Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)

• Incompetent lower esophageal sphincter (LES) allows stomach acid reflux into the esophagus
• Reflux causes irritation, inflammation, and erosion (ulceration)

GERD Complications

• Barrett's esophagus involves changes in the esophageal epithelium, increasing esophageal cancer risk
• Stricture, or narrowing of the esophagus from scar tissue, leads to swallowing difficulties
• Other complications include hemorrhage, aspiration pneumonia, adult-onset asthma, laryngitis, and dental decay

GERD Risk Factors

• Middle-aged to older adults are at higher risk as the LES weakens with age
• Obesity, NG tube presence, and pregnancy increase risk
• Tight clothing, frequent bending, ascites, and hiatal hernias are risks

GERD Manifestations and Assessment

• Heartburn and esophageal pain may radiate to the neck, jaw, and back
• Symptoms occur after meals and can last for hours
• Regurgitation, eructation, flatulence, and bloating after meals can occur
• Dysphagia indicates a narrowed esophagus or painful swallowing
• Individuals may experience a chronic cough, usually at night or when lying down
• Chest pain may stem from esophageal spasms

GERD Diagnostics

• Ambulatory esophageal pH monitoring occurs over 24-48 hours; a catheter measures pH while the patient records activities
• EGD helps visualize changes like Barrett's and strictures
• Barium swallows can identify anatomical issues

GERD Management and Education:

• Management involves nutritional changes, drug therapy, endoscopic procedures, and surgery

Nutritional Changes

• Limit foods that decrease LES pressure (chocolate, alcohol, fatty foods, caffeine, peppermint)
• Decrease foods that increase HCl production (milk) and limit spicy and acidic foods
• Eat 4-6 small meals daily and avoid food three hours before bed
• Eat slowly, raise the head of the bed, sleep on the right side, and avoid smoking and alcohol
• Weight reduction helps
• Avoid oral contraceptives, anticholinergics, sedatives, NSAIDs, nitrates, and CCBs if possible

GERD Drug Therapy

• Aluminum or magnesium antacids provide short-term relief for breakthrough symptoms
• H2RBs ( "-tidine" family name) and PPIs ("-prazole" family name) reduce acid
• Prokinetics (metoclopramide/Reglan) used.

GERD Endoscopic Procedure

• Stretta procedure: Radiofrequency energy near the gastroesophageal junction decreases vagus nerve activity and discomfort
• After the Stretta procedure, follow a liquid diet for 24 hours, then soft foods
• Patients should avoid NSAIDs and aspirin for 10 days and continue PPI therapy
• Liquid medications are preferred, and NG tubes are avoided for one month
• Notify a provider for chest/abdominal pain, bleeding, dysphagia, shortness of breath, nausea, or vomiting

GERD Surgery

• Nissen Fundoplication is a surgical option for GERD.

Hiatal Hernia

• Weakened diaphragm allows the upper stomach (fundus) to slide into the chest through the hiatus
• The stomach moves up and down with intra-abdominal pressure changes (sliding) or herniates next to the esophagus (paraesophageal)

Hiatal Hernia Complications

• Esophageal reflux (GERD) is a common complication
• Rare complications include twisting (volvulus) and obstruction, strangulation with ischemia, and slow bleeding leading to anemia

Manifestations and Diagnosis of Hiatal Hernia

• Manifestations are similar to GERD Diagnosis is made via barium swallow with fluoroscopy and EGD to view the esophageal and gastric mucosa

Management and Patient Education

• Avoid activities that increase intra-abdominal pressure
• Non-surgical treatments are the same as for GERD
• Surgery is needed when hiatal hernia complications are high or reflux is severe
• Laparoscopic Nissen Fundoplication: Post-op care includes incentive spirometry, deep breathing, and NG tube care

Post Laparoscopic Nissen Fundoplication

• NG tube drainage changes from dark brown to yellow-green within 8 hours
• Secure the tube and check placement every 4-8 hours, monitoring for patency
• Provide frequent oral hygiene
• Start clear liquids as bowel sounds return, monitoring for temporary dysphagia

Teaching after Laparoscopic Nissen Fundoplication

• Follow a soft diet for one week, transitioning to a normal diet over 4-6 weeks with small, frequent meals
• Avoid caffeine and carbonated beverages
• Manage "gas bloat syndrome" by avoiding problematic foods/drinks, chewing gum, and straws: eat slowly, ambulate frequently; simethicone may help
• Continue antireflux medications
• Avoid straining and prevent constipation using stool softeners

Postoperative Precautions

• Do not drive for one week and avoid heavy lifting
• Remove small dressings on the second day and leave steri-strips for 10 days
• Wash incisions with antibacterial soap and water
• Report redness, heat, pus, fever, N/V, bloating, or pain
• Avoid smoking/respiratory infections
• Follow-up appointments are usually scheduled for 3-4 weeks post-op

Gastritis

• Inflammation of the gastric mucosa or submucosa results from breakdown of mucosal barrier
• Hydrochloric acid injures the stomach lining, causing edema, bleeding, and erosion

Acute Gastritis

• Risks are spicy foods, alcohol ingestion, emotional stress, infections, NSAIDs, aspirin, corticosteroids, and physiological stressors like trauma or surgery
• Discomfort, cramping, anorexia, nausea, vomiting, and bleeding can manifest
• Mucosal healing usually occurs within days to months

Chronic Gastritis

• Etiology may be autoimmune or related to H. pylori, alcohol abuse, smoking, radiation, systemic conditions, and toxins
• Progressive atrophy occurs from chronic mucosal injury, decreasing acid secretion and intrinsic factor
• Pernicious anemia, peptic ulcers, and gastric cancer are complications
• Symptoms may be absent until ulceration with anorexia, nausea, and epigastric pain.
• Diagnosis involves H. pylori blood tests and EGD for suspicious lesions

Collaborative Management of Gastritis

• It involves treating underlying conditions and H. pylori if present
• Management includes medications such as antacids, H2RBs, sucralfate, PPIs, prostaglandin analogs, and antibiotics

Gastritis Medications

• Administer antacids 2 hours after meals and at bedtime (more effective in liquid form)
• Avoid giving with other drugs due to absorption issues
• Avoid magnesium antacids with renal insufficiency
• H2RBs given once daily; IV ranitidine or famotidine can prevent stress ulcers
• Sucralfate creates a mucosal barrier when administered multiple times daily
• Prescribe PPIs once daily; long-term use increases osteoporosis and fracture risk
• Misoprostol, a prostaglandin analog, protects the mucosa in NSAID users

H. Pylori Treatment

• Amoxicillin, tetracycline (avoid in children under 8), and/or metronidazole (Flagyl) are prescribed
• Avoid alcohol with metronidazole

Peptic Ulcer Disease (PUD)

• Acid and pepsin cause ulcer erosions in the lower stomach or upper duodenum following mucosal injury from H. pylori or gastritis
• Stress from acute trauma, major surgery, head injury, burns, or sepsis is another cause
• Manifestations include epigastric tenderness, indigestion, pain (sharp, burning, or gnawing), nausea, vomiting, weight loss, bloating, and belching

Diagnosis of PUD

• Diagnosis is the same as gastritis
• Chest and abdominal x-rays can identify suspected perforations
• Lab work includes H&H

Collaborative Care and Patient Teaching for PUD:

• The priority is managing acute/chronic pain and potential hemorrhage complications, which may require partial gastrectomy
• Teaching focuses on drug therapy similar to gastritis
• Antibiotics for H. pylori are not for asymptomatic patients due to antibiotic resistance risk
• Dietary recommendations are to avoid triggering foods and gastric secretion stimulants like caffeine, tobacco, alcohol, and milk

PUD Treatment

• Therapy to reduce anxiety
• Teach to recognize potential complications
• Take steps to avoid recurrence
• Small, frequent meals and lying flat after eating can alleviate dumping syndrome after gastrectomy
• B12 supplements, and compliance with medications is important
• Schedule and maintain follow-up appointments.

PUD Complications and Manifestations

• Hemorrhage*
• Gastric: bright red/coffee-ground emesis
• Duodenal: melena stool/occult blood
• Assess for orthostatic hypotension
• Tachycardia/hypotension, chills, palpitations, diaphoresis, and weak/thready pulses indicate acute hemorrhage
• Management includes careful monitoring of input/output, IV fluids (NSS/LR), blood transfusions, H&H monitoring, NG tube placement, GI lavage, and endoscopic therapy
• Perforation (leads to peritonitis)*
• Gastric/duodenal contents leak into the peritoneal space
• Symptoms: sharp mid-epigastric pain, anxiety, tender/rigid/board-like abdomen, and fetal positioning
• Rapid progression to bacterial septicemia and hypovolemic shock
• Assessment reveals rebound tenderness/abdominal rigidity
• Management*
• Fluids, blood, and electrolyte replenishment
• Antibiotics
• Manage septic shock
• Pyloric Obstruction:*
• Abdominal bloating, nausea, and vomiting of undigested food
• Metabolic alkalosis and hypokalemia may follow
• Management involves restoring fluid/electrolyte balance and NG decompression of stomach
• Metabolic correction
• Clamp NG tube after 72 hours and check residual
• Surgery if conservative treatment fails
• Intractability*
• The failure to heal is due to excessive stressors or inability to adhere to therapy

Intestinal Problems: Inflammatory Bowel Disease (IBD)

Ulcerative Colitis

• Inflammation of rectum and sigmoid colon may move upwards
• Continuous pattern affecting the entire colon during alternating periods of remission/flare-up
• Mucosa is hyperemic/edematous, bleeds/erodes, causing narrowed areas/obstruction

Ulcerative Colitis Risk Factors and Manifestations:

• Genetic and autoimmune factors, bloody/mucusy stool, and tenesmus/lower abdominal pain/colic are common
• Systemic symptoms include polyarthritis/ankylosing spondylitis/erythema nodosum and diarrhea urgency
• Secondary stress and other chronic illness concerns are common

Diagnosis for Ulcerative Colitis Includes:

• Colonoscopy/sigmoidoscopy, CT scan, or barium enema if needed
• Labs check H&H, WBC, CRP/ESR, and electrolytes
• Magnetic resonance enterography (MRE) studies bowel

Ulcerative Colitis Complications and Collaborative Care

• Hemorrhage, nutritional deficiencies, anemia, and toxic megacolon can develop
• Management focuses on diarrhea, pain, bleeding, anemia, physical/emotional rest, recording stool, perianal care, and weight monitoring
• Aminosalicylates reduce inflammation, while sulfasalazines suppress the immune system
• Glucocorticosteroids, antidiarrheals (cautiously), and immunomodulators change immune responses
• Surgery for complications or cancer if bowel continence is not possible, ileostomy may be necessary

Ulcerative Colitis Nutrition

• The individual may require NPO/TPN for severe symptoms
• Avoid trigger foods, raw fruits/veggies, and fiber-rich foods

Crohn's Disease

• Crohn's involves inflammation in the small intestine, large intestine, or both due to skip lesions
• Transmural inflammation thickens bowel wall; deep ulcerations in cobblestone pattern cause adhesions, remission, and exacerbations
• Patients may develop similar complications to UC in addition to a high likelihood of malabsorption, fluid/electrolyte imbalances, and anemia

Crohn's Complications

• Bowel fistulas and obstructions are more likely than with UC
• Genes, environment, and immune factors are risk factors
• Manifestations: diarrhea, abdominal pain, fever, steatorrhea, and weight loss

Crohn's Diagnosis

• Proctosigmoidoscopy, stool fat/occult blood tests, barium enema, and CBC can diagnose
• Collaborative care similar to UC: fistula care with attention to nutrition, electrolytes, skin, and infections
• Surgery for complications or non-responsive disease
• Medications: Biologic response modifiers (BRMs) inhibit TNF-alpha

Crohn's Nutrition:

• Individuals need 3000 calories daily if fistula is present
• If they cannot tolerate oral foods, they may require TPN
• Give high-calorie, high-protein, high-vitamin, low-fiber meals with daily weight monitoring

Diverticular Disease

• Diverticulosis is the herniation development in the colon wall
• It develops with aging/low-fiber diets, pouches are asymptomatic unless infected

Diverticular Disease Manifestations:

• pain (LLQ), peritonitis, nausea/vomiting, fever, chills, tachycardia, distention, tenderness, guarding, and rebound tenderness
• Perforation leads to peritonitis, sepsis, hypovolemia, shock, and abscess/fistula formations

Diverticular Diagnosis and Management:

• Diagnosed via CT scan, complete blood count, and ESR/KUB to reveal any perforation of the colon
• Colonoscopies are contraindicated
• Management includes bowel rest, antibiotics, fluids, and pain medication to correct perforations
• Diets are controversial

Diverticular Diet:

• A high-fiber diet has been shown to be effective for diverticulosis
• A low-fiber diet is most effective when symptoms of diverticulitis are present

Bariatric Surgery

• Restrictive procedures such as laparoscopic banding decrease stomach capacity/limit food intake
• Malabsorption procedures are anastomosis of lower esophagus to jejunum, decreasing calorie/nutrient absorption

Bariatric Surgery

• The risk of surgery is significantly increased
• There may be a need for weight loss preoperatively
• Focus postop on patient safety
• Common postop complications include: abdominal binders to prevent wound dehiscence; semi-Fowler's position, C-PAP or Bi-PAP to decrease pulmonary complications

Tubes and Drains after Bariatric Surgery:

• Tubes/catheters are placed to prevent pressure
• The urinary catheter is removed in 24 hours
• Out of Bed on Day of surgery; turn patient every 2 hours

Bariatric Complications

• A common complication of surgery includes dumping syndrome, so encourage smaller meals, low carbs, and to chew well
• May need a dietician, PT, and Psychologist
• Diet progression: clear liquids with one-ounce increments in five minutes, followed by pureed foods/thin soups/milk 24-48 hours, nutrient-dense
• Nausea, vomiting, and/or discomfort occur after the ingestion of too much liquid.

Hemorrhage

• Look for signs of peptic ulcers

Lower GI Bleeding

• Causes are ulcerative colitis, polyps, colon/rectal cancer, diverticulitis, hemorrhoids
• Manifests as stool positive for occult or frank blood.

Intestinal (Bowel) Obstruction

• Obstructions may be mechanical/non-mechanical, contents accumulate
• Intestinal contents collect from the obstruction and cause a range of complications

Intestinal Obstruction Complications

• Metabolic alkalosis in small intestine
• Metabolic acidosis for lower obstructions
• Shock
• Peritonitis

Intestinal Causes

• Adhesions
• Tumors
• Appendicitis
• Strictures
• Ischemia

Intestinal Manifestations

• Small intestine: Abdominal pain and/or cramping
• Vomiting (may contain bile, mucus, orange-brown and foul smelling)
• No stool or flatus with diarrhea if partial obstruction
• Large intestine: Intermittent, colicky abdominal pain with lower abdominal distention and obstipation

Intestinal Assessment

• Abdominal distention
• Visible peristaltic waves
• Proximal high-pitched bowel sounds and the absence of bowel sounds
• Tense fluid-filled bowel loop

Intestinal Management

• Non-surgical: NPO, NG decompression
• Administer IVF

Malabsorption Syndromes

• Deficiencies of salts or enzymes
• Presence of bacteria
• Occurs with disruption of the small intestine

Etiology and Risks of Malabsorption

• Liver: poor fat
• Lactase deficiency: causes deficiency
• Pancreatitis/gastritis: carbs, protein
• Surgery: B12, bile salt, other nutrients

Malabsorption Manifestations

• Weight loss
• Diarrhea (fat)
• Bloating flatus (carbs)
• Decreased libido
• Bruising bone pain
• Anemia
• Edema

Peritonitis

• Inflammation caused by bacterial or chemical reaction
• Blood vessels will dilate and fluid will shift
• Sepsis

Peritonitis Etiology

• Trauma
• Organ
• Gangrenous gallbladder

Peritonitis Manifestations

• Symptoms spread across abdomen
• Rebound tenderness
• Pain
• Decreased bowel sounds

Peritonitis Management

• Fluids and Antibiotics
• NPO and NG
• Pain management
• Possible surgery

Cirrhosis

• With cirrhosis, nodular tissue blocks blood flow

Cirrhosis Etiology and Manifestations

• Hepatitis B/C/D
• Non-alcoholic fatty liver disease
• Alcohol use

Cirrhosis Complications

• Portal hypertension
• Biliary obstruction
• Hepatic encephalopathy

Cirrhosis Assessment

• History
• Physical
• Psychosocial

Cirrhosis Diagnosis

• Liver biopsy
• Abdominal X-rays, CT scan, or MRI

Cirrhosis Collaborative Care

• Fluid and electrolyte replacement
• Potential for hemorrhage
• Lifestyle changes.