GERD Flashcards
GERD
Common problem
Chronic manifestation of mucosal damage
Caused by reflux of gastric contents into lower esophagus
Not a disease, but a syndrome
Etiology and Patho
No one single cause
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
Predisposing factors
Hiatal hernia Incompetent lower esophageal sphincter (LES) -Antireflux barrier Decreased esophageal clearance Decreased gastric emptying
Incompetent LES
Primary factor in GERD
Results in decreased pressure in distal portion of esophagus
-Gastric contents move from stomach to esophagus
-can be due to certain drugs and foods
Risk factors
Obesity
Pregnant women
Cigarette and cigar smoking
Hiatal hernia
Heartburn (pyrosis)
Most common clinical manifestation
Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw
Felt intermittently
Dyspepsia
Pain or discomfort centered in upper abdomen
Regurgitation
Described as hot, bitter, or sour liquid coming into throat or mouth
Hypersalivation may also be reported
Most individuals have mild symptoms like
Heartburn after a meal
Occurs once a week
No evidence of mucosal damage
Healthcare provider should evalauate
Heartburn occurring more than once a week, rated as severe, or occurring at night and waking patient
Older adults w/ recent onset of heartburn
Heartburn occurs
Following ingestion of food or drugs that decrease LES pressure
Directly irritates esophageal mucosa
Potential respiratory symptoms
Wheezing
Coughing
Dyspnea
Nocturnal coughing w/ loss of sleep
Otolaryngologic symptoms include
Hoarseness
Sore throat
Lump in threat
Choking
Chest pain
Described as burning, squeezing, or radiating to back, neck, jaw, or arms
Can mimic angina
More common in older adults
Relieved w/ antacids
Esophagitis
*
*Related to direct local effects of gastric acid on esophageal mucosa
Inflammation of esophagus
Frequent complication
Repeated exposure: esophageal stricture (resulting in dysphagia)
Barrett’s esophagus (esophageal metaplasia)
Replacement of normal squamous epithelium w/ columnar epithelium
Precancerous lesion
Thought to be primarily due GERD
Diagnosed in 5%-15% of patients w/ chronic reflux
S/Sx: none to perforation
Must be monitored every 2-3 years by endoscopy
Respiratory Complications
Due to irritation of upper airway by secretions
-Cough
-Bronchospasm
-Laryngospasm
-Cricopharyngeal spasm
Potential for asthma, bronchitis, and pneumonia
Dental erosion complications
From acid reflux into mouth
Especially posterior teeth
Diagnostic studies
History and physical exam
Barium swallow (can detect protrusion of gastric fundus)
Upper GI endoscopy (useful in assessing LES competence, degree of inflammation, scarring, strictures)
Biopsy and cytologic specimens (differentiate cancer from Barrett’s esophagus)
Esophageal manometric (motility) studies (measure pressure in esophagus and LES)
Radionuclide Tests (diagnostic study)
Detect reflux of gastric contents
Demonstrate rate of esophageal clearance
Monitoring pH
Laboratory or 24-hr ambulatory
Determine esophageal pH by using specially designed probes
4-5 region in stomach. Should be more basic than acidic
Lifestyle modifications
Avoid triggers
Nutritional therapy
Decrease high-fat foods
Take fluids between rather than with meals
Avoid milk products at night
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 w/ mild symptoms
Proton Pump Inhibitors (PPI)
Drug therapy
Promotes esophageal healing in 80%-90% f patients
Decrease incidence of esophageal strictures
Headache is most common side effect
Omeprazole
Long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist, and spine
Associated w/ increased risk of C. difficile infection in hospitalized patients
Histamine-2 receptor (H2R) blockers
Drug therapy Decrease secretion of HCl acid Reduce symptoms and promote esophageal healing in 50% of patients Cimetidine Side effects are uncommon
Acid protective
Drug therapy
Used for cytoprotective properties
Sucralfate
Cholinergic
Drug therapy Increase LES pressure Improve esophageal emptying Increase gastric emptying Bethanechol
Prokinetic drugs
Drug therapy
Promote gastric emptying
Reduce risk of gastric acid reflux
Meoclopramide
Antacids
Drug therapy Quick but short-lived relief Neutralize HCl acid Taken 1-3 hrs after meals/at bedtime Maalox, Mylanta
Surgical therapies when necessary
Failure of conservative therapy Medication intolerance Barrett's metaplasia Esophageal stricture and stenosis Chronic esophagitis *Nissen and Toupet fundoplications
LINX Reflux Management System
Titanium beads w/ magnetic core strung together and implanted laparoscopically into LES
Under resting, nonswallowing conditions, the ring tightens
When individual swallows, the ring opens
Endoscopic therapy
Endoscopic mucosal resection
Photodynamic therapy
Cryotherapy
Radiofrequency ablation
Nursing Management
Elevation of head of bed 30 degrees Not lying down for 2-3 hrs after eating Avoidance of late-night eating Evaluating effectiveness of medications Observing for side effects of medications Stress reduction techniques Weight reduction, if appropriate Small, frequent meals
Avoidance of factors that cause reflux
Stop smoking
Avoid alcohol and caffeine
Avoid acidic foods
Focusing Postoperative Care
Prevention of respiratory complications
Maintenance of fluid/electrolyte balance
Prevention of infection
Respiratory assessment postoperative care
Respiratory rate/rhythm Pulse rate/rhythm Signs of pneumothorax -dyspnea -chest pain -cyanosis
Postoperative care
Deep breathing techniques
Accurate I/O
Observing for fluid/electrolyte imbalance
Pain medication
Medications to prevent N/V
When peristalsis returns, only fluids given initially
Solids added gradually
Normal diet gradually resumed
Pt must avoid gas-forming foods and must chew foods thoroughly
First month after surgery, pt may report mild dysphagia; should resolve after edema subsides
Pt should report persistent symptoms such as heartburn and regurgitation
