Download esofageal disorders

Health Alterations II
Management of Clients
with Problems of the
Gastrointestinal System
Lecture 2.2
Disorders of the Esophagus
The main symptoms of the esofageal disorders:
Dysphagia (difficulty swallowing)
Odynophagia (acute pain on swallowing)
Achalasia
Achalasia is an absent or ineffective
peristalsis of the distal esophagus,
accompanied by failure of the esophageal
sphincter to relax in response to swallowing
Clinical Manifestations
difficulty in swallowing both liquids and solids
sensation of food sticking in the lower portion
of the esophagus
regurgitation of food
chest pain or heart-burn (pyrosis). This pain
may or may not be assotiated with eating
Assessment and Diagnostic Findings
X-ray (dilatation above the narrowing).
CT of the esofagus, barium swallowing,
endoscopy may be used too
diagnosis is confirmed by manometry
Management
The patient should be instructed to eat slowly and to
drink fluids with meals.
As a temporary measure, calcium channel blockers
and nitrates have been used to decrease esophageal
pressure and improve swallowing.
Injection of botulinum toxin (Botox) to quadrants of
the esophagus via endoscopy has been helpful
because it inhibits the contraction of smooth muscle.
Periodic injections are required to maintain remission.
If these methods are unsuccessful, pneumatic
(forceful) dilation or surgical separation of the muscle
fibers may be recommended
Achalasia may be treated conservatively by
pneumatic dilation to stretch the narrowed area of
the esophagus (fig. 1)
Pneumatic dilation has a high success rate. Although
perforation is a potential complication, its incidence is
low
The procedure can be painful; therefore, moderate
sedation in the form of an analgesic or tranquilizer, or
both, is administered for the treatment
The patient is monitored for perforation. Complaints
of abdominal tenderness and fever may be
indications of perforation
Fig. 1. Pneumatic dilation of the lower part of the esophagus
Achalasia may be treated surgically by
esophagomyotomy (Fig. 2). The procedure usually is
performed laparoscopically, either with a complete
lower esophageal sphincter myotomy and an
antireflux procedure, or without an antireflux
procedure
The esophageal muscle fibers are separated to
relieve the lower esophageal stricture.
Although patients with a history of achalasia have a
slightly higher incidence of esophageal cancer, longterm follow-up with esophagoscopy for early
detection has not proved beneficial
Fig. 2. Esophagomyotomy
Diffuse Spasm
Diffuse spasm is a motor disorder of the
esophagus
The cause is unknown, but stressful
situations can produce contractions of
the esophagus
It is more common in women and
usually manifests in middle age
Clinical Manifestations
Difficulty or pain on swallowing
(dysphagia, odynophagia)
Chest pain similar to that of coronary
artery spasm
Assessment and Diagnostic Findings
Esophageal manometry, which measures the
motility of the esophagus and the pressure
within the esophagus, indicates that
simultaneous contractions of the esophagus
occur irregularly
Diagnostic x-ray studies after ingestion of
barium show separate areas of spasm
Management
Conservative therapy includes administration of sedatives and
long-acting nitrates to relieve pain
Calcium channel blockers have also been used to manage
diffuse spasm
Small, frequent feedings and a soft diet are usually
recommended to decrease the esophageal pressure and
irritation that lead to spasm
Dilation performed by bougienage (use of progressively sized
flexible dilators), pneumatic dilation, or esophagomyotomy may
be necessary if the pain becomes intolerable
Hiatal Hernia
In a condition known as hiatus (or hiatal)
hernia, the opening in the diaphragm
through which the esophagus passes
becomes enlarged, and part of the upper
stomach tends to move up into the lower
portion of the thorax
Hiatal hernia occurs more often in women
than men
There are two types of hiatal hernias: sliding and
paraesophageal
Sliding, or type I, hiatal hernia occurs when the upper
stomach and the gastroesophageal junction (GEJ) are
displaced upward and slide in and out of the thorax
(Fig. 3a). About 90% of patients with esophageal
hiatal hernia have a sliding hernia.
A paraesophageal hernia occurs when all or part of the
stomach pushes through the diaphragm beside the
esophagus (see Fig. 3b)
Fig. 2. The Hiatal Hernia Types
Clinical Manifestations
Sliding hernia: heartburn, regurgitation, and dysphagia,
but at least 50% of patients are asymptomatic. Sliding
hiatal hernia is often implicated in reflux
Paraesophageal hernia: sense of fullness after eating or
asymptomatic. Reflux usually does not occur, because the
gastroesophageal sphincter is intact
The complications of hemorrhage, obstruction, and
strangulation can occur with any type of hernia
Assessment and Diagnostic Findings
Diagnosis is confirmed by x-ray studies,
barium swallow, and fluoroscopy
Management
Management for an axial hernia includes frequent, small
feedings that can pass easily through the esophagus. The
patient is advised not to recline for 1 hour after eating, to
prevent reflux or movement of the hernia, and to elevate
the head of the bed on 4- to 8-inch (10- to 20-cm) blocks
to prevent the hernia from sliding upward. Surgery is
indicated in about 15% of patients
Medical and surgical management of a paraesophageal
hernia is similar to that for gastroesophageal reflux;
however, paraesophageal hernias may require emergency
surgery to correct torsion (twisting) of the stomach or
other body organ that leads to restriction of blood flow to
that area
Diverticulum
Clinical Manifestations
Symptoms experienced by the patient with a pharyngoesophageal
pulsion diverticulum include difficulty swallowing, fullness in the
neck, belching, regurgitation of undigested food, and gurgling
noises after eating. When the patient assumes a recumbent
position,undigested food is regurgitated, and coughing may be
caused by irritation of the trachea. Halitosis and a sour taste in the
mouth are also common because of the decomposition of food
retained in the diverticulum
Symptoms produced by midesophageal diverticula are less acute.
One third of patients with epiphrenic diverticula are asymptomatic,
and the remaining two thirds complain of dysphagia and chest pain
Dysphagia is the most common complaint of patients with
intramural diverticulosis
Assessment and Diagnostic Findings
A barium swallow may be performed to determine the
exact nature and location of a diverticulum
Manometric studies are often performed for patients with
epiphrenic diverticula to rule out a motor disorder
Esophagoscopy usually is contraindicated because of the
danger of perforation of the diverticulum, with resulting
mediastinitis
Blind insertion of a nasogastric tube should be avoided
Management
Because pharyngoesophageal pulsion diverticulum is
progressive, the only means of cure is surgical removal of the
diverticulum
Postoperatively, the patient may have a nasogastric tube
inserted at the time of surgery.
The surgical incision must be observed for evidence of leakage
from the esophagus and a developing fistula. Food and fluids
are withheld until x-ray studies show no leakage at the surgical
site
The diet begins with liquids and progresses as tolerated
Surgery is indicated for epiphrenic and midesophageal
diverticula only if the symptoms are troublesome and becoming
worse
Treatment consists of a diverticulectomy and long myotomy
Intramural diverticula usually regress after the esophageal
stricture is dilated
Perforation
Perforation may result from stab or
bullet wounds of the neck or chest,
trauma from motor vehicle crash,
caustic injury from a chemical burn, or
inadvertent puncture by a surgical
instrument during examination or
dilation
Clinical Manifestations
The patient has persistent pain followed
by dysphagia
Infection, fever, leukocytosis, and
severe hypotension may be noted
In some instances, signs of
pneumothorax are observed
Assessment and Diagnostic Findings
Diagnostic x-ray studies and fluoroscopy
are used to identify the site of the
injury
Management
Broad-spectrum antibiotic therapy
A nasogastric tube is inserted to provide suction and
to reduce the amount of gastric juice that can reflux
into the esophagus and mediastinum
Nothing is given by mouth
Surgery may be necessary to close the wound, and
postoperative nutritional support then becomes a
primary concern
Depending on the incision site and the nature of
surgery, the postoperative nursing management is
similar to that for patients who have had thoracic or
abdominal surgery
Gastroesophageal Reflux Disease
(GERD)
Some degree of gastroesophageal reflux (backflow of gastric or duodenal contents into the
esophagus) is normal in both adults and children
Excessive reflux may occur because of an
incompetent lower esophageal sphincter, pyloric
stenosis, or a motility disorder
The incidence of reflux seems to increase with aging
Clinical Manifestations
pyrosis (burning sensation in the esophagus)
dyspepsia (indigestion)
regurgitation
dysphagia or odynophagia (difficulty
swallowing, pain on swallowing)
hypersalivation
esophagitis
the symptoms may mimic those of a heart
attack
Assessment and Diagnostic Findings
endoscopy or barium swallow to evaluate
damage to the esophageal mucosa
ambulatory 12- to 36-hour esophageal pH
monitoring is used to evaluate the degree of
acid reflux
bilirubin monitoring (Bilitec) is used to
measure bile reflux patterns
Management
Teaching the patient to avoid situations that decrease lower
esophageal sphincter pressure or cause esophageal irritation
The patient is instructed to eat a low-fat diet; to avoid caffeine,
tobacco, beer, milk, foods containing peppermint or spearmint, and
carbonated beverages; to avoid eating or drinking 2 hours before
bedtime; to maintain normal body weight
To avoid tight-fitting clothes; to elevate the head of the bed on 6to 8-inch (15- to 20-cm) blocks; and to elevate the upper body on
pillows
Medications such as antacids or histamine receptor blockers, proton
pump inhibitors, prokinetic agents, which accelerate gastric
emptying
If medical management is unsuccessful, surgical intervention may
be necessary
Barrett’s Esophagus
It is believed that long-standing untreated
GERD may result in a condition known as
Barrett’s esophagus. This has been identified
as a precancerous condition that, if left
untreated, can result in adenocarcinoma of
the esophagus, which has a poor prognosis
It is more common among middle-aged white
men; however, the incidence is increasing
among women and among African Americans
Clinical Manifestations
The patient complains of symptoms of
GERD, symptoms related to peptic
ulcers or esophageal stricture, or both
Assessment and Diagnostic Findings
EGD is performed. This usually reveals
an esophageal lining that is red rather
than pink. Biopsies are taken, and the
cells resemble those of the intestine
Management
Monitoring varies depending on the amount
of cell changes. Some physicians may
recommend a repeat EGD in 6 to 12 months
if there are minor cell changes
Medical and surgical management is similar to
that for GERD
Nursing Process
Assessment
Emergency conditions of the esophagus (perforation, chemical burns)
usually occur in the home or away from medical help and require
emergency medical care
The patient is treated for shock and respiratory distress and
transported as quickly as possible to a medical facility
Foreign bodies in the esophagus do not pose an immediate threat to
life unless pressure is exerted on the trachea, resulting in dyspnea or
interfering with respiration, or unless there is leakage of caustic alkali
from a battery
Educating the public to prevent inadvertent swallowing of foreign
bodies or corrosive agents is a major health issue
For nonemergency symptoms, a complete health history may
reveal the nature of the esophageal disorder
The nurse asks about the patient’s appetite. Has it remained the
same, increased, or decreased?
Is there any discomfort with swallowing? If so, does it occur
only with certain foods? Is it associated with pain? Does a
change in position affect the discomfort?
The patient is asked to describe the pain. Does anything
aggravate it? Are there any other symptoms that occur
regularly, such as regurgitation, nocturnal regurgitation,
eructation (belching), heartburn, substernal pressure, a
sensation that food is sticking in the throat, a feeling of
becoming full after eating a small amount of food, nausea,
vomiting, or weight loss? Are the symptoms aggravated by
emotional upset?
If the patient reports any of these symptoms, the
nurse asks about the time of their occurrence, their
relationship to eating,and factors that relieve or
aggravate them (eg, position change, belching,
antacids, vomiting)
This history also includes questions about past or
present causative factors, such as infections and
chemical, mechanical, or physical irritants; the
degree to which alcohol and tobacco are used; and
the amount of daily food intake
The nurse determines whether the patient appears
emaciated and auscultates the patient’s chest to
determine whether pulmonary complications exist
Nursing Diagnosis
Based on the assessment data, the nursing diagnoses may
include the following:
• Imbalanced nutrition, less than body requirements, related to
difficulty swallowing
• Risk for aspiration related to difficulty swallowing or to tube
feeding
• Acute pain related to difficulty swallowing, ingestion of an
abrasive agent, tumor, or frequent episodes of gastric reflux
• Deficient knowledge about the esophageal disorder, diagnostic
studies, medical management, surgical intervention, and
rehabilitation
Planning and Goals
The major goals for the patient may include
attainment of adequate nutritional intake,
avoidance of respiratory compromise from
aspiration, relief of pain, and increased
knowledge level
Nursing Interventions
Encouraging adequate nutritional intake
Decreasing risk of aspiration
Relieving pain
Providing patient education
Promoting home and community-based care:
Teaching patients self-care
Continuing care
Evaluation
Expected patient outcomes may include:
1. Achieves an adequate nutritional intake
a. Eats small, frequent meals
b. Drinks water with small servings of food
c. Avoids irritants (alcohol, tobacco, very hot
beverages)
d. Maintains desired weight
2. Does not aspirate or develop pneumonia
a. Maintains upright position during feeding
b. Uses oral suction equipment effectively
3. Is free of pain or able to control pain within a tolerable level
a. Avoids large meals and irritating foods
b. Takes medications as prescribed and with adequate fluids
(at least 4 ounces), and remains upright for at least
10 minutes after taking medications
c. Maintains an upright position after meals for 1 to 4 hours
d. Reports that there is less eructation and chest pain
4. Increases knowledge level of esophageal condition,
treatment,
and prognosis
a. States cause of condition
b. Discusses rationale for medical or surgical management
and diet or medication regimen
c. Describes treatment program
d. Practices preventive measures so injuries are avoided