Gastric Esophageal Reflux Flashcards
What is GERD?
Common problem
Chronic manifestation of mucosal damage
What causes GERD
Caused by reflux of gastric contents into lower esophagus
Is GERD a disease?
No it is a syndrome
GERD results when?
Defenses of lower esophagus are overwhelmed by reflux of gastric contents into esophagus
Reflux of HCl acid and pepsin secretions cause irritation and inflammation
Intestinal proteolytic enzymes and bile salts add to irritation
What are Predisposing factors of GERD
Hiatal Hernia
Decreased esophageal clearance
Decraesed Gastric Emptying
Hiatal hernia?
Incompetent lower esophageal sphincter (LES): Biggest culprate
Causing:
Antireflux barrier
What is decreasesed esophageal clearance?
incompetent LES (lower esophageal sphincter) takes longer for food to leave esophagus
What does incompetent LES cause?
Primary factor in GERD
Results in ↓ pressure in distal portion of esophagus
Gastric contents move from stomach to esophagus
Can be due to certain foods (caffeine, chocolate, peppermint) and drugs (anticholinergics): decrease pressure in LES increasing GERD
Other risk factors?
Obesity is a risk factor
Pregnant women are at increased risk
Cigarette and cigar smoking can contribute to GERD
Hiatal hernia is a common cause of GERD
Symptoms of GERD?
Heartburn (pyrosis)
Dyspesia
Regurgitation
Symptoms of Heartburn?
Most common clinical manifestation
Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw
Felt intermittently
Symptoms of Dyspepsia
Pain or discomfort centered in upper abdomen
Symptoms of regurgitation?
Described as hot, bitter, or sour liquid coming into throat or mouth
Hypersalivation may also be reported
Most individuals have mild symptoms such as?
Heartburn after a meal:
to consider as GERD it will happen at least twice a week
No evidence of mucosal damage
When does Heartburn occur?
Following ingestion of food or drugs that ↓ LES pressure
Directly irritates esophageal mucosa
Individual may also report respiratory symptoms such as?
Wheezing
Coughing
Dyspnea
Nocturnal coughing with loss of sleep
Can mimic asthma due to inflammation of the trachea causing voice hoarseness and sore throat
Otolaryngologic symptoms include
Hoarseness
Sore throat
Lump in throat
Choking
Symptoms of GERD-related chest pain
Described as burning, squeezing, or radiating to back, neck, jaw, or arms
Can mimic angina
More common in older adults with GERD
Relieved with antacids
Complications of GERD
òEsophagitis
Barrett’s esophagus (esophageal metaplasia): When healing process occurs: follow up with biopsy can be cancerous
Respiratory
Potential for asthma, bronchitis, and pneumonia
Dental erosion
From acid reflux into mouth
Especially posterior teeth
Diagnostic Studies
History and physical examination
Barium swallow
Upper GI endoscopy
Biopsy and cytologic specimens
Esophageal manometric (motility) studies: measures pressure of LES
Radionuclide tests
Detect reflux of gastric contents
Demonstrate rate of esophageal clearance
Monitoring pH
Laboratory or 24-hour ambulatory
Determine esophageal pH by using specially designed probes
Nutritional Therapy
Decrease high-fat foods
Take fluids between rather than with meals
Avoid milk products at night: Temporarily helps but has a rebound effect due to calcium increasing acid content
Avoid late-night snacking or meals
Avoid chocolate, peppermint, caffeine, tomato products, orange juice
Weight reduction therapy
Chewing gum and oral lozenges can increase saliva production and help patients with mild symptoms
What kind of drug therapy is given?
Proton pump inhibitors (PPIs)
What are common PPI’s?
omeprazole (Prilosec)
esomeprazole (Nexium)
How do PPI’s help?
Promote esophageal healing in 80% to 90% of patients
Decrease incidence of esophageal strictures
Decrease the rate of gastric acid secretion
What is the most common side effect of PPI’s and why?
Headache:
It interferes with the absorption of Magnesium and Calcium. Magnesium is crucial for nerve transmission
What other drug alerts are there with PPI’s?
Long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist, and spine: Due to interfering with the absorption of calcium
PPI’s are asssociated with an increased incidence of what and why?
C. difficile infection in hospitalized patients:
Due to altering gastric contents: usually seen in those with a hx
What other types of drugs are used in GERD?
Histamine-2 receptor (H2R) blockers
Cholinergic
Prokinetic drugs
Antacids
Drugs with cytoprotective properties
Histamine-2 receptor (H2R) blockers
Name
How they work
side effects
Decrease secretion of HCl acid
Reduce symptoms and promote esophageal healing in 50% of patients
Example: cimetidine (Tagamet), famotidine (Pepcid): Prophylactic in hospitals to prevent stress ulceres, rantidine
Side effects uncommon
Drugs with cytoprotective properties and teaching needed
sucralfate (Carafate):
Give 30 minutes before you eat because it works better in low Ph
Cholinergic Drugs
Name
How they work
Increase LES pressure
Improve esophageal emptying
Increase gastric emptying
Example: bethanechol (Urecholine):
Prokinetic drugs
Name
How they work
Promote gastric emptying
Reduce risk of gastric acid reflux
Example: metoclopramide (Reglan)
Antacids
Name
How they work
Pt teaching
Quick but short-lived relief
Neutralize HCl acid
Taken 1–3 hours after meals/at bedtime
Example: Maalox, Mylanta
What kind of surgical therapy can be done?
laparoscopic Nissen fundoplication
When is surgical therapy necessary?
Failure of conservative therapy
Medication intolerance
Barrett’s metaplasia
Esophageal stricture and stenosis
Chronic esophagitis
Patient Teaching
Elevation of head of bed 30 degrees
Not lying down for 2–3 hours after eating
Avoidance of late-night eating
Avoidance of factors that cause reflux
Stress reduction techniques
Weight reduction, if appropriate
Small, frequent meals
Postoperative care Focus
Prevention of respiratory complications
Maintenance of fluid/electrolyte balance
Prevention of infection
Postoperative care
Respiratory assessment
Respiratory rate/rhythm
Pulse rate/rhythm
Signs of pneumothorax
What are Signs of pneumothorax
Dyspnea
Chest pain
Cyanosis
Post Operative Care General
Deep breathing techniques
Accurate I/O
Observing for fluid/electrolyte imbalance
Pain medication
Medications to prevent nausea/vomiting
Postoperative care diet
When peristalsis returns, only fluids given initially
Solids added gradually
Normal diet gradually resumed
Patient must avoid gas-forming foods and must chew foods thoroughly
Postoperative care after teaching for after D/C
First month after surgery, patient may report mild dysphagia; should resolve after edema subsides
Patient should report persistent symptoms such as heartburn and regurgitation
