(relates to chapter 42, “nursing management: upper gastrointestinal problems,” in the textbook)...

(Relates to Chapter 42, “Nursing Management:

Upper Gastrointestinal Problems,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2

DescriptionNot a disease but a syndrome

Clinically significant symptomatic condition or histopathologic alteration

Secondary to reflux of gastric contents into lower esophagus


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Etiology and PathophysiologyNo single causeResults when

Defenses of lower esophagus are overwhelmed by reflux of gastric contents into esophagus


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Etiology and Pathophysiology


Fig. 42-3. Esophagitis with esophageal ulcerations.

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Etiology and PathophysiologyPredisposing factors

Hiatal herniaIncompetent lower esophageal sphincter (LES) Antireflux barrier

Decreased esophageal clearance

Decreased gastric emptying


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Etiology and PathophysiologyHCl acid and pepsin secretions reflux—cause irritation and inflammation

Intestinal proteolytic enzymes and bile salts add to irritation.


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Etiology and PathophysiologyIncompetent LES

Primary factor in GERDResults in ↓ in pressure in distal portion of esophagusGastric contents move from stomach to esophagus.

Can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics)


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Etiology and PathophysiologyObesity 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.


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Clinical ManifestationsSymptoms of GERD

Heartburn (pyrosis)Most common clinical manifestation

Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw

Felt intermittentlyRelieved by milk, alkaline substances, or water


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Clinical ManifestationsSymptoms of GERD (cont’d)

DyspepsiaPain or discomfort centered in upper abdomen

HypersalivationNoncardiac chest pain

More common in older adults


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Clinical ManifestationsMost individuals have mild symptoms.Heartburn after a mealOccurs once a weekNo evidence of mucosal damage


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Clinical ManifestationsHealth care provider should evaluateMild symptoms for period of 5 years or longer

Symptoms associated with difficulty swallowing


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Clinical ManifestationsHealth care provider should evaluateHeartburn occurring more than once a week, rated as severe, or occurring at night and waking patient

Older adults with recent onset of heartburn


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Clinical ManifestationsHeartburn occurs

Following ingestion of food or drugs that ↓ LES pressure

Directly irritates esophageal mucosa


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Clinical ManifestationsIndividual may also report

WheezingCoughingDyspneaHoarsenessSore throatLump in throatChoking Regurgitation


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Clinical ManifestationsRegurgitation

Effortless return of food or gastric contents from stomach into esophagus or mouth

Described as hot, bitter, or sour liquid coming into the mouth or throat

Can mimic angina


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ComplicationsRelated to direct local effects of gastric acid on esophageal mucosaEsophagitis

Inflammation of esophagusFrequent complication


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Esophagitis


Fig. 42-4. Nissen fundoplication for repair of hiatal hernia. A, Fundus of stomach is wrapped arounddistal esophagus. B, The fundus is then sutured to itself.

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ComplicationsEsophagitis (cont’d)

Other risk factors include hiatal hernia, chemical irritation.

Repeated exposure—esophageal strictureResulting in dysphagia


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ComplicationsBarrett’s esophagus

Replacement of normal squamous epithelium with columnar epithelium

Precancerous lesionDiagnosed in 5% to 15% of patients with chronic reflux

Signs and symptoms: None to perforation

Must be monitored every 1 to 3 years by endoscopy


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ComplicationsRespiratory

Due to irritation of upper airway by secretionsCoughBronchospasmLaryngospasmCricopharyngeal spasm


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ComplicationsRespiratory (cont’d)

Potential for asthma, bronchitis, and pneumonia

Dental erosionFrom acid reflux into mouthEspecially posterior teeth


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Diagnostic StudiesHistory and PEBarium swallow

Can detect protrusion of gastric fundus

Upper GI endoscopy Useful in assessing LES competence, degree of inflammation, scarring, strictures


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Diagnostic StudiesBiopsy and cytologic specimens Differentiate carcinoma from Barrett’s esophagus

Esophageal manometric (motility) studiesMeasure pressure in esophagus and LES


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Diagnostic StudiesRadionuclide tests

Detect reflux of gastric contents

Rate of esophageal clearance


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Diagnostic StudiesMonitoring pH

Laboratory or 24-hour ambulatory

Determine esophageal pH using specially designed probes


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Collaborative CareLifestyle modifications

Avoid triggersNutritional therapy

Decrease high-fat foods.Take fluids between rather than with meals.

Avoid milk products at night.Avoid late-night snacking or meals.


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Collaborative CareNutritional therapy (cont’d)

Avoid chocolate, peppermint, caffeine, tomato products, orange juice.

Weight reduction therapy


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Collaborative CareDrug therapy

Two approaches1. Step up

Start with antacids and OTC H2R blockers, and progress to prescription H2R blockers and finally PPIs.


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Collaborative CareDrug therapy

Two approaches2. Step down

Start with PPIs, and titrate down to prescription H2R blockers and finally OTC H2R blockers and antacids.


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Collaborative CareDrug therapy (cont’d)

Histamine (H2)-receptor blockersDecrease secretion of HCl acidReduce symptoms and promote esophageal healing in 50% of patients

Side effects uncommonPepcid, Zantac, Tagamet


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Proton pump inhibitors (PPIs)Decrease gastric HCl acid secretionPromote esophageal healing in 80% to 90% of patients

May be beneficial in ↓ esophageal strictures

Headache: Most common side effectPrilosec, Nexium, Aciphex


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AntacidsQuick but short-lived reliefNeutralize HCl acidTaken 1 to 3 hours after meals/bedtimeMaalox, Mylanta


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Acid protectiveUsed for cytoprotective properties

Sucralfate (Carafate)


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CholinergicIncrease LES pressureImprove esophageal emptying Increase gastric emptyingNegative: Stimulate HCl acid secretionBethanechol (Urecholine)


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Prokinetic drugsPromote gastric emptyingReduce risk of gastric acid reflux

Metoclopramide (Reglan)


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Collaborative CareSurgical therapy

Necessary ifConservative therapy failsMedication intoleranceBarrett’s metaplasiaEsophageal stricture and stenosisChronic esophagitisHiatal hernia

Nissen and Toupet fundoplications


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Nissen Fundoplication


Fig. 42-5. A, Normal esophagus. B, Sliding hiatal hernia. C, Rolling or paraesophageal hernia.

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Collaborative CareEndoscopic therapy

Endoscopic mucosal resectionPhotodynamic therapyCryotherapyRadiofrequency ablation


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Nursing ManagementAvoidance of factors that cause reflux Stop smokingAvoid alcohol and caffeineAvoid acidic foods

Stress reduction techniquesWeight reduction, if appropriate

Small frequent mealsCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

41

Nursing ManagementElevation of HOB 30 degreesNot lying down for 2 to 3 hours after eating

Avoidance of late-night eatingEvaluation of effectiveness of medications

Observing for side effects of medications


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Nursing ManagementPostoperative care

FocusPrevention of respiratory complications

Maintenance of fluid/electrolyte balance

Prevention of infection


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Nursing ManagementPostop care (cont’d)

Respiratory assessmentRespiratory rate/rhythmPulse rate/rhythmSigns of pneumothorax

DyspneaChest painCyanosis


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Deep breathing techniquesAccurate I/OObserving for fluid/electrolyte imbalance

Pain medicationMedications to prevent nausea/vomiting


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When peristalsis returns, only fluids given initially

Solids added graduallyNormal diet gradually resumedPatient must avoid gas-forming foods and must chew foods thoroughly.


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First month after surgery, patient may report mild dysphagia—should resolve after edema subsides

Patient should report persistent symptoms such as heartburn and regurgitation.


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After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective?

1. “I can have a glass of low-fat milk at bedtime.”2. “I will have to eliminate all spicy foods from my diet.” 3. “I will have to use herbal teas instead of caffeinated drinks.”4. “I should keep something in my stomach all the time to neutralize the excess acids.”

Audience Response Question


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Case Study20-year-old man complains of loss of appetite and occasional lower sternal chest pain 30 to 60 minutes after meals.

He claims symptoms began about 6 months ago.


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Case StudyHe has a history of asthma.States he has needed inhaler “more than usual”

Does not know what makes it worse or better

EGD suggests GERD.


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Discussion Questions1.How may factors be

affecting his GERD?

2.What nutritional counseling should you do?


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Discussion Questions3. He states that he doesn’t

want to take any medication. How can you best advise him?

4. What are long-term complications of GERD?


(relates to chapter 42, “nursing management: upper gastrointestinal problems,” in the textbook)...

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