Download Chapter_042_GERD UNIT 4

(Relates to Chapter 42,
“Nursing Management:
Upper Gastrointestinal Problems,”
in the textbook)
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Description
 Not 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 Pathophysiology
 No single cause
 Results when
 Defenses of lower esophagus are
overwhelmed by reflux of gastric contents
into esophagus
 Persistent reflux that occurs more than
twice a week is considered GERD
 Assessment : occurs at night, wakes up at
night from sleep, associated with
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Etiology and Pathophysiology
Fig. 42-3. Esophagitis with esophageal ulcerations.
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Etiology and Pathophysiology
 Predisposing factors
 Hiatal hernia
 Incompetent lower esophageal sphincter
(LES)

Antireflux barrier
 Decreased esophageal clearance
 Decreased gastric emptying
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Etiology and Pathophysiology
 HCl acid and pepsin secretions reflux—
cause irritation and inflammation
 Intestinal proteolytic enzymes and bile
salts add to irritation.
 Primary cause is incompetent LES
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Etiology and Pathophysiology
 Incompetent LES
 Primary factor in GERD
 Results in ↓ in pressure in distal portion of
esophagus


Gastric contents move from stomach to
esophagus.
Can be due to certain foods (caffeine,
chocolate) and drugs (anticholinergics)
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Factors effecting LES
 Increase pressure : bethanocol, reglan,
peppermint, tea, coffee, B blockers.
 Decrease pressure: ETOH, anti
cholinergic, chocolate, fatty acids,
nicotine, CA channel blockers, valium,
nitrates, progesterone, theophyline.
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Etiology and Pathophysiology
 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.
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Clinical Manifestations
 Symptoms of GERD
 Heartburn (pyrosis)
 Most common clinical manifestation
 Burning, tight sensation felt beneath the
lower sternum and spreading upward to
throat or jaw
 Felt intermittently
 Relieved by milk, alkaline substances, or
water
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Clinical Manifestations
 Symptoms of GERD (cont’d)
 Dyspepsia
 Pain or discomfort centered in upper abdomen
 Hypersalivation
 Noncardiac chest pain
 More common in older adults
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Clinical Manifestations
 Most individuals have mild symptoms.
 Heartburn after a meal
 Occurs once a week
 No evidence of mucosal damage
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Clinical Manifestations
 Health care provider should evaluate
 Mild symptoms for period of 5 years or
longer
 Symptoms associated with difficulty
swallowing
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Clinical Manifestations
 Health care provider should evaluate
 Heartburn 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 Manifestations
 Heartburn occurs
 Following ingestion of food or drugs that
↓ LES pressure
 Directly irritates esophageal mucosa
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Clinical Manifestations
 Individual may also report
 Wheezing
 Coughing
 Dyspnea
 Hoarseness
 Sore throat
 Lump in throat
 Choking
 Regurgitation
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Clinical Manifestations
 Regurgitation
 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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Complications
 Related to direct local effects of gastric
acid on esophageal mucosa
 Esophagitis
 Inflammation of esophagus
 Frequent complication
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Esophagitis
Fig. 42-4. Nissen fundoplication for repair of hiatal hernia. A, Fundus of stomach is wrapped around
distal esophagus. B, The fundus is then sutured to itself.
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Complications
 Esophagitis (cont’d)
 Other risk factors include hiatal hernia,
chemical irritation.
 Repeated exposure—esophageal stricture

Resulting in dysphagia
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Complications
 Barrett’s esophagus
 Replacement of normal squamous epithelium
with columnar epithelium
 Precancerous lesion
 Diagnosed 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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Complications
 Respiratory
 Due to irritation of upper airway by
secretions




Cough
Bronchospasm
Laryngospasm
Cricopharyngeal spasm
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Complications
 Respiratory (cont’d)
 Potential for asthma, bronchitis, and
pneumonia
 Dental erosion
 From acid reflux into mouth
 Especially posterior teeth
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Diagnostic Studies
 History and PE
 Barium 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 Studies
 Biopsy and cytologic specimens
 Differentiate carcinoma from Barrett’s
esophagus
 Esophageal manometric (motility)
studies
 Measure pressure in esophagus and LES
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Diagnostic Studies
 Radionuclide tests
 Detect reflux of gastric contents
 Rate of esophageal clearance
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Diagnostic Studies
 Monitoring pH
 Laboratory or 24-hour ambulatory
 Determine esophageal pH using specially
designed probes
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Collaborative Care
 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.
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Collaborative Care
 Nutritional therapy (cont’d)
 Avoid chocolate, peppermint, caffeine,
tomato products, orange juice.
 Weight reduction therapy
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Collaborative Care
 Drug therapy
 Two approaches
 1. Step up

Start with antacids and OTC H2R blockers, and
progress to prescription H2R blockers and finally
PPIs.
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Collaborative Care
 Drug therapy
 Two approaches
 2. Step down

Start with PPIs, and titrate down to prescription
H2R blockers and finally OTC H2R blockers and
antacids.
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Collaborative Care
 Drug therapy (cont’d)
 Histamine (H2)-receptor blockers
 Decrease secretion of HCl acid
 Reduce symptoms and promote esophageal
healing in 50% of patients
 Side effects uncommon

Pepcid, Zantac, Tagamet
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Collaborative Care
 Drug therapy (cont’d)
 Proton pump inhibitors (PPIs)
 Decrease gastric HCl acid secretion
 Promote esophageal healing in 80% to 90% of
patients
 May be beneficial in ↓ esophageal strictures
 Headache: Most common side effect

Prilosec, Nexium, Aciphex
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Collaborative Care
 Drug therapy (cont’d)
 Antacids
 Quick but short-lived relief
 Neutralize HCl acid
 Taken 1 to 3 hours after meals/bedtime

Maalox, Mylanta
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Collaborative Care
 Drug therapy (cont’d)
 Acid protective
 Used for cytoprotective properties

Sucralfate (Carafate)
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Collaborative Care
 Drug therapy (cont’d)
 Cholinergic
 Increase LES pressure
 Improve esophageal emptying
 Increase gastric emptying
 Negative: Stimulate HCl acid secretion

Bethanechol (Urecholine)
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Collaborative Care
 Drug therapy (cont’d)
 Prokinetic drugs
 Promote gastric emptying
 Reduce risk of gastric acid reflux

Metoclopramide (Reglan)
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Collaborative Care
 Surgical therapy
 Necessary if
 Conservative therapy fails
 Medication intolerance
 Barrett’s metaplasia
 Esophageal stricture and stenosis
 Chronic esophagitis
 Hiatal 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 Care
 Endoscopic therapy
 Endoscopic mucosal resection
 Photodynamic therapy
 Cryotherapy
 Radiofrequency ablation
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Nursing Management
 Avoidance of factors that cause reflux
 Stop smoking
 Avoid alcohol and caffeine
 Avoid acidic foods
 Stress reduction techniques
 Weight reduction, if appropriate
 Small frequent meals
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Nursing Management
 Elevation of HOB 30 degrees
 Not lying down for 2 to 3 hours after
eating
 Avoidance of late-night eating
 Evaluation of effectiveness of
medications
 Observing for side effects of
medications
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Nursing Management
 Postoperative care
 Focus
 Prevention of respiratory complications
 Maintenance of fluid/electrolyte balance
 Prevention of infection
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Nursing Management
 Postop care (cont’d)
 Respiratory assessment
 Respiratory rate/rhythm
 Pulse rate/rhythm
 Signs of pneumothorax



Dyspnea
Chest pain
Cyanosis
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Nursing Management
 Postop care (cont’d)

Deep breathing techniques
 Accurate I/O
 Observing for fluid/electrolyte imbalance
 Pain medication
 Medications to prevent nausea/vomiting
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Nursing Management
 Postop care (cont’d)
 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.
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Nursing Management
 Postop care (cont’d)
 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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Audience Response Question
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.”
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Case Study
 20-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 Study
 He 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 Questions
1. How may factors be affecting his
GERD?
2. What nutritional counseling should
you do?
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Discussion Questions
3. 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?
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