD, Menetrier’s disease (hyperplastic hypersecretory gastropathy)
gastritis: most common cause
Helicobacter pylori
Helicobacter pylori causes:
PUD
gastritis
HG
gastritis: s/s
Burning sensation, pain, N&V, burping, bloating, red or coffee ground vomit, melena (black stool due to blood), anorexia, weight loss, diarrhea
bacterial gastritis Tx
antibiotics
gastritis: management
avoid meds, etc that irritate stomach
pernicious anemia gastritis Tx
give high dose of oral/IM B12
Menetrier’s disease (hypertrophic gastritis) Tx
recommend high protein (20% kcal) as albumin is low
Peptic Ulcer Disease
mucosal break in stomach (15% cases) /duodenum (85% cases)
PUD: causes
Helicobacter pylori NSAIDS, aspirin, Alcohol gastrinoma (Zollinger-Ellison syndrome) severe stress (trauma, burns), Curling's ulcers bile reflux pancreatic enzyme reflux radiation staphylococcus aureus exotoxin bacterial/viral infection
Zollinger-Ellison Syndrome
cancerous/benign tumors of delta cells in islets of Langerhans in pancreas produce gastrin and cause parietal cells in stomach to over secrete acid.
Zollinger-Ellison Syndrome: s/s
stomach/duodenal ulcers, pain, secretory diarrhea, steatorrhea, malabsorption (due to inactivation of pancreatic enzymes by the excess acid), wt loss/poor appetite/malnutr, vomiting blood
Zollinger-Ellison Syndrome: Management
surgical removal of tumors, PPI’s, if does not work, need a surgical resection or total gastrectomy
gastric PUD: s/s
pain 1/2 - 1 hr after eating which is not relieved by food intake. vomit, hematemesis, gastric cancer (rare), wt loss
duodenal PUD: s/s
pain 2-3 hrs after eating that is lessened by food intake. pain at night, vomiting (rare), melena, wt gain
PUD: Dx
gastroscopy/endoscopy,
barium swallow/upper GI series
PUD: Stop doing
stop taking NSAIDS, aspirin & other meds.
stop smoking.
Helicobacter PUD: meds
flagyl, tetracycline, pepto bismol, PPI’s
PUD PESC meds
PPI’s: esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), Dexlansoprazole (Dexilant), rabeprozole (Aciphex).
Carafate (Sucralfate) - coats ulcer & decreases its exposure to acid and pepsin
PUD & GERD OCT meds
less effective
Histamine receptor blockers: nizatidine (Axid), ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet).
antacids: Mylanta, Maalox, Tums, Rolaids.
Gaviscon - foams and decreases acid reflux into esophagus
PUD MNT
diet does not cause and cannot cause an ulcer.
avoid irritant and acid producing stimulants as for GERD.
avoid eating w/in 3 hr of bedtime.
avoid skipping meals/eating large meals.
check for anemia esp if pt had hematemesis/melena (may need iron).
PUD vagotomy
cut vagus nerve to decrease stimulation, not very effective
PUD antrectomy or partial gastrectomy
the lower half of stomach (makes most acid) is removed w/Billroth I, II, or Roux-en-Y gastrojejunostomy
PUD pyloroplasty
opening up the valve at the outlet of stomach to speed gastric emptying
PUD total gastrectomy
entire stomach is removed and esophagus is anastomosed to duodenum
PUD partial gastrectomy
Billroth I: joining upper stomach to duodenum
Billroth II: joining upper stomach w/jejunum creating “Y” w/the bile drainage and the duodenum.
post gastrectomy MNT
NPO the night before surgery. usually need TPN or jejunostomy after. start w/water and clear juices, soft bland foods 6 X a day, monitor pro and kcal intake, plasma proteins.
post gastrectomy due to cancer or Zollinger-Ellison
best to have surgical jejunostomy inserted at time of surgery as at will have a slow recovery.
steatorrhea post gastrectomy
decrease fat, try MCT oil, pancreatic enzyme capsule, give miscible forms or larger doses of fat sol vit if chronic condition.
post gastrectomy: B12 absorption is
reduces since part of stomach that produces gastric intrinsic factor is removed.
prevent macrocytic/megaloblastic anemia post gastrectomy
large doses PO (500 - 2000 mg/day) or IM B12.
folate will treat anemia but will not prevent nerve damage from cobalamin def, so critical that pt gets B12.
post gastrectomy micocytic iron deficiency
due to blood loss prior/during surgery.
lower iron absorption due to low gastric acid secretion.
plasma iron & ferritin will be low and TIBC will be elevated.
give pt iron injections if does not tolerate PO.
post gastrectomy osteomalacia
due to Ca & vit D malabsorption. check plasma 25-OH vit D levels. give Ca sup daily.
post gastrectomy: detect osteomalacia
w/bone density test as plasma Ca levels are not good indicators of Ca status.
post gastrectomy bezoar
increased fibrous blockages risk in GI.
avoid high fiber: orange, coconut, persimmon, berry, green bean, fig, apple, celery, psyllium, sauerkraut, brussel sprouts, potato peel, legume
post gastrectomy early dumping syndrome
caused by high osmolarity of simple CHO and too much chyme entering SI too fast and rapid distension of SI.
post gastrectomy late dumping syndrome
due to reactive hypoglycemia where BG rises quickly followed by an over response w/too much insulin production
dumping syndrome s/s
flushing, sweating, syncope (fainting), ab fullness, diarrhea, N&V, weakness, tachycardia, hunger, tremors, anxiety
post gastrectomy: Management
don’t drink fluids w/meals. Recline after eating.
small freq feedings, cut rapid acting CHO, try new foods in small amts to assess tolerance, avoid hot/cool liquids.
